14 20 371 https://staging.drfop.org/files/original/e71416996352556efb023812c4eedec5.pdf 25ebf46eaf69e9b152e2c190d46f2a77 https://staging.drfop.org/files/original/b6c5c1116f50d1110f991f8a6c0e582b.jpg 53141fda199ab171208acf35d095a73d https://staging.drfop.org/files/original/42e04c9ddf407f09592f368dc9ff1c12.jpg 651ea138a11022d6edf8e33366739adf https://staging.drfop.org/files/original/bcdce6329da04a8a8f4710fbe3957aec.jpg 227b1bc4f43139dc742e5cfc3434f264 https://staging.drfop.org/files/original/061a0c8f6051439279c49121003e4252.jpg e92f1b105cd71be2e26422d8ed541101 https://staging.drfop.org/files/original/220a179b1734ff365426e6b757fbf1a4.jpg 106d747231911de3f7ab6a749818955f https://staging.drfop.org/files/original/a030df8afdd8d496ea38ff35eb10a376.jpg 099981a8288aa53e4f8ab7a1afcf3ec3 https://staging.drfop.org/files/original/06b6efdef352c9a36c19e593016d0058.jpg 5cf35916d68ebab5f2fa7015770d5ec5 https://staging.drfop.org/files/original/e33abac33eb28c4425dc5ba7d3d9829f.jpg bbf0ffd1753ca99e90634ba88f777e5b https://staging.drfop.org/files/original/741aaf7774c9fb485c220490dfa15d66.jpg 104b74ab4ce49065ab443a4973decc68 https://staging.drfop.org/files/original/c7f5624a84623a65da53be9b14b7ad50.jpg 0d835a39d62f5c64705c7b7f85ff2696 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_004.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 4 - 56 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper Extremity Amputee. I. Design and Scope.</h2> <h5>Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Man's increasing dominion over his natural environment has been ascribed to three specific characteristics a highly developed brain, binocular vision, and an apposable thumb. Although not particularly specialized from a biological viewpoint, these three attributes have enabled him to adapt to a varied physical environment and, perhaps more important, to alter the physical environment to suit his needs. Loss of any one of them deprives him of fundamental human capacities and seriously inhibits his ability to compete, to interact, and to manipulate the objective world around him. Impaired brain function is usually irreversible, and in the case of vision loss heroic measures are often required to obtain even a modicum of functional restitution. But the situation is somewhat different today with respect to the loss of an upper extremity. New concepts and developments in the field of limb prosthetics have increased the potentialities of arm amputees. Not all the problems are solved. Far from it. But systematic and concerted efforts in medicine and engineering are being applied toward reducing the limitations attendant upon the loss of an arm. It is perhaps ironic that historically these constructive efforts have been stimulated by the destructive forces of war.</p> <h3>Historical Development</h3> <p>In the aftermath of World War II, a grateful nation spared no effort to alleviate the condition of those who had been wounded or maimed in its defense. Among its many other services, the Veterans Administration undertook the task of providing prosthetic and rehabilitation services to all veteran amputees. In pursuit of this goal, it soon became clear that existing artificial limbs fell far short of meeting the needs and expectations of their users. Perhaps because of the greater dependence of the leg amputee upon adequate service, and because of the consequent emphasis on attention to his problems, the major needs were found among upper extremity amputees. Arm prostheses were found to be heavy, uncosmetic and unsanitary, and possessed of very limited function (<b>Fig. 1</b>) and (<b>Fig. 2</b>). Too often they were relegated to the closet. Generally accepted standards of prosthetic quality were lacking. Better materials, improved design, new prosthetic components, and improved fitting and fabrication techniques were clearly required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical below-elbow prosthesis, vintage World War II. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical above-elbow prosthesis, vintage World War II. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Not generally recognized was the need for highly individualized training to develop proficiency in the use of an artificial arm so that vocational and other skills could be acquired. Without a common ground of experience, the physician rarely took part in the prescription and fitting of prostheses. Thus, even the most skilled prosthetist, faced with the task of providing his patient with a well fitting, comfortable, and highly functional prosthesis, sometimes found himself in the unfamiliar role of psychologist, therapist, and/or vocational counselor. In short, sound, complete, systematic rehabilitation programs for amputees were lacking. Officials of the Army, the Navy, and the Veterans Administration wasted little time in hand wringing. Authority was soon forthcoming, and funds were made available for a broad attack on these problems. The resources of science, applied during the war years to destruction and demoralization, were now directed toward the restoration of human loss and the enrichment of human life. The first step was the establishment, in 1945, of the Committee on Prosthetic Devices of the National Academy of Sciences National Research Council, which later became the Advisory Committee on Artificial Limbs and which is today the Prosthetics Research Board. This led to the inception of the Artificial Limb Program and to the establishment of research projects for the scientific study of the problems involved. At the University of California at Los Angeles fundamental studies were undertaken of the biomechanical principle involved in normal prehension and of the problems of using artificial arms. At the same time, the industrial laboratories of Northrop Aircraft, as well as the Army Prosthetics Research Laboratory, were creating new materials, new devices, and new fabrication techniques, while New York University was assigned the task of evaluating these developments. The scientific facilities of both industry and government were thus employed to reduce the problem through efforts in basic and applied research.</p> <p>The earliest results indicated that solving the problems and fulfilling the needs of the upper extremity amputee was a task vastly greater than that of improving the mechanical aspects of fitting and fabricating prostheses. The finest artificial limb is of little value without training in its use. Further, the loss of a limb was seen to create important disturbances in the personality as a result of functional loss and distortion of the self concept. The amputee entertains doubts as to how he will appear to and be accepted by his family and friends. He wonders, often with misgivings, about his economic potential. He has what appear to him to be insuperable problems, and he needs help in restoring his self confidence as well as his lost function. In order to meet these amputee needs, a complete and rational system of rehabilitation programming was required, and since 1945 considerable progress has been made in developing such an approach to this problem.</p> <p>After several years of organized effort, a great deal of research information became the basis for an all around approach to the treatment of upper extremity amputees. Through the development of models, the testing of hypotheses, and the experimental treatment of a number of arm amputees of all types, it became possible to indicate with some confidence how certain types of patients should be fitted, how their arms should be constructed, and how they should be trained to use them. As an added result, it is becoming a commonplace that all the amputee's needs cannot be served by a single individual, regardless of his professional status or training. With recognition of individual needs and the variety of amputee problems, it became clear that successful rehabilitation of these patients demanded the highly qualified and specialized services of a number of disciplines. Prosthetists, therapists, and physicians each have vital contributions in this enterprise, as may also nurses, social workers, vocational counselors, and psychologists. The modern concept then became the "team approach," the team consisting minimally of the doctor, the prosthetist, and the trainer and including such other specialists as each case required.</p> <p>In order to evaluate these findings, a series of studies, which came to be known as the "NYU Field Studies," was conceived in 1951 at the Prosthetic Devices Study at New York University.</p> <h3>Goals of the Upper Extremity Field Studies</h3> <p>The NYU Field Studies of upper extremity prosthetics developed as the logical consequence of two main preconditions the laboratory research program and the prosthetics education program. As for the first, out of the laboratories had come a whole series of new devices which, on the basis of preliminary testing on relatively small groups, gave promise of being significantly improved components. Before some of them could be considered "proved" items of a prosthetic armamentarium, more definitive testing on broader, more representative samples under varying conditions seemed essential. But more than gadget testing was involved. New fabrication techniques employing plastics had also been developed, and although arms made according to these procedures seemed superior to older types, it remained to be seen if the procedures could be mastered by limbmakers all over the country and economically and conveniently applied to the production of all types of artificial arms.</p> <p>The second factor to be considered in planning the studies was the matter of broad and speedy dissemination of the new knowledge and skills. It was clear that the new procedures could not be evaluated in clinics whose personnel were not completely familiar with their use. Moreover, considerable urgency prevailed about making new developments and improvements available to all amputees as soon as possible. To fulfill this requirement, a prosthetics education program was organized to train clinic team personnel. But it was generally observed that additional assistance was required in significant numbers of clinics before they could begin to process patients effectively.</p> <p>For all of these reasons, the NYU Field Studies were designed in 1953 with three main objectives in view:</p> <ol> <li><i>To evaluate the utility and acceptability of specific prosthetic materials, components, and treatment procedures</i>. In order to appraise the usefulness of prostheses provided amputees by the program, and in order to gauge the reactions of the patients to the new arms, a comprehensive evaluation procedure was to be developed. The comfort and appearance of a prosthesis and the confidence it inspires in its user are as important in prosthetic service as are structural and mechanical adequacy. Each of these areas was explored.</li><li>To provide direction for future research in relation to practical field needs. Field study operations should provide access to large representative samples of upper extremity amputees. Clinical contact with these patients would furnish a means for determining existing prosthetic problems and, even more important, for evaluating the importance of these problems to amputees themselves. With this information available to the developmental laboratories through a feedback arrangement, their efforts could be directed toward the problems of most immediacy and importance.</li><li>To extend the educational process by rendering administrative and technical assistance to newly organized prosthetics clinics. Shortly after graduation from the prosthetics courses at the University of California at Los Angeles, potential clinic teams were to be visited by NYU representatives, the purpose being to encourage and aid in the establishment of a clinic procedure along the lines taught in the courses. The expeditious organization of a clinic served two functions amputees would have early access to modern treatment, and a clinic treating patients according to these procedures was a potential participant in the field studies and a source of research data.</li></ol> <p>Before these concepts could be tested in the crucible of clinic practice throughout the nation, several preliminary steps were necessary. First, meaningful and reliable methods had to be found for evaluating the effect of prosthetic treatment procedures. Second, a number of clinics had to be organized to participate in the studies if valid inferences about the general utility of the experimental procedures were to be drawn. Third, training in the new prosthetic techniques and procedures had to be given to those who dealt directly with amputees. Actually, all three of these steps were undertaken at approximately the same time.</p> <h4>Inauguration of the Upper Extremity Field Studies</h4> <p>The staff of the Prosthetic Devices Study of New York University had been engaged in developing on a generally theoretical basis a philosophy and methodology for evaluating the status of arm amputees. The problem was approached directly, attempts being made to determine the most important outcomes in prosthetic restoration and to measure the extent to which the newer management procedures provided them. Accordingly, procedures and instruments were devised for determining the extent of residual function and the degree of adjustment to physical disability (<b>Fig. 3</b>). The status of the patient after treatment could thus be compared with his pretreatment condition as a basis for evaluation. But before these instruments could be applied on a broad scale it was necessary to test their reliability and administrative feasibility as well as to refine the procedures for their application. For this purpose, a preliminary "pilot" study was planned, and Chicago was selected as the test site.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Calibrated grid for measuring the arm movements required to perform certain common activities. Use of top and side mirrors provides information in three dimensions simultaneously. Clocks record time data. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Chicago "Pilot" Study</h4> <p>The pilot study carried out in 1952 called for a small number of surgeons, therapists, and prosthetists from the Chicago area to attend a special four week course of instruction in upper extremity prosthetics at the University of California at Los Angeles in order to familiarize the participants with the devices, fabrication techniques, and clinical procedures to be evaluated.<a></a> Upon their return to Chicago, they were joined by representatives of NYU's Prosthetic Devices Study, and the pilot study was launched.</p> <p>This field trial of research instruments and procedures involved the screening of a number of amputees in the Chicago area and the selection of a group for treatment in the Veterans Administration clinic. To enable the clinic properly to prescribe the new prosthesis, each of the selected subjects was given a comprehensive evaluation prior to other treatment. In addition, research evaluations were conducted by NYU representatives to provide baseline data against which the effects of the rehabilitation procedures could be evaluated. The new arm for each participant was then prescribed in accordance with the prescription procedure taught in the UCLA course and was to be fabricated precisely as prescribed and according to the mechanical and cosmetic standards formulated. When the arm was complete, it was brought to the clinic for a checkout which consisted of a detailed examination by the clinic staff to assure themselves of the adequacy of the product. If revisions were required, they were made before the patient was given the arm; if none were needed, the clinic prescribed appropriate training treatments to be administered by the therapist.</p> <p>After training was completed, the amputee was again seen by the clinic team; if the arm were still satisfactory and maximum results had been achieved through training, the patient was to wear the arm routinely in daily living. At the end of a two month period of daily wear, the subjects were re evaluated in a manner similar to the pretreatment evaluation.</p> <p>As a result of the Chicago study, valuable experience was gained in the processing of patients. Research techniques were refined, clinic procedures were crystallized, methods for administering questionnaires and for taking measurements were standardized, and instruments were revised and augmented. With the end of the pilot phase, expansion of the upper extremity field studies to national proportions began, an expansion made possible by the participation in the program of a number of widely distributed private clinics as well as Veterans Administration clinics.</p> <h4>Organization Of Participating Clinic</h4> <p>The unprecedented nature of the projected field studies made the selection of a number of clinics a formidable task. It was first necessary to locate interested and qualified clinic personnel. Then it was necessary to orient them as to the nature of the program as well as to the need for special training. Steps for integrating the clinics into the field program required explanation, and specific operating procedures had to be worked out with individual groups. This task was undertaken by the Director of the Prosthetic Devices Study, Dr. Sidney Fishman.</p> <p>After completion of the pilot study in Chicago early in 1953, and continuously for two years thereafter, Dr. Fishman and Dr. Miles H. Anderson, the Director of the Prosthetics Education Project at UCLA, visited many large population centers throughout the country in order to meet with medical and paramedical personnel interested in the treatment of arm amputees. On the basis of expressions of interest, and of an appraisal of the available facilities and potential case loads, a number of clinical facilities were invited to participate. During these discussions, research procedures were described, expected outcomes were explained, and the roles of the clini members and of the NYU research workers were defined. Arrangements were made for members of each clinic staff to attend the courses in upper extremity prosthetics at UCLA (see below).</p> <p>It was quickly realized that financial problems would be encountered both by private clinics and by participating limbshops. In the former, the newer training procedures called for increased services of therapists and doctors. In the latter, the employment of newer fabrication and fitting techniques required an initial investment on the part of the prosthe tists in components, equipment, and materials. In addition, the checkout of an arm by the clinic team often resulted in revisions adding to initial fabrication costs. For these reasons, certain fiscal arrangements were indicated. Monies were made available to clinic teams to pay the training fees for amputee cases participating in the work. In order to spur the fabrication of the new type arms and to permit participation in the program by the prosthe tists, arrangements were made to purchase five experimental limbs from each shop participating in the studies. As a result of these efforts, 75 clinics representing 30 states and the District of Columbia (<b>Fig. 4</b>) participated in the field program. Each treatment center was directed and staffed by graduates of special upper extremity prosthetics training courses. Of the total number of clinics involved, 28 were Veterans Administration installations and 47 were other public and private institutions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Location of the participating clinics See facing page. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetics Education Program</h4> <p>The new knowledge and techniques, organized into courses of instruction and revised after the pilot school, were offered in a series of 12 schools (<b>Fig. 5</b>) conducted at UCLA, the chief purpose being to familiarize doctors, therapists, and prosthetists with the new developments and to encourage the team approach to the prosthetic rehabilitation of the upper extremity amputee. It thus became possible to teach to those with primary interest new concepts for the management of upper extremity cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Students and instructors of one of the 13 courses in upper-extremity prosthetics offered at the University of California at Los Angeles. This particular course was held in the autumn of 1954. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In effecting the transfer of information and skill to the primary amputee treatment grou consisting of the doctor, the therapist, and the prosthetist, academic tradition was broken. It seemed plain that if the "team approach" were to be taught, the members of the team should go to school together. Accordingly, in a unique educational enterprise, orthopedic surgeons, specialists in physical medicine, physical and occupational therapists, and prosthetics craftsmen became classmates. The six week course offered at UCLA began with a three week session of instruction for prosthetists only. During this portion of the course, prosthetists were exposed to a highly concentrated educational dose of prosthetic design and construction principles, plastics technology, anatomy, and kinesiology. Then they tested their knowledge by fitting patients under the direct supervision of their instructors.</p> <p>In the fourth week, the prosthetists were joined by the therapists. This group began with a concentrated portion of mechanics, biomechanics, and the characteristics of a wide variety of both newly developed and the older prosthetic components. Under the supervision of the instructors, they also received experience in training the patients previously fitted by the prosthetist students.</p> <p>At the beginning of the sixth week, the prosthetists and therapists were joined by the physicians and surgeons, who were given several days in which to review and digest the course materials. Practice clinic teams, consisting of the doctor as clinic chief and of at least one therapist and one prosthetist, were then organized. The entire class then proceeded to operate as clinic teams until graduation, whereupon each of the individuals returned home, a potential participant in the soon to follow upper extremity field studies. The new knowledge and skills were broadly disseminated by these educational efforts, but their utility and effectiveness on patients could not be clearly seen until large numbers of varying types of patients had been treated and evaluated.</p> <p>The Prosthetic Devices Study, charged with the responsibility for following up the program concepts, designed studies to evaluate the modern treatment methods. The central questions to be answered were deceptively simple: Are upper extremity amputees better served by means of the program procedures? In what specific areas can improvement, detriment, or indifference be found?</p> <h4>Areas of Research</h4> <p>In relatively unexplored fields, the formulation of meaningful research questions is often laborious, unsure, and time consuming. Merely selecting the most scientifically promising problems from the many questions which arise is in itself an important research task. Many possible approaches to the field must be evaluated, and those selected for study must give promise of becoming part of and contributing to the solution of larger problem areas. The research plan developed at the Prosthetic Devices Study to achieve the objectives of the field study program evolved in this way. It provided for three major interrelated study areas to be exploited concurrently.</p> <p>The first of these, a census of amputees, called for interviewing large numbers of upper extremity amputees in order to begin the organization of a broader body of knowledge concerning them and to provide a large population from which to select a sample for more detailed study. This was the "Survey Phase." Secondly, a segment of this population was selected for clinic treatment by means of the rehabilitation procedures under study. These efforts of the field operations, referred to as the "Clinical Studies," were designed to provide information about the feasibility of clinic procedures and prosthetic fabrication methods. The third study area provided for the pre and post treatment evaluation of a portion of the sample selected for clinic treatment. This approach, called "Evaluation Studies," was intended to elicit more detailed information about a smaller number of amputees than was possible in the survey and to provide a basis for evaluation of the methods and materials employed in the treatment procedure.</p> <p>In its final form, the research plan provided for trips by NYU field representatives to attend the monthly meetings of each participating clinic. Consequently, a given member of the staff would be in the field approximately two weeks out of each month, and a routine field trip often took him to five or six cities, where he would visit perhaps six or eight clinics and observe 20 to 30 amputees under treatment. With 75 participating clinics to serve, a field staff of 10 representatives directed by two field supervisors was organized. Since clinic meeting dates and times were quite firmly fixed, and since the time required to be spent with each subject varied from fifteen minutes to four hours, depending upon the stage of treatment, the trips required considerable planning. To minimize loss of time, schedules were arranged by correspondence, and confirmed when possible, before each trip. Despite the difficulty of control, the attrition rate when the studies ended was low. Some what less than 10 percent of those initially selected failed to complete the full treatment course and follow up studies.</p> <p>The NYU representative served two main functions: he established liaison among the treatment centers in the field and between them and New York University, which resulted in interchange of information and coordination of effort, and he was responsible for the collection of the research information. These data were gathered in the field by means of interviews, questionnaires, tests, and measurements.</p> <h4>Survey Studies</h4> <p>Each arm amputee referred to a participating clinic was considered a prospective research subject, and each was given a screening interview, the purpose being to obtain pertinent information concerning the patient, his prosthesis, and his needs and aspirations. Initially, clinics screened only those amputees who were immediately in need of treatment. The information thus gleaned contributed to the survey to be made of the status of upper extremity amputees in the United States and was also useful in the selection of subjects for more detailed study. On the basis of the screening data, two classes of subjects were selected. One group was to be treated only in the clinic by the prescribed procedures. The other, in addition to the clinic treatment, was to undergo a detailed pretreat ment evaluation and a similar post treatment procedure.</p> <p>At the screening interview, the purposes and general procedures of the program were explained to the prospective participant, and information of an administrative and medical nature was collected. The common vital statistics dealing with age, height, weight, and marital and occupational status were recorded. In addition, the date, cause, and site of amputation were obtained, and the length, range of motion, shape, and condition of the stump were described. Detailed descriptions were compiled of prostheses worn by candidates, and their quality and the subjects' ability to use them were evaluated. The data contributed by each amputee were recorded on forms developed for this purpose (Appendices IA and IB).</p> <p>The selection of amputees to be processed at the first and subsequent prescription meetings was made at the Prosthetic Devices Study on the bases of available information and the sampling requirements of the study. Factors taken into account in the selection of the subjects included type of amputation, general health and physical condition of stump, and motivation of patient (his interest and willingness to participate). The entire census included 1630 male upper extremity amputees, of whom 826 were below elbow cases, 668 had amputations above the elbow, 89 had disarticulations at the shoulder, and 47 were bilateral amputees of all types. The findings arising from these survey studies are described in the article by Berger.</p> <h4>Clinical Studies</h4> <p>The idea of the clinic team was the key concept of the newly developed management procedures. The clinic was viewed as a means and a method for focusing the special skills of all the necessary medical and ancillary specialists on the specific problems of providing the amputee with the best possible replacement for the lost member. The primary service group consisted of physicians and surgeons, therapists, and prosthetists. Other specialists, such as administrative personnel, vocational rehabilitation counselors, social service workers, or psychologists, were added according to the special needs of individual cases. The fundamental nature of the clinic was emphasized by the requirement that each of the basic members be present before an "official" meeting of the clinic could be opened. It was at these clinic meetings that the treatment concepts to be evaluated were applied. There were six basic steps in the clinic procedure prescription, preprosthetic treatment, fabrication of the prosthesis, initial checkout, training, and final checkout. Of these, three prescription, initial checkout, and final checkout required meetings of the full clinic team.</p> <h5><i>Prescription</i></h5> <p>Prescription, during these studies, called for the selection of specific components from an armamentarium of tentatively approved devices for assembly into an individual prescribed prosthesis. Most of these components were designed for specific types of cases or uses and were to be prescribed in accordance with their design purposes. The final prescription was to be the concensus of the clinic members as to the most applicable components in each case. In practice, however, the medical, surgical, and physical therapy needs of each patient were considered, as were also personal and vocational indications for specific components and materials. Required was a written prescription specifying every component to be used, and all deviations from standard applications were avoided unless expressly written into the prescription. To standardize the type and quality of the information collected at these meetings, the prescription form in Appendix IIA was developed. This procedure not only was the first treatment step but it also permitted the collection of research data describing the specific devices fitted to the subjects. On the basis of subsequent acceptability and utility to the amputees, inferences could be drawn as to the worth of these components.</p> <h5><i>Preprosthetic Treatment</i></h5> <p>As part of the prescription process, the patient was examined for conditions which might produce difficulty in wearing or using an artificial arm. Particular efforts were made to institute treatment prior to fitting a limb and thereby to avoid the influence of these factors upon the acceptance and use of the prosthesis. Medical and surgical problems involving disease, infection, inflammation, redundancies, bone overgrowth, neuromata, and plastic alterations were referred to the physician for treatment. Muscular weakness and limitations in joint mobility considered amenable to treatment were referred to the therapist.</p> <h5><i>Fabrication of the Prosthesis</i></h5> <p>When the prescription was completed, instructions were given to one of the attending prosthetists to fabricate the arm. With strict adherence to the details of the prescription, the limbmaker produced the arm by use of the techniques of fitting taught by the program. He was encouraged to inspect the completed arm by means of a checklist embodying the structural, functional, and cosmetic standard that his product would have to meet at the next clinic meeting.</p> <h5><i>Initial Checkout</i></h5> <p>When the arm had been fabricated, it was brought to the clinic prior to being worn by the subject. At this clinic meeting, called "initial checkout," the standards developed in the program were applied. The initial checkout included an objective and subjective appraisal to see that the device fulfilled the prescription requirements and that it met established standards of fit, comfort, function, and appearance (<b>Fig. 6</b>). The information thus obtained described the ranges of motion available with the arm, the forces required to operate it, and stability, fit, comfort, and weight. In addition, some 30 items dealing with details of fabrication, appearance, color, specific components, and general quality were checked. These standards were considered to represent minimal levels of prosthetic adequacy. All the appropriate measurements and checks were recorded on a form similar to that shown in Appendix IIB.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. A typical clinic meeting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These data were used to control the quality of the arms in order to permit valid generalizations about their worth. In addition, when compared with the outcomes of the treatment procedure, these data provided the basis for evaluation of the standards themselves.</p> <p>The checkout was performed at a regular meeting of all members of the clinic. If the arm failed checkout, it was referred to the prosthetist for appropriate revisions (<b>Fig. 7</b>). Consequently, it was sometimes necessary for the subject to appear at the clinic more than the minimum of three times. If the prosthesis met all the requirements, the amputee was permitted to wear the arm regularly and was scheduled for training by the therapist, the next step in the clinic procedure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Checkout. Final harness adjustments are made on a new arm prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Training</i></h5> <p>The training given to each subject by the therapist was organized in two parts controls training and use training.</p> <p><i>Controls Training.</i> In the preliminary step, the objective was to familiarize the amputee with the mechanics of his appliance and to develop his ability to control its movements.</p> <p>First he was taught to operate the arm freely so as to learn by kinesthetic reaction the motions and forces required to control it. Then various objects with abstract forms and of varying consistencies were introduced t develop prehension skill. When, in the opinion of both therapist and amputee, these control motions were adequately developed, the next training phase began.</p> <p><i>Use Training.</i> Once the basic operating techniques were learned, they were applied to performing the practical activities of daily living, including self help, home tasks, and vocational and social activities (<b>Fig. 8</b>). The training objectives were now to give the amputee confidence in his ability to use the arm by exploring a variety of activities and to achieve proficiency in performing them. In this connection, it was necessary to recognize that the prosthesis cannot replace the lost member and that at best it becomes an auxiliary of the remaining arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Use training. The therapist explains how to approach, grasp, and manipulate a variety of common objects. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By application of this fairly standardized sequence of activities, it was possible to collect research information relating to achievement levels and to the number of hours of training required to achieve satisfactory performance. When the amputee seemed capable of satisfactory performance with his prosthesis, the therapist arranged for him to reappear at the clinic for a final checkout.</p> <h5><i>Final Checkout</i></h5> <p>The final checkout concluded the process of providing the amputee with an arm. In a fashion similar to the pretraining initial checkout, it was conducted at a regular meeting of the clinic, all members present. The purpose at this time was threefold to recheck the mechanical and functional adequacy of the arm after use in training, to assure the clinic that satisfactory proficiency levels had been attained, and to be sure that nothing further in the way of service could be offered the patient if the first two conditions were met.</p> <p>The objective and subjective appraisal was again accomplished by means of the standardized checkout procedure (Appendix IIB). The arm was carefully inspected for signs of wear, and evidence was presented that the amputee was adequately trained. If the condition of the arm and proficiency of the subject in its use were deemed satisfactory, he was discharged with instructions to use the arm in accordance with his daily needs.</p> <h5><i>Recapitulation</i></h5> <p>Altogether, the group treated in the clinics included 378 below elbow, 321 above elbow, 46 shoulder disarticulation, and 24 bilateral amputees. Of the total of 769, 410 received no further treatment, while 359 were extensively studied prior to and after completion of the treatment procedures.</p> <p>The complete procedures employed in these studies are rather too complex for convenient presentation here in more than outline form. The full description and explanation of the most recent modification of these procedures is the subject of short term courses of instruction currently being offered at the University of California at Los Angeles and at New York University. The manuals used in these courses<a></a> contain detailed descriptions of the procedures and may be referred to for further information.</p> <p>The results of these clinic studies are presented in the article by Springer.</p> <h4>Evaluation Studies</h4> <p>The prosthesis for an upper extremity amputee is a necessarily limited means of providing those motions lost through amputation prehension, pronation supination, wrist flexion extension, and, in the case of the above elbow amputee, the additional function of flexion extension of the forearm. The chief goals of the evaluation procedures were to determine the extent to which a prosthesis provided functional as well as cosmetic replacement. A corollary purpose was to discover additional parameters of prosthetic utility and acceptability by increasing our knowledge of why an amputee accepts and uses more readily and efficiently one prosthesis in preference to another.</p> <p>The extent to which prosthetic restoration is successful is dependent upon what each subject brings to the appliance in terms of physical and mental characteristics and on what the appliance brings to him in terms of functional capabilities and qualities of comfort and cos mesis. Evaluation procedures were, therefore, aimed at the analysis and understanding of both the human and the mechanical variables that are involved in the successful use of an arm prosthesis. Although the potential significance of the pre injury personality was recognized, it was not investigated because of the difficulty of obtaining such information in a field study of this nature.</p> <p>Some of the significant evaluation factors lent themselves to objective measurement; others, of a more personal and subjective nature, could be obtained only from the amputee himself. For this reason, the evaluation procedures and instruments were designed to collect both objective measurements and more subjective data dealing with the reactions and responses of the amputee.</p> <p>In this connection, the measurement rationale underlying the collection of data should be understood. Quantitative data are convenient for systematic analysis. But quantification can be meaningful only within well developed and clearly defined evaluation areas. The appraisal, for example, of certain functional characteristics of an arm lends itself readily to objective or quantitative measurement, since the problem area is defined by the extent to which the prosthesis replaces certain lost motions. The problem here is clear; the ranges of motion and the forces applied can actually be measured. In much the same way, an evaluation of performance may be made by scoring such objective aspects as speed, errors, and even some types of quality. On the other hand, in dealing with those effects of treatment procedures relating to feelings, attitudes, emotions, comfort, and fit, the parameters to be measured are not at all clear. For this reason, in such obscurely defined areas qualitative data deriving from interviews and from both structured and unstructured responses of the subject tend to be more valuable in outlining and clarifying the areas of study. Once this is done, the particular factors may become amenable to quantitative measurement.</p> <p>Actually, only three possible sources of data were available objective measurements describing events, the expert opinions and judg ments of qualified observers, and the reactions of the subjects. Each of these sources was exploited. Specific mechanical and biomechani cal factors were measured by objective methods. Prosthetic quality and proficiency in performance with an arm were appraised by trained observers whose reliability was periodically checked and re established. Finally, the amputee himself provided information relating to his reactions to the arm, its quality, and its usefulness to him. Within two broa categories, the human and the mechanical, the following were studied:</p> <h5><i>Biomechanical Data</i></h5> <ol> <li>The strength and ranges of motion of the arm and shoulder girdle and the general physical condition of the amputee.</li><li>The ranges of motion permitted by the prosthesis, its efficiency, and the forces required to operate it.</li></ol> <h5><i>Performance Pattern</i></h5> <ol> <li>Proficiency in accomplishing the basic activities of prehension, transportation, and release in various planes and at different levels.</li><li>Quality of performance of practical daily life activities.</li><li>The range of activities in which prostheses are used and the extent of their importance.</li></ol> <h5><i>Amputee Reactions</i></h5> <ol> <li>Importance and extent of use of prostheses in daily living.</li><li>Reactions to treatment procedures.</li><li>Appraisal of prostheses and components.</li></ol> <h5><i>Psychological Reactions</i></h5> <ol> <li>Personal meanings of amputation and prosthetic restitution.</li><li>Social consequences of loss of limb and of prosthetic replacement.</li></ol> <h5><i>Biomechanical Data</i></h5> <p>It is reasonable to assume that an upper extremity prosthesis which affords the amputee a greater range of motion and which requires a minimal amount of energy or force for operation will be a more desirable appliance. While much more information is necessary before final judgment can be made, comparative data on these factors formed one of the bases for the evaluation of arm prostheses. This kind of data was obtained through direct measurement using such instruments as rulers, spring scales, and goniometers. They were used to measure pinch force between hook or hand fingers; efficiency of force transmission through the cable system; ranges of pronation, supination, and forearm flexion; socket displacement under axial load; and weight of the prosthesis. In the case of the above elbow amputee, additional information was collected on force input required to flex the forearm, angular deflection of the humerus needed to produce given ranges of forearm flexion, and ranges of motion at the shoulder. These measures were recorded on th instrument shown in Appendix IIIA. The outcome of these evaluations will be presented in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h5><i>Performance Patterns</i></h5> <p>The performance of the subjects in standardized, specially designed activities was observed and analyzed. This procedure was employed to provide information concerning the effectiveness and appearance of the performance patterns. Two approaches to the evaluation of performance were taken. Both abstract and practical function were evaluated. In the former, the ability accurately to grasp, transport, and release objects of varying sizes, shapes, weights, and consistencies was graded (<b>Fig. 9</b>). In the evaluation of practical function, amputees were graded on their performance of meaningful daily life activities (<b>Fig. 10</b>). Proficiency scores and time and motion data were recorded on the forms appearing in Appendix IIIB, while activities were tabulated as shown in Appendix IIIC.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Evaluation of abstract function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Evaluation of practical function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Amputee Reactions</i></h5> <p><em>Analysis of Importance and Extent of Use of Prosthesis in Daily Living.</em> In an attempt to appraise the importance of the prosthesis to the amputee, and to determine some of the specific ways in which prostheses were used, the interview technique was utilized. The subjects were asked if they used their prostheses in specific activity areas, including work, home tasks, social life, dressing, and eating. If thei response was positive in any area, they were asked to specify the particular use they made of the arm. They also were asked to rate the importance they placed on their prostheses in each of the activity areas.</p> <p>The extent to which a subject used his prosthesis to accomplish the tasks of daily life seemed to be a significant factor in appraising the degree of functional restoration afforded by the prosthesis. For this reason information was gathered about the frequency with which the prosthesis was used in ordinary two handed activities. In order to make this more meaningful, additional information was collected concerning the frequency with which each activity was encountered in the course of the daily life of the particular amputee. Additional information about common activities which were not done and the reasons therefor also was gathered.</p> <p>The following key questions were used:</p> <ol> <li>How often does the occasion arise for the amputee to perform each of a number of typical two handed activities?</li><li>How often does the amputee use his prosthesis in performing each activity?</li><li>If the need for an activity arises more often than the prosthesis is used in accomplishing the task, why does the amputee not use his prosthesis?</li><li>What is the relative importance of each of a number of activities?</li></ol> <p>These evaluations were made by means of the instrument shown in Appendix IIIC. The results of this study will appear in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <p><em>Reactions to Amputation and Prosthetic Experience.</em> The subjective reaction of an amputee to his prosthesis was deemed an important factor in its evaluation. Apart from his feelings about the characteristics of the prosthesis, his experiences in securing it and wearing it are also contributing factors in his acceptance or rejection of the arm, and information in this regard may be important to an understanding of his status. This type of information was obtained through the use of interviews and questionnaires. By these means, data were gathered relating to:</p> <ol> <li>Time lapse between amputation and first prosthesis.</li><li>Preprosthetic physical therapy.</li><li>Procedures in prosthetic prescription.</li><li>Services of prosthetist.</li><li>Procedures in initial checkout of prosthesis.</li><li>Training in the use of the prosthesis.</li></ol> <p>The article by Springer describes the findings of this study.</p> <p><em>Amputees' Appraisal of Prosthesis and Components.</em> An evaluation of the prescribed components was an essential aspect of the studies. An armamentarium had been developed, and components had been prescribed on the basis of their design features. In order to appraise the relative value of these components, the amputees were asked to comment on specific characteristics of all the components of their prostheses and to describe the suitability or inconvenience of any device with which they were familiar. The following information was elicited:</p> <ol> <li>The extent of his acquaintance with prosthetic components.</li><li>His appraisal of certain specific characteristics of each device with which he was familiar.</li><li>His expression of the suitability of prosthetic components for activities.</li><li>A comparison of currently and previously worn prostheses.</li></ol> <p>These opinions and experiences were recorded as shown in Appendix HID. The results and significance of this study will appear in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h5><i>Psychological Reactions</i></h5> <p>It is frequently observed that some amputees fail to wear or use a prosthesis which seems to be well fitted and functional. Others, with properly prescribed and well fitted arms, and even those with inadequate prostheses, accept and use them extensively. These reactions were attributed to the varying, highly personal meanings of amputation and prosthetic restoration. For this reason, a psychological analysis by means of interviews and questionnaires was undertaken to explore the significance of these factors.</p> <p>The instruments used included a 57 item multiple choice questionnaire (Appendix HIE) developed by the Prosthetic Devices Study. Completed by the subject in the presence of an NYU representative, it was designed to provide information about the feelings and behavior of amputees relative to amputation and prosthetic restoration. The following reactions were elicited: feelings of functional adequacy, acceptance of loss, sensitivity about disability, ability to cope with social situations, feelings of independence, and attitudes toward prostheses.</p> <p>Another questionnaire (Appendix IIIF) contained nine open end questions. This provided an opportunity for the subject to express his feelings about the effects of his condition and treatment upon his personality and social activities. It supplemented the more highly structured 57 item questionnaire (Appendix IIIE).</p> <p>The third instrument (Appendix IIIG) was a novel (experimental) application of a projective device. It consisted of nine cartoons depicting common social situations in which the fact of amputation might lead to awkwardness or embarrassment. It permitted the amputee to select one of a number of possible responses to each potentially embarrassing situation. By his reaction, the patient was expected to express his feelings of independence, the degree to which he faced reality, hi acceptance of the amputation, and his sense of security. Each response represented a gradation of possible reactions to each situation.</p> <p>A fourth questionnaire (Appendix IIIH) was employed specifically to elicit information from subjects who had never previously worn prostheses. It consisted of 15 multiple choice questions relating to the amputee's knowledge of prosthetic components and his expectations regarding the functional, cosmetic, and comfort qualities of artificial arms. A series of open end questions was included to determine opinions of prosthetic usefulness and difficulties of prosthetic wear.</p> <p>Upon execution of these procedures, the evaluation of an amputee was complete, but the entire process was performed twice. The first appraisal, conducted by the NYU representative prior to the prescription meeting, provided a detailed description of the pre treatment condition of the patient with respect to his physical condition, functional capacity, experience as an amputee, quality and usefulness of his prosthesis, and his emotional reaction to disability. Approximately three months after a satisfactory final checkout, or six to nine months after fitting, the previously evaluated subjects were again processed for a post treatment evaluation, the procedures followed being essentially the same as in the pretreatment evaluation. The instruments used are given in Appendices IIIE, IIIF, IIIG, and IIIH.</p> <p>These data are analyzed and discussed in an article to appear in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h3>Summary</h3> <p>Some of the problems involved in prosthetic service to amputees just after World War II, and the steps taken by governmental and private organizations toward their solution, have been described in this section. The development of the Artificial Limb Program has been traced briefly from its inception throug the initial studies in which problems were isolated and new methods and materials to solve them were developed. The dissemination of new knowledge through the organization of a prosthetics education program has been discussed, and the design and scope of the studies undertaken to evaluate the new developments have been described. "Survey Studies" were carried out to increase the available knowledge about amputees in this country. "Clinical Studies" were pursued to evaluate the effect of the newly developed treatment methods. And "Evaluation Studies" of the changes in amputees' conditions brought about by these treatments were planned and executed.</p> <p>The evaluation instruments and techniques have been described briefly in this section in the interest of presenting a clear overview of the whole process. A total of 359 amputees were studied by means of these procedures. This group contained 168 below elbow, 158 above elbow, 23 shoulder disarticulation, and 10 bilateral amputees.</p> <p>The upper extremity field studies represented a pioneering effort to apply special skills to special problems in a broad, only partially understood field. A multiplicity of interests, unique requirements, and a paucity of previous research combined to broaden the scope of the studies. The methods and instruments employed are considered a first step toward the establishment of more precise and valid methods for evaluating the condition of those with physical impairment. But despite the broadness of the field and the research requirements, service to the amputee was always a paramount consideration.</p> <p><b>References:</b></p> <ol> <li> Universeity of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prsthetics</i>, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </li> <li>New York University, Prosthetics Education Project, Post-Graduate Medical School, Prosthetic clinic procedures, 1956. Chapter I.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Universeity of California (Los Angeles), Department of Engineering, Manual of upper extremity prsthetics, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">New York University, Prosthetics Education Project, Post-Graduate Medical School, Prosthetic clinic procedures, 1956. Chapter I.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Universeity of California (Los Angeles), Department of Engineering, Manual of upper extremity prsthetics, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., W. R. Santschi and Marian P. Winston, eds., in press 1958. A preprint was used.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper Extremity Amputee. I. Design and Scope. Creator An entity primarily responsible for making the resource Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/3ed6e858fb0862d7d2be1b23db392979.pdf 341e77544bf40d3db543a912bb5f0a44 https://staging.drfop.org/files/original/5bc396e4cedef13cf16a253eff163040.jpg ec592855cdba2557e088f78921c41388 https://staging.drfop.org/files/original/fdb6f406a2d352fb47a3cee9e8f38369.jpg 231b76d1408171ad64fae7742ecb2080 https://staging.drfop.org/files/original/7c0842c290468ef1fba4f4843d047f6e.jpg f826d6e153080c737808def1263cdd8b https://staging.drfop.org/files/original/e8a75b8ff67cee7bfa961096b4546fc2.jpg 1b87a973e8f3e3194184030a5e733712 https://staging.drfop.org/files/original/e9b74a814d560aa381bdccc572202d18.jpg 7e4403cff18523ddfb3120463a4be570 https://staging.drfop.org/files/original/ef75d0139e58c59e14d6dd35acdb17a2.jpg 70501d19f818f8d17d3b4ab798b5c8e3 https://staging.drfop.org/files/original/db9be3d7b4042ee252c02a83e44410f6.jpg 811f62d0d758421359d9516a636cc7f9 https://staging.drfop.org/files/original/9d40c9562a0fa9212368f1e2168e0414.jpg 2a71a8f8ae7d5478f89c2d59c2fd982b https://staging.drfop.org/files/original/79520afc4856b97de75b65ceca55ed6d.jpg c56d209e3cc0b131ddf0552ec40728ef https://staging.drfop.org/files/original/11938c318c7cf07237c990a66332d5e6.jpg e3023baa4d85b0b47a1f48737de7838c https://staging.drfop.org/files/original/b7f3d4881f3418405d87e322dad4c534.jpg 2d3c7a9b149b79c2b05043f12da68c06 https://staging.drfop.org/files/original/7f2f89a25a05551ade1e71a258885300.jpg 1c7361b6419e0d308961d5e58f72b6a2 https://staging.drfop.org/files/original/d8559825156298574f27b394d24be4e6.jpg 9c4e998131de15aafcc55e58721cf377 https://staging.drfop.org/files/original/251a6125624f21d3c3f26d9da96c3938.jpg 13d793d6f5c11a23a6232ac42f78aec2 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_073.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 73 - 87 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_01_073.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_073.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee III. The Treatment Process</h2> <h5>Warren P. Springer, M.A. <br /></h5> <p>The amputees who took part in the NYU Upper-Extremity Field Studies obtained their new prostheses through a treatment process characterized by seven clear-cut steps. These were preprescription examination, prescription, preprosthetic therapy (if indicated), fabrication of the prosthesis, initial checkout, training, and final checkout.</p> <p>The preprescription examination was conducted at the beginning of the treatment process in order to obtain information that would be useful in formulating the prescription and planning the entire treatment program for the patient.</p> <p>As for prescription, the research and educational program strongly encouraged the clinic-team approach, wherein the physician, as clinic chief, involved the prosthetist, the therapist, the patient, and frequently other individuals, such as the social worker or the vocational counselor, in the prescription process. The resulting prescription not only covered the strictly medicosurgical aspects of management but also specified the type of prosthesis and components that were to be used and the training the patient was to receive.</p> <p>The preprosthetic phase of treatment, when indicated, was directed toward providing the patient with the necessary strength and range of motion to operate his prosthesis and toward conditioning his stump for wearing it.</p> <p>In the fabrication process, the prosthetist, working with the patient, carried out the construction and fitting of the prosthesis in accordance with the specifications of the prescription.</p> <p>Initial checkout, which was done on a team basis, consisted of a systematic inspection and evaluation of the prosthesis to ensure that accepted standards of construction and function were achieved. This step was accomplished before the amputee received training and before he was permitted to wear his prosthesis for any extended period.</p> <p>Training consisted essentially of two parts—controls training and use training. The purpose of controls training was to develop the ability to open and close the terminal device, control prehension force, operate the wrist unit, interchange terminal devices, and, in the above-elbow cases, flex the prosthetic elbow and operate the elbow lock. Use training was designed to develop the ability to utilize the prosthesis in practical tasks related to daily-living activities and to occupational requirements.</p> <p>Final checkout was performed after the completion of training or after an initial period of wear. It paralleled initial checkout in that many biomechanical evaluation procedures were repeated to determine if wear had given rise to any difficulties or deficiencies. But in addition to the evaluation of the prosthesis itself final checkout also included an evaluation of training and of the amputee's ability to use the prosthesis at a practical level.</p> <p>This paper is primarily an account of the experiences and opinions pertaining to the treatment process as obtained from interviews with 359 adult, male amputees both at the beginning and at the end of their participation in the studies. The information concerning checkout and training is supplemented by clinical data from records of an additional 410 amputees who participated in clinical aspects of the study.</p> <p>The general characteristics of the research group of 359 amputees closely parallel those of the 1630 amputees in the survey group (Section II). Between the two groups there were no significant differences with respect to age, height, weight, marital status, cause of amputation, or strength and range of motion on the side of the amputation, although there were slight differences in educational level, in experience with arm prostheses, and in the relative frequency of below- and above-elbow types.</p> <p>In interpreting the data in this section, certain considerations should be kept in mind. First of all, a considerable portion of the information is based on the amputees' recollections of past events. The differences that may exist between the recollection of events and the events as they actually happened constitute a possible source of error. A second consideration has to do with the amputees' interpretations of the questions asked during the interviews, especially at the beginning of the study. Terms such as "clinic," "prescription," "checkout," "physical therapy," and "training" may have had widely varying meanings for different subjects. For example, a subject might have said that the prosthesis he was wearing at the beginning of the study had been subjected to a checkout when in reality it had been given only a cursory inspection instead of the systematic examination and evaluation that constituted a "checkout" in our meaning of the term.</p> <p>A third factor has to do with the number of amputees who were able to give meaningful responses to these questions. In some instances and for various reasons usable responses were not obtained from the entire group. In some cases questions were not answered. In most instances, however, classifiable responses were obtained from at least 80 percent of the group, and it seems reasonable that these responses are representative of the attitudes of the entire group.</p> <p>On the positive side, there is good reason to assign a considerable degree of importance to the opinions and reactions expressed by the subjects, since, in the last analysis, the amputee is the final judge of his prosthesis. The extent to which he accepts and approves of the process through which he obtains his prosthesis may have considerable bearing on the extent to which he accepts and uses the device.</p> <h3>Prescription</h3> <p>Prior to their participation in the research studies, only 17 percent of the amputees had ever received an arm that was prescribed by a clinic team (physician, limbfitter, and therapist). In the great majority of cases, decisions as to the type of limb and components had been made either on an individual basis by the limbfitter or the amputee or jointly by both limbfitter and amputee. Fifty-six percent of the amputees approved of this procedure, the most frequent reason (21 percent) given for approval being that they were consulted concerning their choice.</p> <p>In the group (44 percent) that did not approve of the preprogram procedure through which they had received a limb, 14 percent reacted negatively to the fact that they were not consulted. It was somewhat surprising to find that an additional 18 percent expressed the opinion that the amputee should not be consulted. Of the total group, 12 percent felt that the doctor should prescribe the prosthesis. Apparently a significant number of amputees prefer to trust the judgment of others in the matter of prosthetic replacement. Others (and the number probably increases with their prosthetic experience) prefer to become personally involved in the selection of components best suited to their needs.</p> <p>Since all of the prescriptions for the new prostheses and related treatments were arrived at on a clinic-team basis, the amputees were asked the following question to obtain their reactions to the team method of prescription: Do you think that prescription of a new arm by a clinic consisting of a doctor, limbfitter, and therapist is a good procedure? Ninety-four percent of the amputees answered in the affirmative. Compared to the mixed reactions concerning the preprogram procedures, the figure of 94 percent clearly indicates that the amputees preferred the new procedure. By far the most frequent reason given for this response was that the combined experience which could be obtained through the clinic procedure was useful. Typical comments were:</p> <blockquote><p>". . . more heads are better than one."</p> </blockquote> <blockquote><p>". . . experience of several people is helpful."</p> </blockquote> <blockquote><p>". . . no aspect is overlooked."</p> </blockquote> <p>Other reasons that were mentioned relatively frequently can be classified under these headings:</p> <blockquote><p>". . . prevents errors."</p> </blockquote> <blockquote><p>". . . team members act as a check on each other."</p> </blockquote> <blockquote><p>". . . amputee becomes involved in the prescription."</p> </blockquote> <p>Among the 6 percent who did not approve of the procedure, the most common reason offered was that:</p> <blockquote><p>"An old wearer knows what he needs."</p> </blockquote> <p>To obtain information on the parts the various clinic members played in prescription, the amputees were asked: Who was most influential in deciding the kind of arm you should havef The replies are summarized in the accompanying chart.</p> <h4>Terminal Devices</h4> <p>The next two charts show the relative frequency with which the various types of terminal devices were prescribed in the research study. For purposes of comparison, data on the hands and hooks that were being worn at the beginning of the study are included under the heading "Old Prosthesis."</p> <p>In interpreting the prescription data on hands and hooks, consideration should be given to the fact that it was a policy of the research program to encourage the prescription of APRL hands and hooks in order to obtain additional data for evaluation of these devices. This accounts for part, but by no means all, of the changes in terminal components of the old and the new prostheses. Other factors involved in the changes were related to an increasing tendency on the part of clinic groups to prescribe aluminum hooks and hooks with rubber or neoprene facings and to a natural interest in the possibilities of voluntary-closing terminal devices with their wide range of grasp forces. In the case of the APRL hand, the wide range of grasp forces was combined with improved appearance. This natural curiosity and interest in new devices is reflected in the increased use of the Sierra two-load hook also.</p> <h4>Wrist Units</h4> <p>The new prostheses showed a marked increase in the prescription of positive-locking wrist units with the "quick-change" disconnect. The chief reasons for this increase related to:</p> <ol> <li>Specific vocational or avocational indications for a positive lock to control rotation.</li><li>Prescription of both hand and hook for approximately four out of five subjects. A substantial majority of these cases required a wrist unit with a "quick-change" feature to facilitate interchange of hand and hook. (<b>Fig. 1</b>)</li></ol> <h4>Wrist-Flexion Units</h4> <p>There were only two wrist-flexion units on the old prostheses. Both cases were bilateral amputees. Twenty-two wrist-flexion units were prescribed in the research group. Ten were for bilateral amputees; six were for above-elbow, four for shoulder-disarticulation, and two for below-elbow amputees. (<b>Fig. 2</b>, <b>Fig. 3</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Below-elbow Hinges</h4> <p>A marked increase in the number of flexible hinges prescribed reflects the increased awareness of the value of utilizing residual rotation of the forearm stump whenever possible so that the need for pre-positioning the terminal device with the sound hand can be reduced or eliminated entirely. An additional advantage of flexible hinges is that they are less likely to damage the sleeves of the wearer's clothes.</p> <h4>Below-elbow Cuffs</h4> <p>Prescription for below-elbow cuffs showed a marked change toward smaller cuffs and elimination of straps. This change is a result of increased recognition of the desirability of providing a cuff large enough to give adequate stability and suspension but which would also have minimum bulk, would restrict motion as little as possible, and would give greater comfort.</p> <h4>Elbow Units</h4> <p>A guiding principle in the prescription of prosthetic elbow units for above-elbow and shoulder-disarticulation prostheses was that locking should be accomplished independently by controls attached to the harness, without recourse to operation of controls by the sound hand. The extent to which this principle was applied can be seen from the data, which show that all elbow units prescribed were harness-operated. This is a highly significant change from the data relating to the old prosthesis, which show that only 46 percent of the old elbow units were harness-operated.</p> <h4>Sockets</h4> <p>Practically all of the prescriptions for the new prostheses specified plastic laminate as the material to be used in fabricating the socket. The data on the socket material used in the old prostheses show that 37 percent were made of plastic, 28 percent were made of leather with a steel frame, and the remainder were made of fiber and metal, wood, or leather. Approximately four out of five of the new prostheses had double-wall sockets, as compared to less than one out of five of the old prostheses. Twelve percent of the old and 14 percent of the new below-elbow sockets were of the split-socket, step-up type in both the old and the new prostheses. (<b>Fig. 4</b>, <b>Fig. 5</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harnesses</h4> <p>The data on harnesses show a highly significant increase in the number of figure-eight harnesses prescribed for below-elbow and above-elbow cases with the new prostheses as compared with the old. The reasons for this increase are related to the favorable attitude of the program toward this simple type of harnessing, except for cases wherein heavy lifting was expected. Practically all of the shoulder-disarticulation amputees had chest-strap harnesses on both the old and the new prostheses.</p> <p>Vinyon tape was specified in 96 percent of the prescriptions for new prostheses, and cotton webbing or nylon or dacron tape were prescribed in the remaining 4 percent. (<b>Fig. 6</b>, <b>Fig. 7</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the old prostheses, 83 percent of the harnesses were made of cotton webbing, 8 percent were of leather, and the remaining 9 percent were made of vinyon or nylon tape. The marked shift to the use of vinyon tape was due primarily to the presumably superior characteristics attributed to vinyon with respect to dimensional stability, washability, fraying, and resistance to bacteria and fungi.</p> <h4>Control Systems</h4> <p>All of the prescriptions for new prostheses called for the use of the Bowden cable in the control system. In the old prostheses, 58 percent utilized Bowden cable; the remainder utilized nylon cord, leather, or steel cable without a housing. The change to Bowden cable was effected to take advantage of its higher efficiency in transmitting forces.</p> <h3>Preprosthetic Therapy</h3> <p>Four out of ten subjects said they had received treatment by some form of exercise or other physical therapy prior to their entrance into the study. The same proportion of the group indicated that their stumps had been bandaged to bring about shrinkage.</p> <p>In response to the question, Do you think these [preprosthetic] treatments were helpful?, 79 percent replied in the affirmative and offered the following reasons (in order of decreasing frequency): increased strength, increased range of motion, helped stump shrinkage, reduced pain, improved function, reduced flabbiness.</p> <p>During the course of the research studies, preprosthetic exercise or other physical therapy was prescribed for 13 percent of the amputees treated. That only a relatively small proportion of the subjects received preprosthetic treatment is accounted for by the fact that most of the amputations occurred quite some time before the amputees participated in the program. In most cases, treatment consisted primarily of exercise to increase strength and range of motion of the stump. Other physical-therapy measures, such as diathermy, massage, and hydrotherapy, accounted for a relatively small proportion of treatments. Almost all of the subjects indicated that treatment was received daily. (<b>Fig. 8</b>, <b>Fig. 9</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Seven percent of the amputees had their stumps bandaged to cause shrinkage. About two thirds of this small group indicated that bandaging had been continued over a period of 4 to 12 weeks; the remainder of the group said that bandaging had been continued for more than 12 weeks.</p> <p>Of those who did receive preprosthetic treatment, 88 percent considered the treatments helpful. The reason given most frequently was that the treatments increased strength and range of motion. About one out of five subjects mentioned stump shrinkage as the chief beneficial effect.</p> <h3>Initial Checkout</h3> <p>With reference to arms worn prior to entrance into the program, the subjects were asked: Was your arm checked for fit, comfort, and function before it was delivered to youf Four out of five indicated that their prostheses had been subjected to some form of initial checkout or evaluation, even though this was not done on a formal basis. One third of this group said that the limbfitter had made the check. Thirteen percent designated the physician as having made the check, and 9 percent said the check was made at the hospital. The others did not provide specific information as to who performed the checkout or evaluation.</p> <p>A basic principle guiding operations in the Field Studies was that the amputee would not be permitted to wear his new prosthesis or proceed to training until initial checkout had been passed successfully. If deficiencies were encountered that would interfere with wear or training, recommendations for correction were made, and the amputee was scheduled to appear again so that initial checkout could be completed.</p> <p>Several factors serve to explain why a relatively large proportion of amputees had to appear before the clinic two or more times in order to pass initial checkout. One is that the checkout procedure proved to be highly effective in directing attention to the necessary corrections and adjustments in individual components and to the prosthesis as a whole. A second related to the relatively high and rigid standards established by the checkout procedure. A period of time was generally required before the prosthetic experience necessary to meet these standards was gained. The relatively greater frequency with which above-elbow and shoul-der-disarticulation amputees failed to pass initial checkout on the first appearance, as compared to below-elbow amputees, was for the most part due to difficulties in harnessing. In addition, the relatively small number of shoulder disarticulations seen meant that it took correspondingly longer to obtain substantial experience in their fitting and harnessing. (<b>Fig. 10</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While a majority of prostheses passed initial checkout on the first presentation, this does not mean that no deficiencies were found at initial checkout in these cases. More often than not, a number of minor deficiencies were found, which resulted in a "provisional pass" rather than a "pass." When a provisional pass was given, recommendations were made for correction of the minor deficiencies found. When the amputee reported for his first training period, a check was made to see that the recommended changes had been effected.</p> <p>Among the below-elbow subjects, the most frequent deficiencies found at initial checkout were in connection with sockets. With above-elbow amputees, the deficiencies found most frequently were in connection with harnessing. The fewest deficiencies were encountered with wrist units. The charts show the order in which the various components ranked according to the number of deficiencies found.</p> <p>The amputees taking part in the study were asked: Do you think it was worth while that the new arm was checked for fit, comfort, and function before it was delivered to you? Ninety-four percent of the replies were yes. The most common reasons given for these replies were:</p> <blockquote><p>". . . to correct and prevent problems."</p> </blockquote> <blockquote><p>". . . provides a check on fit."</p> </blockquote> <blockquote><p>". . . provides a check on comfort."</p> </blockquote> <blockquote><p>". . . provides a check on prescription."</p> </blockquote> <p>Some of the comments of those few who did not think it was a good procedure were:</p> <blockquote><p>". . . made no necessary changes to arm."</p> </blockquote> <p>". . . am intelligent enough to decide for myself if it is comfortable."</p> <blockquote><p>". . . could be checked out at limbshop."</p> </blockquote> <blockquote><p>". . . had to wear it first to see if anything was wrong."</p> </blockquote> <h3>Training</h3> <p>The data pertaining to previous training showed that 42 percent of the amputees had received prosthetic training sometime prior to the beginning of the study. Eighty-nine percent of this group expressed the opinion that this training was helpful. Three fourths of the amputees who received no previous training said they thought training would have been helpful, while the remaining fourth thought it would have been of no use.</p> <p>Data obtained from the clinical studies showed that 81 percent of the subjects received training, that 14 percent received no training, and that owing to incomplete records the training status was indefinite for the remaining 5 percent. Among the amputees who received no training, the most common reasons offered were: the amputee had worn a prosthesis before and previous training was considered adequate; the amputee passed the prosthetic-use test without training; the amputee declined training. (<b>Fig. 11</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In response to a query concerning the value of prosthetic training, four out of five amputees replied in the affirmative. Among the most frequent reasons given for the affirmative answer were:</p> <blockquote><p>". . . training gives an idea of what can be done with the prosthesis."</p> </blockquote> <blockquote><p>". . . learned mechanical operation of components."</p> </blockquote> <blockquote><p>". . . expedited use of arm."</p> </blockquote> <p>Of the group who did not believe that training was valuable, there were proportionately twice as many below-elbow as above-elbow amputees. They offered such comments as:</p> <blockquote><p>". . . using an arm is easy."</p> </blockquote> <blockquote><p>". . . training was not well organized."</p> </blockquote> <blockquote><p>". . . I would rather learn my own way."</p> </blockquote> <blockquote><p>". . . amputee was left on his own too much."</p> </blockquote> <blockquote><p>". . . training helped very little."</p> </blockquote> <blockquote><p>". . . training was not long enough "</p> </blockquote> <p>In response to the question, Do you believe the training you were given in the use of your new prosthesis could be improved?, 41 percent answered in the affirmative. About one fourth of those who answered in the affirmative expressed the opinion that there should be more training in activities of daily living. An equal number thought that more time was needed. Among the group that expressed the opinion that more time was needed there were more than three times as many above-elbow amputees as there were below-elbow amputees.</p> <p>Other suggestions for improvement of training were:</p> <blockquote><p>". . . there should be more enforced training."</p> </blockquote> <blockquote><p>". . . provide a training manual which would allow the amputee to practice at home."</p> </blockquote> <blockquote><p>". . . adapt training to occupational needs."</p> </blockquote> <blockquote><p>". . . there is not enough supervision of training."</p> </blockquote> <p>The total training time for an individual amputee ranged from half an hour to 99 hours, but more than nine out of every ten amputees received less than 20 hours of training. Except for bilateral amputees, more than eight out of every ten amputees received 10 hours or less of training. The average number of hours of training for each amputee type is based on the great majority of amputees (94 percent) who required less than 20 hours of training. Of the small remaining group of amputees (6 percent), one half received from 21 to 30 hours of training; the other half received from 30 to 99 hours. It must, however, be emphasized again that the larger part of this group had had previous prosthetic experience. (<b>Fig. 12</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The average length of individual training sessions for the amputees in the clinical studies was one hour and forty minutes. There was no significant difference in the figures for below-elbow, above-elbow, shoulder-disarticulation, and bilateral amputees. For almost 50 percent of the amputees, the length of the individual sessions was one hour.</p> <p>In reply to the question, Did any difficulties arise in connection with the operation or comfort of your new prosthesis during training or the initial period of use?, 54 percent of the amputees replied in the affirmative. Among the below-elbow subjects, the socket was the most frequent source of difficulties relating to fit and comfort, while among the above-elbow group the harness constituted the major source of trouble. With respect to function, operation of terminal devices and the control system were the most troublesome. The control system was the most common source of difficulty with respect to maintenance.</p> <h3>Final Checkout</h3> <p>Prior to participation in the Field Studies, less than 30 percent of the amputees had had their prostheses rechecked for fit, comfort, and function after the period of initial wear or training. In accordance with the procedures</p> <p>described in Section I, all prostheses in the Field Studies were subjected to final checkout after the completion of training or the initial period of wear. At this time not only was the prosthesis given a systematic and thorough inspection and evaluation but, in addition, an appraisal was made of the patient's ability to use the prosthesis, and a careful examination was made to see if there were any medical or surgical problems that might interfere with successful wear and use. Clinics considered that an amputee had "passed" final checkout only when there were no further surgical, medical, or prosthetic problems of any kind that required attention.</p> <p>Sixty percent of the prostheses passed final checkout on first presentation, 26 percent passed on second presentation, and 14 percent required more than two appearances to pass final checkout. This compares with 69 percent, 24 percent, and 7 percent, respectively, for initial checkout.</p> <p>The decrease in the number of prostheses that passed final checkout on first presentation, as compared with initial checkout, was due chiefly to the results of wear of the prosthesis, the emphasis on the amputee's ability to use the prosthesis, the apparent need for additional training, and the need for modifications which had been overlooked at the initial checkout or on which judgment had been withheld until the effect of wear could be determined. The actual number of deficiencies found at final checkout was, however, smaller by far than the number at initial checkout. Among the below-elbow amputees, the total number of deficiencies recorded at final checkout was only 339 as compared with 801 at initial checkout. The corresponding figures for above-elbow amputees were 358 at final checkout and 970 at initial checkout. These figures show clearly that the prostheses were far better at final checkout than they were at initial checkout, even though it took a little longer to get through the checkout procedure. (<b>Fig. 13</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As was the case at initial checkout, the difficulties found most frequently at final checkout were related to socket fit for the below-elbow amputee and to harnessing for the above-elbow amputee. The fewest difficulties were encountered in relation to wrist units. The order in which various components ranked according to the number of deficiencies found is to be seen in the combined data for initial and final checkout.</p> <p>The effects of wear and use were to be seen in the continued difficulties with fit and comfort of the below-elbow socket at final checkout and also in the relative increase in deficiencies encountered with terminal devices. The more common deficiencies in the latter case were related to malfunctions of hand or hook, staining of or damage to the cosmetic glove, and excessive backlash with voluntary-closing devices.</p> <p>At both checkouts, deficiencies of the elbow unit rank fairly high on the list. Analysis indicates, however, that most of these difficulties were not with the internal mechanism but rather with other factors such as adjustment of the harness and control attachments that activate the elbow lock.</p> <p>In response to the question, Do you think it was worth while that your arm was rechecked for fit, comfort, and function after training and initial period of wear?, 90 percent of the replies were in the affirmative. The most frequent reason for this reply was that the recheck permitted problems to be corrected. Typical comments were:</p> <blockquote><p>". . . gives an opportunity to correct problems after wear."</p> </blockquote> <blockquote><p>". . . experts can see difficulties better."</p> </blockquote> <blockquote><p>". . . it is important to find out if arm still functions properly."</p> </blockquote> <blockquote><p>". . . it provides a general check."</p> </blockquote> <h3>Summary</h3> <p>The amputees' experience in the field-studies program differed quite markedly from their previous prosthetic experience with respect to prescription and final checkout. Prior to their participation in the study, less than one out of five had ever had a prosthesis that was prescribed by a clinic team, and less than one third had had their previous prostheses subjected to a final comprehensive checkout. (<b>Fig. 14</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The differences with respect to preprosthetic treatment, initial checkout, and training were less marked. Relatively fewer amputees received preprosthetic treatment in connection with the new prostheses than was the case in connection with the prostheses that were being worn at the beginning of the study. This, of course, can be accounted for by the lessened need for these services with increased prosthetic wear.</p> <p>Although a substantial majority of the amputees said that their previous prostheses had been subjected to some form of initial checkout or evaluation, these had not been done on any formal or systematic basis and had in general not involved the application of standards of acceptance.</p> <p>Forty-two percent of the amputees who had worn a prosthesis prior to the beginning of the study had received training in its use, although the nature or extent of this training is not clear from the data. More than eight out of ten subjects received training with the prostheses obtained in the research program.</p> <p>Amputee opinion pertaining to the treatment process, as indicated by the data gathered, was for the most part strongly in favor of the new procedures. Ninety-four percent of the amputees approved of the team method of prescription. Eighty-eight percent of those who received preprosthetic treatment said the treatments were helpful. Ninety-four percent were of the opinion that initial checkout was worth while.</p> <p>Four out of five amputees were of the opinion that the training they received in the use of their prostheses was valuable. But 41 percent of the group thought that training could be improved. The most frequent suggestions for improvement were to increase the amount of training time and the amount of training in meaningful activities of daily living.</p> <p>The final checkout to which all of the prostheses in the research studies were subjected was particularly comprehensive and designed to uncover any medicosurgical, prosthetic, training, or other factors that might interfere with successful wear and use. Nine out of ten amputees were of the opinion that this procedure was worth while.</p> <p>All in all, the treatment process inaugurated as part of the studies was considered valuable and achieved a high degree of amputee acceptance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <br /> Figure 1 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-46.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-47.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-48.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-49.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-50.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-51.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-52.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-53.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-54.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-55.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-56.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-57.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-58.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-45.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee III. The Treatment Process Creator An entity primarily responsible for making the resource Warren P. Springer, M.A.  https://staging.drfop.org/files/original/6480fc01f37b5e97a22a6791c3a18bc9.pdf 8cadb11a4c01808e922c22cffe349ece DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_088.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 88 - 93 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_01_088.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_088.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee IV. Educative Implications</h2> <h5>Sidney Fishman, Ph.D. <br /></h5> <p>From the foregoing discussions, it will be apparent that one of the major purposes of the Upper-Extremity Field Studies was to introduce certain influences into the professional activities of the several groups (physicians, therapists, prosthetists) concerned with the care of the amputee and his reintegration into society. It was anticipated that changes in methods of patient care arising from these influences would in turn affect the welfare of the amputee group. In this sense, therefore, a major aspect of the Field Studies was the educative process involved in the attempt to change the operational patterns of those responsible for amputee care by strengthening the philosophies, attitudes, and skills which had been taught during the short-term courses of instruction. Continued encouragement, assistance, and guidance were required to habituate these groups to the procedures proposed during the instructional courses.</p> <p>The second phase of the Field Studies, the results of which will be discussed in the next issue of Artificial Limbs (Autumn 1958, Vol. 5, No. 2), is most properly considered a research activity. The purpose in this phase of the program was to attempt to evaluate the effects of these efforts on the over-all status of the amputee through the use of objective and subjective measurements. To accomplish this second phase, detailed studies were made of the status of the group of amputees prior to their treatment by the prosthetic clinic and again at a time after the completion of treatment.</p> <p>In approaching the task of estimating the effectiveness, or lack of effectiveness, of a two-pronged (research and education) program of this type, a number of problems arise. In this particular case, fortunately, we have the opportunity of deferring evaluation of the second phase, the research activities, until after those results are presented in a second installment.</p> <p>The results of the educative effort are perhaps best considered in terms of Jesus' parable of the sower, as set forth in <em>The Gospel According to St. Matthew </em> (Chapter 13):</p> <blockquote><p>3 ... Behold, a sower went forth to sow;<br /> 4 And when he sowed, some seeds fell by the way side, and the fowls came and devoured them up:<br /> 5 Some fell upon stony places, where they had not much earth: and forthwith they sprung up, because they had no deepness of earth:<br /> 6 And when the sun was up, they were scorched; and because they had no root, they withered away.<br /> 7 And some fell among thorns; and the thorns sprung up, and choked them:<br /> 8 But other fell into good ground, and brought forth fruit, some an hundredfold, some sixtyfold, some thirty fold.<br /> 9 Who hath ears to hear, let him hear.<br /></p> </blockquote> <p>In some few places and among some persons, no effects are to be noted. Among others minor temporary changes evolved, and in still other instances important permanent improvements were brought about. We may consider these effects under three broad categories-impact on the medical management of the amputee, impact on public and private rehabilitation agencies, and impact on social attitudes.</p> <h3>Impact on the Medical Management of the Amputee</h3> <p>It has been emphasized consistently throughout the foregoing sections that a "prosthetic-clinic approach" to the problem of the amputee was a basic tenet of the field-studies program. In this approach, the fundamental decisions relating to the rehabilitation of the patient were made in concert by a group consisting minimally of a physician or surgeon, a physical and/or occupational therapist, and a prosthe-tist. Whenever possible, vocational counselors and other personnel trained in the psychosocial aspects of rehabilitation also were included.</p> <p>The second aspect of the prosthetic-clinic approach involved an attempt at considerable standardization of the process of patient care and usually included eight more or less formal treatment steps-preprescription examination, prescription, preprosthetic therapy, prosthetic fabrication, initial checkout, prosthetic training, final checkout, and follow-up. As a consequence of these efforts, three major changes occurred in the medical care of amputees- introduction of prosthetic-clinic procedures, staff and patient education, and upgrading of existing services.</p> <h4>Introduction Of Prosthetic-clinic Procedures</h4> <p>Although similar clinical procedures have been developed and practiced in the treatment of other disabilities, and even occasionally in prosthetics, the attempt at systematic introduction of such procedures on a broad basis was a novel one. In addition, experimental exploration and validation of the essential adequacy of such procedures is hardly ever available. As a major outcome of the Field Studies, however, the basic validity of the clinical procedures in the field of upper-extremity prosthetics has been established. In addition to these accomplishments, certain other changes occurred with respect to the patient-care activities of each of the specific professions-the physician and surgeon, the physical and occupational therapist, and the prosthetist-concerned with the handling of the upper-extremity amputee.</p> <h5><i>The Physician and Surgeon</i></h5> <p>As a result of the principles and procedures instituted under the program, the period during which the amputee is considered a patient under medical management was extended significantly. Formerly an amputee was a patient during surgery and through a limited period of postoperative care. Today, the period of medical supervision continues through the entire process of limb prescription, fabrication, training, and evaluation.</p> <p>As an additional outgrowth, a subspecialty within the fields of orthopedic surgery and physical medicine has been developed. A limited number of physicians have become expert in the field of limb prosthetics. Since the amputee represents a relatively small portion of the total population requiring medical service, it is not feasible for large numbers of physicians to specialize in this field. But in order to provide competent service for amputees it was essential that a few physicians in each major population center be thoroughly equipped to provide the care required. Physician specialization in the very restricted field of prosthetic restoration has come about as a direct result of the program.</p> <p>Through the program the physician has learned much concerning the technical specifics of prosthetic restoration. As a result of this education, his respect for the contributions made by the skill and experience of the therapist and prosthetist in the process of amputee rehabilitation has increased. The interdisciplinary approach to the problem of amputation and prosthesis has become accepted and appreciated as a significant forward step in the medical management of the amputee. As a general consequence, the physician has been able to acquaint himself with, adapt, and then apply modern-and gradually higher-standards of prosthetic care for his patients. Knowing, perhaps for the first time, what constitutes and what is involved in providing a good prosthesis, the physician is now able to require a standard of service not previously possible.</p> <h5><i>The Physical and Occupational Therapist</i></h5> <p>For the therapist, the short-term courses in upper-extremity prosthetics filled a gap left by the usual curricula in schools of occupational and physical therapy. Perhaps for the first time, a systematic approach to the amputee problem was taught and practiced. As a result, the therapist has been able to carry out the major responsibility of amputee training with a background of general technical knowledge directly relating to artificial limbs. In addition, closer professional liaison developed between the therapist, the physician, and the prosthetist with regard to the amputee. As a result, in most instances upper-extremity amputees are now routinely referred to the therapist for instruction in the use of the artificial limb, whereas in the preprogram days the number of therapists qualified to give this service and the number of amputees availing themselves of it were both insignificant.</p> <h5><i>The Prosthetist</i></h5> <p>The program sought and helped to provide a proper professional role for the prosthetist. As a group, prosthetists were for the first time exposed to formal university instruction and to closer relations with medical, paramedical, and psychosocial disciplines. Thus the prosthetist has been helped toward a redefinition of his status on a higher professional level.</p> <p>This progress in the direction of a more professional role was aided in no small measure by the acquisition of a new technology involving the use of biomechanical principles, plastics fabrication, and principles of harnessing and controlling artificial limbs. This improved knowledge has resulted in improved service, increased status, and greater interprofessional satisfactions.</p> <p>One cannot say at this early stage in the evolution of this field just what the ultimate or proper interrelations may be between the professions concerned. Certainly the appropriate relationships will tend to vary from location to location, depending upon personnel and situational considerations. There can, however, be no gainsaying the facts that a period of growth has been stimulated, that the adequacy of the present treatment situation far surpasses that of the old, and that there has been developed a climate which gives every indication of providing additional professional status for the prosthetist.</p> <h4>Staff And Patient Education</h4> <p>A second value provided by the studies relates to the matter of staff and patient education. It is as true in limb prosthetics as in the other healing arts that there are no standard procedures which will apply with equal effectiveness to every patient. Moreover, limb prosthetics is still a field in which the contributions of each of the specialists are but partially understood by the others. Consequently, there is an important need for a cross-fertilization of ideas and a distillation of the best thinking for a given patient by the process of group activity. In this sense, an important achievement of the prosthetic clinic may be considered the intraclinic education of the team members.</p> <p>Equally important is the role that the clinic must play in the education of the patient. Most amputees, when arriving for prosthetic care, are subject to wide and varied misunderstandings and misinterpretations as to the procurement and ultimate use and value of a prosthetic device. Clinic personnel have become more effective in educating the patient concerning realistic goals and anticipations, in addition to providing him with the best type of prosthesis for his particular needs.</p> <h4>Upgraing Of Existing Services</h4> <p>In the process of applying and studying clinic procedures experimentally, the last important result evolved-that of an upgrading of existing services, as well as the establishment of services where none had existed previously. In this respect, the major contribution apparently has grown out of the introduction of a coordinated pattern of treatment.</p> <p>Previously, it had not been uncommon for a prosthetist, physician, and vocational counselor, for example, to proceed with the care of an amputee independently of one another. This procedure was often adopted in spite of the fact that in any situation where an individual is receiving treatment from more than one specialist, and where the anxieties are such as to provoke some degree of patient discontent, there is a noticeable tendency for some patients to distort the intentions and contributions of each profession in relation to the others. Such problems are further aggravated in those instances where the patient himself is called upon to act as the means of communication between the professions involved, since we may be sure that there will always be a certain degree of distortion of the patient's perceptions of the treatment processes. The clinic procedures were especially effective in reducing this troublesome method of communication between the specialists.</p> <p>We may also anticipate that the behavior and demeanor of the patient toward the pros-thetist will differ from that he exhibits toward the physician, therapist, or counselor. These differences in overt behavior patterns may easily and logically suggest different patterns of treatment to each of the individual professions. Yet it should be clear that these varying behaviors on the part of the patient are transitory and that the real solution lies in a uniform treatment plan rather than in a number of discrete ones. It therefore becomes clear that, in order to provide amputees with the best available medical and prosthetic service, the contribution of each of the professional specialties is best coordinated and amalgamated with that of each of the others. The prosthetic-clinic procedures, introduced through the studies, permitted a more uniform evaluation of the patient and assisted in circumventing the problems inherent in uncoordinated care.</p> <h3>Impact on Public and Private Rehabilitation Agencies</h3> <p>Many groups who have as their adopted or assigned mission the reintegration of the handicapped individual as a productive member of society have long been aware of the significance of the process of prosthetic restoration as a link in the over-all process of rehabilitation. As a direct consequence of this awareness, and as a necessary outgrowth of their over-all responsibilities in the rehabilitation field, federal agencies such as the Veterans Administration, the Armed Forces, and the Department of Health, Education, and Welfare, the state divisions of vocational rehabilitation, workmen's compensation, and health and public welfare, and such nongovernmental agencies as the state societies for crippled children and adults, rehabilitation centers, insurance companies, and a number of other private agencies have become the largest purchasers of prosthetic services in the United States.</p> <p>Through the NYU Field Studies these groups have been made increasingly aware of the potentialities of prosthetic restoration and have responded by raising their standards in the field of upper-extremity prosthetics. Having been provided with professionally competent avenues for the processing of their beneficiaries through prosthetic prescription, fabrication, training, and evaluation, these agencies have begun to insist that their clients be treated by special amputation teams headed by physicians who are experts in the field. Since these agencies may be considered "consumers" in the sense that they most frequently pay for the prosthetic services provided, they have been instrumental in raising the standards by rejecting prostheses and services that do not meet the minimum standards first set up through the program.</p> <p>A by-product is that the groups mentioned tend more and more to order prostheses from those prosthetists who have fully qualified themselves by virtue of training and experience. In a good many instances, these agencies have shown themselves willing to spend the additional monies required to obtain services of the highest quality. In some instances the program has been instrumental in stimulating the inauguration of local services to avoid the necessity for these rehabilitation agencies to contract for prosthetic services from distant sources. The widespread introduction of the clinic-team concept to the field of limb prosthetics provided the means for greater liaison between rehabilitation agencies and those persons medically responsible for the process of prosthetic restoration. Since the clinic-team meetings ordinarily involve a conference of all of the participants in a given case, the agency itself is frequently represented at such conferences by a professional staff member. This, of course, makes for considerable improvement in the continuity of the rehabilitation process.</p> <h3>Impact on Social Attitudes</h3> <p>Beyond their influence on the medical and rehabilitation agencies, the effects of the Upper-Extremity Field Studies also permeated through other facets of our social structure, although as one departs further and further from the professional groups directly responsible for the care of the amputee the impact of the effort becomes more diffused and less specific. Nonetheless, a number of significant effects remain to be noted. They may be viewed as influencing the attitudes and thinking of sponsoring agencies, scientists concerned with physical disability, other groups of disabled, and society at large.</p> <h4>Sponsoring Agencies</h4> <p>Perhaps one of the most important contributions was the demonstration that within a relatively brief period of time research and development can be accomplished and the benefits therefrom made available to the average patient with a disability. It should be recalled that the entire upper-extremity research program did not get under way until several years after the close of World War II and that the major prosthetic design improvements depended upon several years of fundamental biomechanical research. Thus the entire concept and technology of the care of the upper-extremity amputee has been revolutionized within a remarkably brief period of six or seven years.</p> <p>Such demonstrable progress is of inestimable value to those whose prerogatives require that they decide where substantial private or public monies should be spent in medical or rehabilitation research. Although it is always important to verify or evaluate the results of a broad program of research, this is not always possible. Yet this is precisely what the Upper-Extremity Field Studies have done.</p> <p>In the first instance, scientific evidence has been provided concerning the over-all value and contribution of the six or seven years of research and development. Secondly, and from a more technical point of view, information was brought forth concerning those aspects of the care of the upper-extremity amputee which had progressed most satisfactorily and those phases which require continuous improvement and attention.</p> <h4>Scientists Cconcerned With Physical Disability</h4> <p>The program of research and education also assisted in the general growth of scientific thinking on problems of human disability. Some detailed discussion of these research considerations will be included in the next issue of Artificial Limbs (Autumn 1958, Vol. 5, No. 2), which will deal with the research aspects of the studies. The discussion of the educative aspects of the Upper-Extremity Field Studies would be incomplete without note being taken of the progress that has occurred in the attitudes and thinking of researchers in the field of physical disabilities. These advances have been summarized at the recent conference on the Contributions of the Physical, Biological, and Psychological Sciences in Human Disability sponsored by the New York Academy of Sciences (page 125).</p> <h4>Other Groups Of Disabled</h4> <p>It is clear that a special service was performed for those individuals who have incurred disabilities related to, but not identical with, amputation. These groups are perhaps best typified by those disabilities which require functional restoration by use of braces or other orthopedic appliances.</p> <p>Until the time of these studies, there was very little overt expression of the need for progress in the field of bracing. The prevailing situation was one that had remained static for decades. With limited exceptions, personal unvalidated opinion, professional and otherwise, pervaded and still characterizes the entire field.</p> <p>Partially as a consequence of the broad educative aspects of the Upper-Extremity Field Studies, a spontaneous development of interest and desire for systematic progress arose in this related field, which is often served by the same doctors, therapists, and pros-thetists-orthotists. People who were suffering from these types of disabilities and those who cared for them generated a new feeling of hope and enterprise. The results of these changes in attitudes are just now being translated into planning for active research and education.</p> <h4>Society At Large</h4> <p>Further evidence was provided that the systematic treatment of the disabled is a fundamentally effective and socially desirable process. The "collective concern" which society experiences concerning the physically handicapped tends to be reduced with the knowledge that constructive things can be done, and have been done, for this group in an orderly, scientific manner. Associated with this growth in knowledge is a reduction in anxiety and prejudice concerning the physically handicapped and a corresponding increase in their acceptance by society.</p> <br /> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee IV. Educative Implications Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D.  https://staging.drfop.org/files/original/c737cb139033e8c4e783bb778fe2e303.pdf afba2b2f06d76842bef498473100a1b1 https://staging.drfop.org/files/original/53a89d8480ff368ebfc6962ec042be72.jpg b2d8f26b2c1cafd28d9b7ad03029a668 https://staging.drfop.org/files/original/2ef1058566b5da2b2e748d2d399df4c3.jpg a8237eb97aeffbee15ffa247a537a667 https://staging.drfop.org/files/original/0e0af5faf2d7d019ccf6efbf80ecc4e4.jpg 81b5c27b0158cb11f17f9b3811ec9ac7 https://staging.drfop.org/files/original/9fae0d917cf822fda036ea66b7f8ff35.jpg 39a6b402d16ad8e2ef8e5667351eef50 https://staging.drfop.org/files/original/fda55ff8d76b3af1f4afc1d3a8cc3787.jpg a25e75a93fc30ecdd9c8b6975d942de6 https://staging.drfop.org/files/original/635c07500a4b3f511b40baacfd0ec89f.jpg adb8ecb8590d21be56e26f5405cf8bf4 https://staging.drfop.org/files/original/881b402166909b183a592b5b932f5677.jpg 7a3a00e45dd8702373b17959937a5126 https://staging.drfop.org/files/original/867e91a41092a8cb68da465cd4034cf0.jpg da1b4fa8505ac79518e6226d88cac8c5 https://staging.drfop.org/files/original/05fd05eb81ff45ee5e7dcdccc396ce52.jpg dc75320f708c13452a69fae429e97894 https://staging.drfop.org/files/original/e6f7b2da3a4fadbf8a3a527edd3b5316.jpg 374c020c738c1a7a0b67d6f9b7e5072f https://staging.drfop.org/files/original/b0841997a49c9c7aab4eec937823c93b.jpg af43b44b1a7974fa376e7e9cc4272e4a https://staging.drfop.org/files/original/3ecc27bcefe23c8876046fa46a244a58.jpg 0cc9e916aae2a19c818aa922e2e9dd6d https://staging.drfop.org/files/original/3f61c1ac694eecb5767bc99734eebdca.jpg 84b791ff84fc7c8e0ba091dd088d83ad https://staging.drfop.org/files/original/6c08a4ed2a642bee3bf78630fcb66ac5.jpg 4dd94891a6ce8096342cf7ecff639b6e https://staging.drfop.org/files/original/b3b7237e745179d1ea21a21d0e3d3ecc.jpg d402232aa9be558b350be8c78a1075dc https://staging.drfop.org/files/original/b8ba70d807eb81df01ce717eb7db28ef.jpg cc62f2333467e76a57f6725f0c159351 https://staging.drfop.org/files/original/9cb3b4e808194b8ed3234d51106c404f.jpg 74505ee95ad7d6144a9d5ef5dff2fc5f https://staging.drfop.org/files/original/67170ee9e96df59048a0de1aa68a16c4.jpg ced97b253b8926ea606e2d78a8c894ab https://staging.drfop.org/files/original/8d01098d0675e6e9c890d0e24af2e450.jpg c3cd02b27f4bda7a2e64bc3d1b4b3807 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_004.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 4 - 30 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee V. The Armamentarium</h2> <h5>Edward R. Ford, CP. <a style="text-decoration:none;">*</a><br />Earl A. Lewis, M.A., R.P.T. <a style="text-decoration:none;">*</a><br /></h5> <p>One of the most interesting aspects of the evaluation procedures is concerned with comparisons between the prosthetic equipment worn by the participating amputees prior to the NYU Field Studies and that later provided as part of the studies. Some amputees entering the program were found to be wearing modern arms based on the latest components and materials and constructed according to the latest methods of fabrication. Others had outmoded and sometimes outworn prostheses. And a third group either had never worn prostheses before or else were not wearing a prosthesis at the time the program began. Accordingly, the data gathered were not only on the new program prostheses but also on the old arms previously worn, if any, and hence the present analysis deals not only with the effects of program arms but also to a considerable extent with comparisons between the old and the new prostheses.<a style="text-decoration:none;">*</a> Of the 1630 arm amputees involved in the NYU Field Program, 359 were available for comprehensive investigation throughout the period covered by the evaluation studies. Of the 359, which together form the basis for this discussion, 168 were below-elbow amputees, 158 were above-elbow amputees, 23 had shoulder disarticulations, and 10 were bilaterals. Those who had prior experience with prostheses were used to form the comparative analysis of old vs. new.</p> <p>Although the subjects making up the group were generally available for intensive study, it was not possible to obtain from every amputee an answer to every question. In other instances, the investigators received multiple responses to questions. Moreover, certain areas of investigation called for responses in relation to the number of components involved, in which case the number of responses varied with the bilateral group and with those patients who utilized more than one terminal device. Although the reflection of these factors in the data causes some inconsistency in numbers of replies, it does not reduce the over-all value of the results.</p> <p>For purposes of identification, all prostheses worn by the amputees prior to inception of the NYU Field Studies are here referred to as "old prostheses" or "preprogram arms," although in a few cases they were rather new and reflected some of the latest techniques and components. All prostheses fitted during the course of the research studies are identified as "program" or "new" prostheses, although some of the components and techniques had for some time enjoyed either limited or general use in the prosthetics field. While the "old prostheses" represent an admixture of various techniques and components, some old, some new, the "program prostheses" represent the best of the old plus the latest innovations in the field of limb prosthetics at the time.</p> <p>In passing, it should perhaps be noted that the data concerned were for the most part gathered on program prostheses fabricated shortly after the prosthetists' completion of the prosthetics courses at the University of California at Los Angeles. The skills and experience available for handling the latest components, materials, and techniques were therefore somewhat limited during the early days. As experience and attendant skills increased, the quality of the prostheses improved. No apology for the program treatment procedures and prostheses (which, as will be seen, were clearly superior to preprogram efforts), this circumstance indicates that expansion of present gains can be expected as prosthetists and prosthetics clinics continue to accumulate experience with latest procedures.</p> <h3>Terminal Devices</h3> <p>The artificial hand or hook is generally considered to be the most important single component of an artificial arm. A major functional purpose of all other components of the upper-extremity prosthesis is to make it possible for the terminal device to be positioned and the function of grasp to be utilized. Moreover, the hook or hand is important from the standpoint of aesthetics, since it is exposed to view almost constantly and is a matter of curiosity to all who recognize it as a prosthetic device. Today's prosthetic armamentarium presents a choice, from a selection of hooks and hands, of terminal devices most likely to meet the wearer's needs. Within this framework are devices which operate on the voluntary-opening or the voluntary-closing principle<a></a>. Available hands are either essentially cosmetic or else are designed to provide prehension as well as cosmesis<a></a>. Either type permits the functions of pushing, pulling, and holding down objects.</p> <p>Were any one of these devices completely satisfactory, it would enjoy exclusive use by all wearers of arm prostheses. Since such is not the case, amputees frequently interchange two or more terminal devices, say a hand and a hook, and some even interchange two hooks of different shapes and operational characteristics. In any event, many factors influence the selection of terminal devices<a></a>, so that what- ever is chosen usually represents a compromise based upon consideration of the psychological, environmental, and biomechanical circumstances of the individual amputee.</p> <h4>The APRL Hand and Glove</h4> <p>One of the most widely publicized developments in the Artificial Limb Program has been the APRL voluntary-closing terminal devices—the APRL hook and the APRL hand with its companion glove of plasticized polyvinyl chloride<a></a>. Prior studies<a></a> had established the usefulness of these devices, and the Upper-Extremity Field Studies presented a unique opportunity to introduce these items into many more clinics over the country and to obtain additional information concerning the value of the devices to amputees. The APRL hand was therefore prescribed in almost all research cases where a prosthetic hand was indicated (285 out of 291). Four patients expressed strong desires to continue with voluntary-opening hands, while two others elected to continue with passive, cosmetic hands.</p> <p>Tests showed that grasp forces available with the APRL hand, in which grasping force is related directly to the force that can be exerted by the wearer, were much higher than those to be had with other types of functional hands. Almost all wearers of the APRL hand (89 percent) could exceed 20 lb., a force not uncommon in the palmar prehension of non-amputees <a></a>. Voluntary-opening mechanical hands, in which the force is limited to that available from springs or rubber bands, showed a maximum prehension force of 5 lb.</p> <p>When these tests were completed, the subjects were questioned regarding their reactions toward the APRL hand in the areas of usefulness, appearance, ease of operation, and weight.</p> <h5><i>Usefulness</i></h5> <p>Most of the amputees considered the APRL hand to be a useful device or at least one of limited use. Less than 12 percent considered the hand to be of no use. But the pattern of responses clearly indicates that the hand becomes less useful to the wearer as the level of amputa- lion becomes higher, presumably owing to the increased difficulty of using a prosthesis with decreasing stump lengths.</p> <p>The ability to control grasp and to maintain it (by automatic locking) was well received by 50 percent of the amputees for whom APRL hands had been prescribed, and increased function over a wide range of activities elicited important voluntary comments from another 27 percent. The choice of using either the large or the small finger opening prompted positive comments by 11 percent of the sample. When comparisons were made of the amputee reactions to usefulness, the APRL hand was rated considerably higher than other types of hands previously worn. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Appearance</i></h5> <p>Noted was an exceptionally high degree of amputee satisfaction with the appearance of the APRL hand. As might have been expected, level of amputation did not seem to influence the wearers' reactions in this area. More than 90 percent of all the amputees felt the APRL hand and glove to be either "very satisfactory" or "satisfactory" in appearance. In no other component of the prosthesis do we have such a large number of amputees exhibiting this degree of positive response.</p> <p>The size of the APRL hand was felt by 6 percent of the wearers to be a problem. Discoloration and difficulty in keeping the glove clean elicited negative comments from 12 percent of the subjects. Poor wear characteristics of the glove (abrasion, tearing, rubbing through) elicited negative comments from 9 percent of the sample. When amputee reactions to the appearance of the AFRL hand were compared with the corresponding reactions to the appearance of other hands previously worn, the results were very favorable toward the APRL device.</p> <h5><i>Ease of Operation</i></h5> <p>Almost 72 percent of the amputees for whom an APRL hand had been prescribed felt that it was easy to operate, another 26 percent considered it somewhat difficult to operate, and less than 3 percent found it very difficult to operate. Below-elbow amputees experienced the least difficulty in hand operation. As expected, fewer found the APRL hand "easy" to operate as the level of amputation became more proximal. <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some of the amputees had worn other "functional" hands prior to the APRL device. When they compared ease of operation of their old prosthetic hand with that of the APRL hand, the APRL model was preferred. It is interesting to note that the shoulder-disarticulation and above-elbow cases exhibited dramatic changes in their reactions to use of functional hands, a fact which would suggest that the APRL hand has much greater applicability than the older hands. For one thing, in the dual-control system<a></a> the cable-excursion requirements are lower for voluntary-closing devices than for voluntary-opening devices, and this circumstance exerts an important influence on the use of above-elbow and shoulder-disarticulation prostheses. Apparently the additional control motions needed for operation of voluntary-closing devices did not constitute an objection insofar as ease of operation was concerned.</p> <h5><i>Weight</i></h5> <p>Judging from amputee opinions relating to the weight of the APRL hand (15 oz. with glove), the below-elbow group found the weight more satisfactory than did any other. In view of the greater residual anatomy in the below-elbow case, this result is generally understandable even though the short below-elbow case, without assistive forearm lift<a></a> is at a disadvantage. It is significant to note that 42 percent of all amputees for whom a hand had been prescribed felt that the APRL hand was somewhat heavy or very heavy, an indication that further improvements, aimed at weight reduction, are needed. Nevertheless, amputees who had worn other hands considered the APRL hand lighter. All in all, the wearers' reactions consistently favored the APRL hand.</p> <h5><i>Discussion</i></h5> <p>It should be understood that amputee reactions toward the APRL hand were of special interest to the research program. Consequently, many such hands were prescribed not for specific vocational or avocational reasons, nor because of patient interest, but to observe the effects upon a rather large number of amputees who had no specific objections to being fitted on a trial basis. Many confirmed hook wearers were therefore included in the group fitted with APRL hands.</p> <p>The data show that mass fitting (285) of the APRL hand caused an additional 27 percent of the patients to wear hands on a more or less regular basis. Very few amputees expressed serious over-all negative feelings toward the APRL hand and glove.<a style="text-decoration:none;">*</a> Apparently, however, 25 percent of the patients for whom APRL hands had been prescribed wore them less than one day a week. Some, after a brief experience with the hand, declined to wear it at all and preferred to return to exclusive use of a hook. Since this response cannot be related to any specific dislike for the APRL hand and glove, it appears to relate more to a basic preference for a hook.</p> <p>A number of improvements in the APRL hand were suggested during interviews with the amputees. One was that a range of sizes would be most welcome since the one size available at the time was often either larger or smaller than the corresponding normal hand. Amputees with large hands seemed to feel that the APRL hand and glove were too small and effeminate. Another, cited especially by those with the higher levels of amputation, concerned the need for reducing the weight of the APRL hand. Other proposed improvements related to appearance and durability (especially of the glove) and to the complexity of function arising from the double control motion required for locking and unlocking.</p> <p>In brief, the APRL hand, with its two-position prehension range, its voluntary-closing self-locking mechanism, and its cosmetic glove, showed superior grasp forces and was considered to be more useful, easier to operate, and much better in appearance than other mechanical hands. Although the wearers indicated that weight reduction in the APRL hand would be welcomed, the existing hand was considered more satisfactory than other mechanical hands. Despite these positive findings, it was apparent that design changes directed toward weight reduction, improved durability in the cosmetic glove, establishment of a range of sizes, and simplification of operating requirements would improve the device significantly.</p> <h4>Rubber-Band-Loaded Hooks</h4> <p>The type of hook which, historically, is the standard in the prosthetics field, and the one to which all other designs are compared, is the steel or aluminum voluntary-opening split hook in which the fingers rotate about a single pivot and are held in the closed position by the contraction of rubber bands that stretch during opening<a></a>. Addition of more and more rubber bands increases the maximum available finger forces at the expense of added work in opening.</p> <p>Many variations in finger shape are to be had. Some fingers are lined with rubber to reduce slippage, others are unlined. In the studies concerned, prescription of rubber-band-loaded hooks was often on the basis of previous amputee experience. Sometimes clinical judgment favored them, especially for use with bilaterals, because of the simplicity of operation as compared with voluntary-closing, self-locking terminal devices which, although superior in grasp forces, demand additional control motions, a requirement generally considered to be a shortcoming. In tests involving 68 of these simple hooks as worn by amputee subjects, it was found that the rubber bands had been selected to yield prehension forces ranging from 1 lb. to 14 lb. (average, 4.3 lb.), depending on individual preference.</p> <p>With regard to usefulness, appearance, ease of operation, and weight, amputee reactions to rubber-band-loaded hooks are rather consistent regardless of level of amputation. Although in general there is a high degree of acceptance, 21 percent of the below-elbow amputees and 8 percent of the above-elbow cases indicated that rubber-band-loaded hooks are of limited use only. Thus again improvement is needed. The subjects themselves suggested more durable rubber inserts for the fingers, elimination of rubber bands, and reduction in the conspicu-ousness of the hook without reducing its functional value. <b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Sierra Two-load Hook</h4> <p>A relatively new design for voluntary-opening hooks, which traditionally have used rubber bands for closing, is the Sierra two-load hook featuring a spring to close the fingers<a></a>. Heavy or light closing forces are selected by positioning a small mechanical switch located on the post provided for attachment of the control cable. The case which houses the operating mechanism is made of aluminum, and the hook fingers, also of aluminum, are lyre-shaped and lined with neoprene for increased security of grasp.</p> <p>The novel design of the two-load hook, with its simplicity of operation (voluntary-opening) and choice of two grasp forces, interested both clinics and amputees. Consequently, 64 of these devices were prescribed in the study. Data taken on 51 subjects show that pinch forces averaged 3.4 lb. for the light-load setting of the mechanism, 6.6 lb. for the heavy loading.<a style="text-decoration:none;">*</a> <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputee reactions to the two-load hook were generally positive insofar as usefulness, ease of operation, weight, and, to a lesser extent, appearance were concerned. As with rubber-band-loaded hooks, there were indications of need for improvement, for 13 percent of the below-elbow amputees and 12 percent of the above-elbow cases indicated that the two-load hook was of limited use only. That 12 percent of the above-elbow amputees felt the device somewhat difficult to operate is a finding hard to interpret, unless perhaps these particular subjects had been accustomed to extremely light loadings on hooks operated by rubber bands.</p> <p>In general, there was a favorable reaction toward the availability of two levels of grasp force from which to select. Although apparently the light load was used most often, the wearers found that the heavier loading was sometimes very desirable. The indications were that a desirable improvement could be effected if the ranges of prehension force could be made adjustable by the wearer (perhaps by use of a simple tool). When amputee comments were compared (two-load hook versus rubber-band-operated hooks worn previously), there was no clear-cut preference for either type, although the two-load fared slightly better in all areas except appearance. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>APRL Hook</h4> <p>The APRL hook is, like the APRL hand, a voluntary-closing, automatic-locking terminal device<a></a>. The body and fingers are of aluminum to keep weight within reasonable limits, the fingers being lyre-shaped and lined with neoprene to increase the security of grasp. Opening ranges of approximately 1-1/2-in. or 3 in. are selected by manipulation of a small switch protruding from the hook case. The control cable attaches to a lever arm projecting from the side of the housing for the mechanism. As with the APRL hand, prior studies<a></a> had established the general acceptability of the hook, and the NYU Field Studies presented a unique opportunity to gain additional insight into its application and to introduce it into more climes throughout the country.</p> <p>The basis for prescription was to furnish the APRL hook in a majority of cases where a hook was required. The only exceptions were those cases where a clear contraindication was apparent (for example, in cases of patient refusal to wear any type of hook, or to change from some other type to the APRL hook, or where occupational requirements demanded extremely rugged construction, or where the subject was interested in trying the Sierra two-load hook). Consequently, rather large numbers of amputees in the study were equipped with the APRL hook.</p> <p>The data obtained with 228 hooks were similar to those obtained with the APRL hand when it was compared to voluntary-opening hands. Grasp forces were found to be considerably higher with the APRL hook than with voluntary-opening hooks. Eighty-nine percent of the wearers could exert forces over 9 lb., 54 percent over 20 lb.</p> <p>Although amputee reactions to the APRL hook were generally positive, the present design evidently leaves much to be desired in the area of appearance and, to a lesser degree, in the area of usefulness. In interviews, the amputees mentioned:</p> <ol> <li>The possibility of reducing length and bulk by incorporating the terminal-device mechanism in the forearm.</li><li>Dissatisfaction with the reliability of operation (locking after closing), although some wearers were generally aware that the fault might lie with themselves in not permitting the mechanism to alternate.</li><li>Backlash, which in varying degrees caused some wearers distress.</li><li>The potential advantages (aesthetic as well as functional) of having the hook "thumb" as well as the moving finger on the medial aspect. At present, when the "thumb" is on the medial side the moving finger is on the lateral side and opens away from the wearer's body. If the wearer wants the moving finger to open toward him, the "thumb" is placed on the lateral side.</li></ol> <p>Some interesting points are observed when we compare the responses to the APRL hook with those to the APRL hand. Since in general hooks are conceded to be more functional than artificial hands, it comes as no surprise that in the area of usefulness the APRL hook rated higher than did the hand. As regards appearance, reactions were much more favorable to the hand than to the hook, but, in the case of the latter, amputation level had no apparent effect on amputee feelings. In any event, a significant number of patients found both hand and hook unsatisfactory in appearance. <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>More than 80 percent of the amputees wearing the APRL hook indicated that it was easy to operate regardless of amputation level. Conversely, responses by wearers of the APRL hand indicated that operation became somewhat more difficult at the higher levels of limb loss. By far the majority of wearers registered satisfaction with the weight of the hook (8-1/4-oz.), whereas the weight of the gloved hand (15 oz.) was less well received. The higher the level of amputation the more critical weight became. Next to be considered are the reactions voiced in regard to the usefulness, appearance, ease of operation, and weight of rubber-band-loaded hooks (voluntary-opening) worn prior to the studies and of the APRL hook (voluntary-closing) supplied during treatment. The below-elbow and shoulder-disarticulation wearers considered the rubber-band and APRL hooks approximately equal in usefulness, while the above-elbow wearers felt the APRL hook to be somewhat more useful. As for appearance, about 70 percent of the subjects found both APRL and rubber-band hooks generally "satisfactory." Whereas 15 percent indicated dissatisfaction, the remaining 15 percent said that in appearance both hooks were "very satisfactory." When ease of operation was considered, the below-elbow and above-elbow wearers favored the APRL hook slightly, although both hooks were rated highly with regard to operating characteristics.</p> <p>The wearers of shoulder-disarticulation prostheses showed a distinct preference for the APRL hook with respect to ease of operation, probably because of the ease with which closure can be effected and because of the low excursion requirements peculiar to voluntary-closing terminal devices. This finding may indicate that rather light prehension forces are used by most wearers of shoulder prostheses, for were this not the case they would react against the difficulty of reopening the hook. There is no indication from the data that the additional control motions required for use of the APRL hook made hook operation less "easy." <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Hook weight appeared to present no major problem regardless of level of amputation. Although the 8-1/4 oz. APRL hook was generally considered by the wearers to be more satisfactory than the Dorrance No. 555 (3 oz.), the Dorrance No. 5 (7 oz.), or the Dorrance No. 7 (8-3/4 oz.), the responses may have been influenced by the use of a new prosthesis, which very often was better fitted, more comfortable, and more efficient than the old arm with the rubber-band hook.</p> <p>It is apparent from the foregoing discussion that functional, split hooks were rather highly valued regardless of type. In all cases, usefulness, ease of operation, and weight were apparently quite acceptable to almost all wearers. Only in the area of appearance did a significant number of subjects indicate dissatisfaction, and even then most of the amputees accepted prevailing appearance.</p> <p>The amputees who used rubber-band-closing hooks prior to the study and changed over to the APRL hook during the study were in an excellent position to compare terminal devices. The below-elbow amputees felt that the APRL hooks and those of the rubber-band type were approximately equal in usefulness, the responses favoring the APRL hook slightly. The above-elbow cases seemed to favor the APRL hook rather strongly, the responses indicating an attitude considerably more positive toward the usefulness of the new hooks. The shoulder-disarticulation cases seemed to favor the rubber-band hooks slightly with respect to usefulness, but the smallness of the sample (13 patients) prohibits drawing any conclusions in favor of either type of hook for this special group.</p> <p>In sum, it appears that the rubber-band and the APRL types are about equal in usefulness, the data favoring slightly the APRL design. No clear-cut advantage in the use of one over the other is evident from amputee reactions. In all probability, personal preference based on past experience, influence of the clinic team, or other intangibles are contributing factors. The entire area affecting the choice of terminal devices is one that should be given additional study.</p> <h3>Wrist Units</h3> <p>Prosthetic wrist units are designed to facilitate attachment of the hand or hook to the forearm and to permit pronation-supination of the terminal device<a></a>. The most common type (screw-in type) bears a female thread such as to accept the terminal-device stud, and a rubber washer and retaining plate are used to control the tendency toward excessive loosening or tightening when the terminal device is rotated. A newer type of wrist unit, intended to provide not only for easy rotation but also for easier interchange of terminal devices, incorporates a control button which, when depressed, frees the hand or hook for rotation. Further depression of the control button permits removal of the terminal device from the wrist unit, the need for unscrewing being thus eliminated. In still another wrist, also designed for quick interchange of terminal devices, the turn of a knurled ring releases the hand or hook for rotation or removal. <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the NYU Field Studies, prescription of wrist units favored the button- or ring-operated wrist (plug-in type) wherever more than one terminal device was to be used. When a single terminal device was prescribed, the screw-in type was generally favored, since then interchange was not a major consideration. Plug-in wrists fitted to 266 research patients and screw-in types fitted to 93 were followed over an average wear period of six to nine months, and amputee reactions were obtained concerning two aspects of wrist function-attachment and removal of the terminal device, and pronation-supination to achieve acceptable attitudes of approach. Of the 359 amputees wearing program arms, those equipped with plug-in units were slightly more satisfied with the attachment function than were those who wore screw-in wrists. Pronation-supination was fairly satisfactory with both types.</p> <p>Despite the general amputee acceptance of both types of wrist, however, there was also evidence of substantial dissatisfaction. Interviews with the amputees and observation of their performance revealed that a simpler and faster method of exchanging terminal devices was required, as were also improvements in the cable connections, which were then cumbersome and difficult to manipulate with one hand. Evidently, improved rotation mechanisms were needed to permit easy correction of terminal-device attitude for best angle of approach.</p> <p>When specific wrist features (ease of operation, usefulness, weight, and appearance) were explored (page 16), the wearers were even more positively inclined toward the plug-in wrist unit. The reactions of 138 amputees who had screw-in wrists on their old arms and plug-in wrists on their program arms show that, insofar as exchanging terminal devices was concerned, the plug-in wrists were favored by a greater percentage of the below-elbow wearers than were the screw-in wrists. The opinions of the above-elbow amputees showed only a slight trend in favor of the plug-in wrists. Because only a small number of shoulder-disarticulation cases changed to plug-in wrists, their reactions were not recorded. The responses of 107 amputees who had used screw-in wrists on their old arms and plug-in wrists on the program arms showed that the plug-in type of wrist was considered by below-elbow wearers to be easier to rotate than was the screw-in type.</p> <p>Opinions concerning the locking function of wrist units are of interest since only the plug-in type locks the hook or hand in its selected attitude, the screw-in type depending upon friction to maintain terminal-device orientation. In 106 cases, both below-elbow and above-elbow wearers considered the plug-in type of wrist (with its ability to permit rotation of the terminal device as well as to lock it) somewhat more useful than the screw-in, nonlocking type.</p> <p>In the areas of weight and appearance, the plug-in type was again, and somewhat surprisingly, favored over the simpler, screw-in unit. Despite the fact that the plug-in wrist is actually heavier than the screw-in type, amputees favor it. Apparently the "halo effect" of the new prosthesis with its generally superior comfort, appearance, and efficiency may be responsible for the positive responses in the areas of wrist weight, wrist appearance, and ease of wrist rotation.</p> <p>In summary, the plug-in type of wrist was favored slightly over the screw-in type, first because of the relative ease with which terminal devices could be exchanged and second because the hand or hook could be locked in any desired attitude of pronation-supination. Below-elbow amputees seemed to favor the plug-in type more than did the above-elbow group, an understandable result when it is considered that below-elbow wearers are generally more active with their prostheses and more inclined to exchange terminal devices than is the case with above-elbow amputees. In any event, it was apparent from observations and from amputee remarks that improved cable attachments were needed to facilitate ease of connecting and disconnecting hands or hooks. Despite the fact that some below-elbow wearers considered rotation of terminal devices easier with plug-in wrists, observation leaves little doubt but that the screw-in type is superior in rotation features. It seems clear that attitudes toward the rotational qualities as well as toward the weight and appearance of the plug-in wrist were positively affected by concomitant reactions toward superior locking and attachment qualities. <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Elbow Joints for Below-Elbow Prostheses</h3> <p>Almost all below-elbow prostheses are suspended from cuffs fitted above the bony prominences of the elbow joint. The cuff and prosthetic forearm are connected by means of mechanical elbow joints, some of which (rigid hinges) are designed to permit flexion and extension only, others (flexible hinges) permitting also pronation and supination.<a></a> Metal hinged joints are generally used for shorter stumps where stability against inadvertent rotation is a major requirement. Flexible leather, steel-cable, or fabric-type joints are generally used in prostheses for longer stumps where residual, natural forearm rotation can be utilized. Short stumps typically have limited purchase in the prosthesis and therefore require a snug, high-fitting socket in order to obtain forearm stability<a></a>. But the high-fitting socket often restricts the wearer's range of flexion owing to crowding of flesh as the forearm is raised. Special joints, known as "step-up" joints<a></a>, are designed to relieve this condition and to produce an increased range of flexion. Since in such a case the range of motion increases at the expense of lifting power, it is sometimes necessary to use an assistive forearm lift similar to that commonly used with above-elbow prostheses <a></a>. Whenever the very short below-elbow stump is un-suited for lifting the prosthetic forearm, it is fitted with locking joints actuated either by movement of the stump or by a cable control similar to that used for the above-elbow case.<a></a></p> <p>Evaluated comprehensively with both old and new prostheses were 136 unilateral below-elbow amputees, the elbow components of the prostheses being as follows: <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The data show that in general the new arms permitted a greater range of forearm flexion than did the preprogram arms, partly no doubt because of an increased use of step-up joints in the new prostheses and partly because of improved socket shaping to avoid restriction of flexion through crowding of flesh at the brim of the socket. <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the advent of the Upper-Extremity Field Studies, use of flexible elbow joints had been reserved almost entirely for patients with wrist disarticulations or long below-elbow stumps. Of all the amputees in the group investigated, only 17 had had flexible joints in their preprogram arms, and of these only one had a stump shorter than 6-1/2 inches. Moreover, the available stump rotation was rather good, only one having less than 20 deg. of pronation-supination. Experience indicated that even still shorter stumps might retain slight but useful rotation and that patient comfort might be increased and clothing damage decreased with use of flexible hinges. Consequently, during the program many stumps within the group of 136 amputees (74 arms) were fitted with flexible joints even though the rotation possibilities were knowingly limited (22 cases with residual stump rotation of less than 20 deg., 13 patients with stumps shorter than 6-1/2 in.).</p> <p>As expected, the average rotation range for the entire group with the new prostheses decreased as compared with the average rotation range of the 17 who had been provided with flexible hinges on their old arms. But it must be pointed out that many more amputees now had not only the facility of active pronation-supination but also the greater comfort and reduced clothing damage inherent in the use of flexible joints. The 16 amputees who used flexible hinges on both old and new arms exhibited the same range of pronation-supination with the two prostheses. <b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The reactions of the below-elbow subjects to the various elbow joints evaluated during the study were in general very positive in the areas of usefulness, ease of operation, and weight but a great deal poorer in the area of appearance. Although the step-up and stump-actuated joints were unacceptable to a few amputees, negative generalizations are impossible because the size of the sample was too limited (24 step-up joints, 7 locking joints). And indeed these components must be widely acceptable, judging from the overwhelming percentages of positive responses. The negative comments made by wearers of step-up joints indicate an inability to stabilize the forearm sufficiently to obtain effective use of the terminal device. The development of locking step-up joints has been suggested as a means of stabilizing the prosthetic forearm for amputees with short or very short stumps.</p> <p>The principal findings with regard to elbow joints for below-elbow prostheses center around a shift toward increased use of flexible hinges and a corresponding decrease in the number of rigid joints used.<a style="text-decoration:none;">*</a> Of special interest is the finding that stumps shorter than 6-1/2 in. should also be considered for flexible elbow joints. Although the shorter stumps can be expected to provide only minimal pronation-supination, even slight gains in rotation are important for hand and hook positioning. There was no reported instance of socket instability on the shorter stumps fitted with flexible joints on program arms, and the gains in patient comfort and in reduction of clothing damage lead to the conclusion that use of any joint other than flexible should be advocated only after serious consideration of the specific needs of the individual patient. Although the sample using step-up or locking joints was small, and although it is apparent that the joints were generally satisfactory, development of a step-up joint capable of locking the prosthesis in flexion seems quite desirable, since stabilization of the forearm for effective terminal-device operation or for lifting objects appeared to be difficult with the step-up joints used both before and during the study.</p> <h3>Elbow Joints for Above-Elbow and Shoulder-Disarticulation Prostheses</h3> <p>Positioning of the prosthetic forearm and terminal device of a modern above-elbow or shoulder-disarticulation prosthesis in the flexion-extension plane requires that the elbow be unlocked. Locking of the elbow permits control-cable forces to by-pass the forearm lift and to act upon the terminal device.<a style="text-decoration:none;">*</a> Rotation of the prosthesis about the humeral axis to facilitate mediolateral positioning of the forearm is accomplished by means of a turntable incorporated in the elbow and controlled by a friction element which resists free movement.<a></a> In general, about 2 lb. of force and half an inch of cable travel are needed to lock present mechanical elbows, about 5 lb. to unlock. But the exact figures vary slightly from elbow to elbow and from manufacturer to manufacturer. Program arms fitted during the early phases of the study were built around Sierra Model C elbows<a></a>, which had unlocking forces (6.3 lb.) and excursion requirements (9/16-in.) slightly higher than those of the Hosmer E-400 units (4.0 lb. and 1/2 in.), which in turn became available to the clinics later in the study and which were identical in operating principle. Besides this, the Hosmer E-400<a></a> was at the time a new component, clinics were therefore particularly interested in its application, and consequently it was prescribed almost routinely during the latter part of the program. Of the 170 internal elbows fitted and evaluated during the study, 110 were Sierra Model C's, 42 were Hosmer E-400's, and 18 were Hosmer E-300's (an earlier elbow incorporating a locking mechanism of quite different design, now discontinued). External elbow locks<a></a>, intended for amputees with long humeral stumps or with elbow disarticulations, were used in 11 cases.</p> <p>Above-elbow and elbow-disarticulation amputees achieve elbow locking and unlocking by a combined extension-abduction of the humeral stump, a motion which exerts pull upon a control cable attached between the elbow and the shoulder harness.<a></a> Alternate pulls on the elbow-lock control cable result in locking and unlocking or vice versa. Shoulder-disarticulation amputees usually control the elbow lock by elevating the shoulder on the side of the amputation, thus exerting pull on a control cable attached between elbow lock and waistband. <a></a> </p> <p>All of the elbow-disarticulation, above-elbow, and shoulder-disarticulation prostheses provided in the program were equipped with locking elbows of the alternating type. Of the 181 cases (170 internal locking, 11 external locking) available for study, 76 had had prior experience with prostheses incorporating the older manual locks, and 18 had worn arms without locking elbows. Fifty-two had previously used alternating elbows of the type used in the program arms. In 35 cases, either the patient had not previously worn an arm or else the type of elbow was unknown.</p> <h4>Internal-locking Elbows</h4> <p>The data show that a considerable number (36 out of 101) of the preprogram arms provided little or no initial elbow flexion, owing chiefly, no doubt, to fabrication technique and workmanship rather than to the nature of the elbow units themselves. Program arms tended to group around the standard of 10-15 deg. of initial flexion, a feature that tends to make initiation of forearm lift less difficult. Moreover, forearm flexion was restricted in the old arms, less than a third of them being capable mechanically of approaching 135 deg. of flexion. In general, program arms could be flexed to much greater extent, almost two thirds of the subjects reaching or surpassing 135 deg.</p> <p>As for other deficiencies in the new arms, 35 cases exhibited serious impairment of elbow-lock operation, primarily because of harnessing inadequacies. A considerably larger number of prostheses showed less than optimal elbow function, mostly because of poor arrangement of the elbow control cable and the front support strap. In 12 cases, malfunction of the elbow mechanism was apparent, and 37 of the new prostheses required adjustment for insufficient initial elbow flexion. Thirteen arms required attention to correct friction characteristics in the elbow turntables.</p> <p>Generally, then, more careful attention to adjustments and to harnessing detail for elbow-lock operation was obviously required. Direct amputee reactions to the cable-controlled, internally locking elbows were quite favorable, only 4 of the 170 wearers experiencing negative feelings when all aspects of elbow use were considered. Of the few negative comments made (25), the majority related to lack of dependability in elbow operation, probably because of such factors as careless harnessing or inadequate training in the required operational pattern. As might have been expected, the cases with the shorter stumps found operation of the lock more difficult than did those with the longer stumps. Except where the fitting of the short-above-elbow patient was expertly done, the shoulder-disarticulation cases had less difficulty in elbow locking and unlocking by means of shoulder elevation than did the short-above-elbow cases using the same control motion.</p> <h4>External-locking Elbows</h4> <p>External-locking elbow joints are sometimes used for elbow disarticulations and for very long above-elbow cases<a></a>. Although in the study 11 elbow-disarticulation amputees were fitted with external joints, only 8 had had experience with internal-locking elbows on their old arms. From the viewpoint of usefulness, they favored the internal mechanism slightly, perhaps because of the rotation turntable and because of the greater number of available locking positions in the internal elbows. As for appearance, the arms fabricated with outside-locking elbows seemed to be more acceptable than those constructed with internal units because, while the outside-locking units protrude on the medial aspect of the arm, internal units may be fitted to elbow disarticulations and to very long above-elbow cases only by lowering the elbow center abnormally.</p> <p>Ease of operation gave rise to some differences in amputee reactions toward internal as compared with external elbows. Since the forces and control motions are essentially identical in the two types, the discrepancies probably relate more to the nature of the harnessing or to the skill of the patient than to the particular characteristics of the elbows themselves.</p> <p>As one might have anticipated, amputee reactions to weight favored the outside-locking units, which are somewhat lighter than the internal elbows. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Summary</h4> <p>To summarize, only 29 percent of the 181 amputees studied were known to have worn on their preprogram arms locking elbows of the alternating type. In the studies, all unilateral above-elbow patients were fitted with the more modern locking units, thus freeing the normal arm from the responsibility of operating a manual lock for the amputated side. Program arms had greater ranges of forearm flexion and were adjusted to provide greater initial flexion so as to make it easier for the patient to lift the forearm. But elbow-lock operation with the new arms was often impaired by poor harnessing arrangements that required correction. While in general the amputees were quite favorably disposed toward the cable-controlled, locking elbows, infrequent negative complaints of lack of dependability related to inadequacies in harnessing and to poor operational patterns on the part of some wearers. A limited number of amputees fitted with external-locking joints provided sufficient positive evidence to ensure the future of these components in the array of items available for long-above-elbow or elbow-disarticulation patients.</p> <h3>Harnessing</h3> <p>If the upper-extremity prosthesis is to be of functional use to the amputee, two basic needs must be met. A suitable attachment of the prosthesis to the body must be made, and power must be provided for operating and controlling the limb. Although the socket is made to conform to the stump, it tends to become displaced, especially during lifting. The prosthesis is therefore suspended from the shoulder by means of a harness which keeps the socket in close contact with the stump and resists any tendency for the prosthesis to shift out of position. Usually the same harness serves as the force-transmitting medium between body sources of power and the cable system of the prosthesis<a></a>. For both above- and below-elbow amputees, two basic types of harness are in common use today-the figure-eight harness and the chest-strap harness <a></a>. Commonly, the chest-strap design is applied in the shoul-der-disarticulation case too <a></a>.</p> <p>Of all artificial arms, the unilateral below-elbow prosthesis is perhaps the simplest to suspend and to power. In the figure-eight method, suspension is obtained by a loop of 1-in. fabric tape passing under the axilla on the sound side and over the shoulder on the amputated side, the front end of the tape being attached to a biceps cuff (which in turn supports the elbow joints connecting to the prosthetic forearm), the other end (the back) to the control cable for the terminal device. Forward rotation of the arm upon the shoulder on the amputated side causes forces to be applied to the cable and gives the excursion necessary to operate the hook or hand. In the chest-strap method, suspension of the biceps cuff is achieved through use of adjustable leather or fabric straps attached to the anterior and posterior aspects of a leather shoulder saddle, and the control cable is attached to an adjustable fabric tape sewn to the chest strap in the region of the seventh cervical vertebra. Although the figure-eight type of harness is used almost universally for the unilateral below-elbow prosthesis, it is considered by some that the chest-strap type, with its broader weight distribution over the shoulder, is indicated for amputees anticipating extremely heavy-duty services or for those who cannot tolerate the axilla pressures typical of the figure-eight loop <a></a>.</p> <p>For the unilateral above-elbow prosthesis, the figure-eight and the chest-strap harnesses enjoy in general a more equal popularity. Program arms tended strongly, however, toward the simpler figure eight, in which the fabric tape loops over the sound shoulder, under the axilla on the sound side, and then over the shoulder on the amputated side <a></a>. It is generally conceded that the above-elbow chest-strap harness, which uses a leather or fabric saddle to reduce the unit pressure on the shoulder, is preferred whenever the patient anticipates activities involving heavy lifting or when he cannot tolerate the axilla pressure characteristic of the figure-eight harness <a></a>.</p> <p>For the unilateral shoulder-disarticulation or forequarter amputation, the most common harness in use today is that of the chest-strap type, elbow locking and unlocking being achieved by elevation of the shoulder on the amputated side. A fabric tape extends from the elbow-lock control cable and attaches to another surrounding the waist. Scapular abduction gives power and excursion for forearm lift or, when the elbow is locked, for terminal-device operation <a></a>.</p> <p>In the evaluation studies, harnesses were individually prescribed according to type and made in accordance with the latest techniques. But because the harness is always a custom-made item fitted by the prosthetist according to the requirements of the individual patient, there were introduced a number of variables involving such intangibles as skill and judgment. Although in program prostheses each harness had to meet certain requirements designed to ensure proper suspension and adequate power and excursion, it was apparent almost from the beginning that serious harnessing problems existed. About 45 percent of all arms showed harness deficiencies at checkout. The above-elbow prostheses were notably troublesome, 375 harnessing faults showing up on the 303 arms going through checkout. The below-elbow prostheses, though considerably simpler, were also a source of difficulty, 150 harnessing faults being discerned on 361 below-elbow patients. The shoulder-disarticulation group of 53 patients had 39 harnessing faults. <b>Table 1</b>, <b>Table 2</b>, and <b>Table 3</b> reflect the types of harnessing faults found at clinical checkout of the program arms.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should be pointed out that the prostheses were rated at checkout according to criteria evolving from material presented at the prosthetics courses offered as part of the program. Accordingly, any deviations from the accepted harnessing practices taught in the courses were considered "faults." But it was recognized that arm harnessing is an individualized procedure and that therefore certain faults might be less critical than others depending upon the amount of deviation from the standard, the physique of the patient, his threshold of tolerance for discomfort, and other intangible considerations. Consequently, it should be made clear that recognition of a fault did not necessarily mean the prosthesis was unusable but, more often than not, that the limb simply was not operating at a peak level of performance and/or comfort. Fortunately, the problems encountered with the harnesses at checkout were markedly reduced as the prosthetists gained experience. Strict adherence to the checkout standards, along with increased understanding and skill, served to ensure that each arm wearer was ultimately harnessed so that he could use the prosthesis in a functional manner. After checkout (and prosthetic corrections, when indicated), the amputees embarked upon a long-term period of wearing the new prosthesis.</p> <p>Amputee reactions to the new arm harnesses were checked with regard to comfort, appearance, and fit as these matters affected the function of the prosthesis. Generally, the wearers' reactions were quite favorable, and it was apparent that the subjects generally had a higher regard for the new harnesses than they had for the old (<b>Table 4</b>). Although program harnesses scored highly with all amputee groups, the above-elbow amputees consistently rated their harnesses slightly lower than did the below-elbow or shoulder-disarticulation groups, probably because the above-elbow figure-eight harness is more com- plex and in comparison with below-elbow harnesses somewhat more snug-fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Interviews with the amputees disclosed that most participants who had worn prostheses prior to the studies felt that the new harnesses were much better than the old ones. Particular comments evidenced satisfaction with reduction in amount of harness needed to obtain satisfactory prosthetic function with the new arms. Some wearers commented upon possible areas of improvement, a response which almost always involved the desire to be burdened with no more harness than necessary to control the arm. A number of subjects indicated discomfort at the axilla, and problems relating to shift of the harness out of place were not uncommon. Although difficulty in operating the elbow lock was corrected in most cases, some wearers felt that other means should be sought for control of elbow lock.</p> <h3>Power-Transmission Systems</h3> <p>To achieve functional use of a prosthesis, the amputee must be able to avail himself of residual sources of body power. Flexion, extension, and abduction of the arm, extension of the forearm, shoulder elevation, scapular abduction, and chest expansion are the most common power sources harnessed by the prosthetist to provide movement of the artificial arm.<a></a> Transmission of the forces thus generated is accomplished by the use of Bowden cables connecting the points of force generation (harness components) and the points of force application (forearm or terminal device). In the below-elbow prosthesis, forward movement of the shoulder on the sound side, flexion of the arm on the amputated side, singly or in combination, exerts against the harness system a force that is transmitted for operation of the terminal device, the forearm being lifted by the stump. Above-elbow and shoulder prostheses utilize the same type of power-transmission system, except that with arms of this type the cable is used also to lift the prosthetic forearm whenever the elbow is unlocked (dual control). <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Prior to the Upper-Extremity Field Studies, many arm amputees had been using Bowden cable for power transmission. Others used steel cable without housing, nylon cord, leather or rawhide thongs, and other miscellany, as shown in <b>Table 5</b>. But all program arms were equipped with Bowden cable and subjected to checkout procedures to ensure that minimum standards of power-transmission efficiency (below-elbow prostheses, 70 percent; above-elbow and shoulder-disarticu-lation prostheses, 50 percent) were met. When checked, the program arms showed for every amputation level substantial increases in efficiency over the standards shown by the power-transmission systems of the corresponding old prostheses. Indeed, the new arms exceeded the minimum efficiency standards with such regularity that raising of the standards is now indicated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Full opening and closing of the terminal device was possible for an increased number of amputees through use of the new arms. When function of the terminal device was tested at each of four operating positions (at full extension, at 90 deg. of flexion, at waist, and at mouth), the results showed a marked increase in opening range for each amputee type at all four positions.</p> <p>Doubtless this improvement was due to the use of better harness and belter-fitting sockets, with better transmission of force and excursion through the cabling system, if not to application of the voluntary-closing terminal devices, which inherently use less excursion than do the voluntary-opening hooks that predominated in the old prostheses. <b>Fig. 15</b>, <b>Fig. 16</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initial checkout of all patients provided with program arms revealed some problems in application of the Bowden cable (<b>Table 6</b>). faulty placement of retainers, improper cable lengths, and poor. soldering of connections were the main sources of trouble. Of course some of the arms had more than one fault, whereas about half of the 790 arms fitted and checked out in the study had no faults at all in the transmission system.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those in the study who had used power-transmission systems in both old and new arms (285) generally found the Howden-cable system easy to use, acceptable in noise level and in appearance, kind to clothing, and free of excessive maintenance requirements. Of these amputees, 201 responded to questions intended to elicit preference either for their old or for their new cable systems. Only 10 of the 201 in the group preferred their old power-transmission systems, 103 preferred the new. Yet 88 had no preference, which indicates that a significant number of preprogram arms had the advantage of an adequate power-transmission system.</p> <p>Suggestions for improvement indicated that the amputees would have liked to have seen the cables concealed within the prosthesis, although the existing appearance was not considered unsatisfactory. Easier and quieter operation might also constitute an improvement, although here again there appears to have been no major criticism. <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Complete Prosthesis</h3> <p>Thus far we have considered only the individual elements of the prosthesis. A matter of equal importance, however, is the consideration of the prosthetic appliance in its entirety and of the effects of clinical treatment and training with the prosthesis. Although the data presented here concern the below-elbow, above-elbow, and shoulder-disarticulation cases only, findings from the 10 bilateral amputees who were available for evaluation may also be considered indicative of probable trends. The responses of the small bilateral group, consistently positive toward the new program arms, were substantially in agreement with the responses from the other amputees. Although most wearers considered their new arms to be useful, the desire for further improvement was reflected in the significant percentage of wearers who considered the arms to be of limited use only. When the amputees compared the general usefulness of the old prostheses with the general usefulness of the new arms, the new arm was preferred. The greatest improvement showed up in the shoulder-disarticulation and above-elbow groups. When all amputation levels were considered together, only 59 percent of the wearers felt that the old prosthesis was "useful." With the new arms, the figure went up to 79 percent. While nearly 5 percent of the wearers felt the old arm to be of no use, less than 1 percent reacted in this manner to the new arms.</p> <p>Perhaps the most meaningful gains in function were made in the area of harnessing and in routine use of locking elbow joints for above-elbow and shoulder-disarticulation cases. Although harnessing problems existed initially with program arms, the checkout procedures brought the difficulties to light so that suitable improvements could be made. Certainly arm harnessing was a major problem prior to the Field Studies also, as indicated by the fact that the new harnesses were preferred over the old by a ratio of five to one (<b>Table 4</b>). Locking elbow units, which stabilize the forearm and terminal device for above-elbow and shoulder amputees, are obviously superior to nonlocking elbows from a functional standpoint. For without elbow lock, prehension is handicapped, pushing and pulling with flexed elbow are seriously impaired, and carrying with flexed elbow (as in carrying a coat over the arm) is so difficult as to be impractical. Although manual elbow-locking mechanisms are effective, the newer elbows, operated through the harness system, free the sound hand for more important services. But it must be remembered that all these gains, which now bring prostheses for all types of arm amputation to a relatively high level of usefulness, depend upon a number of factors, including prescription of suitable components, quality of design and construction, and training in prosthesis use, all of which doubtless contributed to the positive attitudes displayed by the test wearers.</p> <p>The appearance of the new plastic-laminate arms was accepted in a perfunctory way only, most of the arms being considered "satisfactory." When 266 amputee responses were compared (appearance of new arm vs. that of old arm), it was evident that positive changes in reaction had taken place. In general the amputees favored the newer arms. It is in the area of appearance alone that the responses indicate serious reservations in acceptance of any artificial arm, old or new. Since under certain social conditions amputees might well be inclined to limit their activities rather than bring attention to the fact that an artificial arm is being worn, sensitivity toward appearance is extremely important. Even the best arm prostheses available today fall far short of being cosmetically adequate and cannot hope really to satisfy either wearers or observers. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Ease of operation of the new prostheses apparently left something to be desired for a substantial number of the amputees, especially those of the above-elbow and shoulder-dis-articulation types. Simpler elbow-lock operation and reduction in the difficulties of terminal-device positioning (perhaps by providing more mobility at the wrist) were mentioned as important areas requiring improvement. When the amputees compared old and new prostheses with respect to ease of operation, the new arms nevertheless proved superior. Many amputees (59 percent) felt that operation of their old prostheses was "easy." But when later they were asked to comment on the ease of operation of their new arms, 84 percent replied that operation was "easy." Slightly over 7 percent of the wearers felt that operation was "very difficult" with the old arms, whereas less than 1 percent felt that way about the new arms. Although again these important gains were most prevalent among the shoulder-disarticulation and above-elbow cases, significant improvements were noticed among the below-elbow amputees also. <b>Fig. 19</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although to date very little attention has been given to study of its significance, the weight of the prosthesis has always occasioned a great deal of interest. Generally speaking, the practice has been to keep weight at a minimum, since amputee weight tolerance has not as yet been determined specifically. The data indicate that the below-elbow arms furnished in the program were slightly lighter than the corresponding preprogram arms (1.8 lb. compared with 2.1 lb.). Above-elbow prostheses weighed an average of 2 3/4 lb., there being no significant differences between the old and the new. The average weight of the new shoulder-disarticulation arms was about 3 1/2 lb., about 1/2 lb. heavier than preprogram types. Amputees at all levels generally felt that the total weight of the new prosthesis was satisfactory, although there were some indications that further weight reduction would be welcomed. About 7 percent of the subjects felt that the prostheses were somewhat heavy, less than 2 percent that they were very heavy. But 33 percent of the wearers considered the new prostheses more acceptable in terms of weight than the old arms, even though only slight differences in actual weight were noted. Such reactions are thought to be related to increased function, improved comfort, better fit, and/or improved weight distribution in the new arms. <b>Fig. 20</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When comparisons were made between amputee reactions to the old and to the new arms, the data for all levels of amputation clearly favored the newer, program-type, plastic-laminate prostheses. Such endorsement by wearers reflects not only the superior construction and the improved mechanical components incorporated into the newer prostheses but also the values of the patient-management procedures advocated by the program-prescription of carefully selected arm components, checkout to ensure basic adequacy of the fitting, and finally proper training in the use of the prosthesis.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>Prosthetics research and the amputation surgeon</i>, Artificial Limbs, 1(3): 4 (September 1954).</li> <li>Fishman, Sidney, and Norman Berger, <i>The choice of terminal devices</i>, Artificial Limbs, 2(2): 66 (May 1955)</li> <li>Fletcher, Maurice J., <i>New developments in hands and hooks</i>, Chapter 8 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium</i>, Artificial Limbs, 1(1): 15 (January 1954).</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr., <i>New developments in artificial arms</i>, Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Fletcher, Maurice J., and Fred Leonard, <i>The Principles of artificial-hand design</i>, Artificial Limbs, 2(2): 78 (May 1955).</li> <li>Leonard, Fred, and Clare L. Milton, Jr., <i>Cosmetic gloves</i>, Chapter 9 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Field test of the APRL hook</i>, April 1950.</li> <li>New York University, Prosthetic Devices Study,Report No. 115.12 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Field test of the APRL hand and glove</i>, April 1951.</li> <li>Pursley, Robert J., <i>Harness patterns for upper-extremity prostheses</i>, Artificial Limbs, 2(3): 26 (September 1955)</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity</i>, Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>The biomechanics of control in upper-extremity prostheses</i>, Artificial Limbs, 2(3): 4 (September 1955).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Dual control. See Pursley 10 or Taylor 11.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">See Artificial Limbs, Spring 1958, p. 77.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hook, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The prehension forces of the two-load hook are predetermined at time of manufacture and are not readily adjustable as are those in the simpler hooks, where rubber bands can be added or removed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Less than 3 percent had over-all negative reactions to the hand; 6 percent had over-all negative reactions to the glove.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hook, April 1950.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.12 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hand and glove, April 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and Fred Leonard, The Principles of artificial-hand design, Artificial Limbs, 2(2): 78 (May 1955).</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and Fred Leonard, The Principles of artificial-hand design, Artificial Limbs, 2(2): 78 (May 1955).</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The data reported here were all recorded on forms similar to those shown in Appendices IIB, IIIA, and HID of the issue of Artificial Limbs for Spring 1958 (pp. 25-28, 29-31, and 40-45).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Earl A. Lewis, M.A., R.P.T. </b></td></tr><tr><td class="clsTextSmall">Field Supervisor, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Field Representative, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward R. Ford, CP. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Laboratory, Orthopedic Aids, Inc., Garden City Medical Center, Garden City, N. Y., and Consultant, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Project Coordinator, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee V. The Armamentarium Creator An entity primarily responsible for making the resource Edward R. Ford, CP. * Earl A. Lewis, M.A., R.P.T. * https://staging.drfop.org/files/original/76945f6516dcc0545d2b91cfc6caeb8b.pdf c7a89a78b48b8aa9065dc973197081da https://staging.drfop.org/files/original/8272f870d623593975109366a1d714b7.jpg b08648bc765812c399bac1c19cce2712 https://staging.drfop.org/files/original/4b7fd07801fb1d9d0ea15226722773a1.jpg 31e1b3419fb5675d97f4c3ca9ddaef2b https://staging.drfop.org/files/original/648d969a13a9bfcbf9776e7f897bb027.jpg e6e25a69ad3a0eecb8b14f7d3cc6e198 https://staging.drfop.org/files/original/b2768987a6f827aa82820f33774881c2.jpg 3263b9f8e8039406c257c4297c706577 https://staging.drfop.org/files/original/565d4cdb0cb7c3928f0cc609eecabbad.jpg 23623942433011b5212537b43ff50a42 https://staging.drfop.org/files/original/bf659b0d50d8c30b699e980c1f46cfc3.jpg 2a10c2a368eda3fd3271e2c3d0b654bf https://staging.drfop.org/files/original/9ce4a3a221bb7e80fe9d0ac6e9038998.jpg a5593d13ccca338b6ac13c4fa60b0c30 https://staging.drfop.org/files/original/35f43c3f17c550391dc44c8477510bc7.jpg ee2788f57195e89a29eb725640ddf569 https://staging.drfop.org/files/original/1da9a7a00eb343939657082c12fdb22c.jpg 909ebcfb948c3e308eeea4c9c6129fca https://staging.drfop.org/files/original/107f8865b76201e760a87b25a700925f.jpg ac9a63d4f56b0bfe2d3d809c5be4b62a https://staging.drfop.org/files/original/da057c8bdbf8ceb1905f88c4011035d6.jpg 1364e32658239dc95d96ff1f793bc60e https://staging.drfop.org/files/original/142e0aebc5734f02b98738402171591a.jpg 23e4623a64eb2c8d4be159bc6b0f03ac https://staging.drfop.org/files/original/60c955ee13d73d7d06dd7a1ca0a291f1.jpg f9b06353c26a48c7556434f08d6d1a30 https://staging.drfop.org/files/original/d5169c0556a5fc30c968ca2e1bee5b6d.jpg 6222c5563bd9f4c29aa01964ed644fcd https://staging.drfop.org/files/original/21aa54f2cc58f1d7bbbf371460f09293.jpg 91d6c232ce2547fd4a92b2da4bdfa3ce https://staging.drfop.org/files/original/43a8e159de0c26aa574ccfee54b66866.jpg d697bc4196132af4b6a33226ea167054 https://staging.drfop.org/files/original/bbd717fc89481bf516d899e84e674930.jpg fa7da43c15df8f4730367e7d1a28d083 https://staging.drfop.org/files/original/095050e87ef41d2f053cf7fdb2d3f9d8.jpg 8d867d08333393bb2170844cf6d76586 https://staging.drfop.org/files/original/5fd0bdf92a32a8d7b20419407e0a6e07.jpg 0d975f91d4cbfda7367c753e55bfbd73 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_031.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 31 - 87 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_031.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee VI. Prosthetic Usefulness and Wearer Performance</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Systematic research in limb prosthetics has, during the past decade, produced not only better prostheses but also improved techniques for their application. Similarly, programs of prosthetics education have provided a new generation of physicians, prosthetists, therapists, and associated professional personnel with a greater appreciation of the amputee's physical and emotional needs and a greater understanding of how best to meet them. But ultimately research and education in the fitting of artificial limbs have real worth only to the extent that the individual amputee can accept and utilize the prosthesis provided him.</p> <p>The degree of acceptance and utilization is governed ultimately by the single consideration : <i>Of what value is the prosthesis to the amputee?</i> While the wearer himself must provide the essential elements of this valuation, his feelings and attitudes about other matters can significantly affect his opinions and judgments about the worth of his prosthesis. Accordingly, data which included both subjective amputee reactions and more objective ratings and judgments of independent observers were collected. Properly analyzed, these data provide a firm assessment of recent achievements in arm prostheses as well as some measure of the effectiveness of the techniques now recommended for the management of arm amputees.</p> <p>The classification, analysis, and interpretation of the more subjective portions of the data (those collected by interrogation of amputee subjects) make up Part 1 of this two-part discussion. Presentation and support of the more objective material (that obtained by tests and observation) constitute Part 2. All of the data reported were recorded on the special forms illustrated in Appendices IIIB and IIIC of Section I of this series (Artificial Limbs, Spring 1958, pp. 32 through 39).</p> <p>The opinions and statements reported in Part 1 and the test results and observations presented in Part 2 relate to the meaning and the value of program prostheses in various tasks normally encountered in everyday life. As a perceptive reader will note, the term "activities of daily living" is used throughout this article to denote that specific context and is not meant to be synonymous with the term "ADL," which through increasing currency has become part of the professional jargon of physical and occupational therapy. As used here, it encompasses a broader range of activities than it does when generally used in the treatment of human disability. Generally ADL is limited to tasks relating to personal independence and self-care in the home; in our context, recreational and vocational activities are included.</p> <h3>Part 1. Amputee Opinions Concerning Utility of Arm Prostheses in Activities of Daily Living</h3> <p>In general, the prosthesis that will be most valuable to the arm amputee will be the one with which he can perform, most efficiently and with the least effort and discomfort, the greatest number of useful activities ordinarily performed with the normal upper extremity. Thus an evaluation of an arm prosthesis can be based upon the usefulness of a prosthesis to the patient as indicated by his need for it in performing daily activities, the activity level of the patient with respect to the number of activities which he performs with his arm, the ease with which he uses the prosthesis, and the frequency with which he uses it for the performance of activities which are important to him.</p> <p>To obtain amputee reactions concerning the general utility of arm prostheses, the participating subjects were intensively interviewed, and the essential data were recorded on two sets of questionnaires. One set was used to record amputees' opinions of the usefulness of their arms in activities of daily living, the activity level as regards the number of different activities they performed, and the degree of ease or difficulty with which they were able to use their prostheses. The second set of questionnaires was used to collect data concerning the use of prostheses in 20 selected bimanual activities, specifically the frequency with which these activities were performed and the importance to the amputee of being able to perform these activities. With certain minor exceptions, the interrogation was conducted with respect both to the old prosthesis (Evaluation I) and to the new (Evaluation II). The time lapse between the two interviews varied for individual amputees; it was never less than six months for any, as much as 18 months for a few, and approximately 12 months for the average case.</p> <h3>Usefulness, Activity Level, and Ease of Use in Activities of Daily Living</h3> <p>In view of the complexities of everyday human activities, almost any attempt to study the circumstances affecting prosthetic utilization is difficult. As a practical approach to the problem, however, the subjects were queried in a pattern designed to elicit their opinions concerning the value of both their old and new prostheses in the key activity areas of eating, dressing, work, social and recreational functions, and home tasks.<a style="text-decoration:none;">*</a> To determine general usefulness, the amputees were asked to rate their prostheses (first the old and then the new) as essential, very useful, of limited use, of no use, or as a hindrance, the purpose being to establish the amputees' own valuations of their prostheses in performing activities in the five activity areas. Secondly, the subjects rendered their own estimates as to the relative number of activities performed with old and with new prostheses, again with respect to the five key areas of activity. Finally, the subjects were asked to estimate the relative ease with which their old and new prostheses could be used in each of the same five areas.</p> <p>The questionnaires regarding usefulness, number of activities performed, and ease of performance with both old and new prostheses were applied to all available types of upper-extremity amputees, unilateral and bilateral. Because the problems of the bilateral arm amputee differ from those of the unilateral, and because the number of available bilateral cases was too small to have statistical significance, the results for 349 unilateral subjects are treated first, those for the 10 bilaterals in a separate section.</p> <h4>Unilateral Subjects</h4> <p>Among unilateral arm amputees especially, the level of use to which an arm prosthesis is put is determined to a considerable extent by the ease and convenience of performance with the prosthesis as compared with the ease and convenience of performance without it or as compared with the ease and convenience of not performing at all. If a particular activity is too difficult or too time-consuming for a given unilateral arm amputee to perform with his prosthesis, he will either avoid it completely or else find some other way of getting it done. If he elects to accomplish the activity without using the prosthesis, he may do so in any of several ways:</p> <ol> <li>He may use the remaining sound hand, with or without assistance from other parts of the residual anatomy or from external objects. Unilateral arm amputees commonly perform with one hand many activities which under normal circumstances would be bimanual (e.g., tying necktie or shoelaces).</li><li>He may use special devices and techniques (e.g., various tools intended for one-handed performance of tasks ordinarily bimanual), again with or without assistance from some other available source.</li><li>He may prevail upon another person either to provide assistance or to perform the task for him more or less completely.</li></ol> <p>Although any one of these alternatives may serve the purpose of accomplishing essential activities, none of them suggests adequate restoration of loss, either in terms of true personal independence or in the sense of normal appearance. In addition, factors such as temperament, disposition, motivation, and habit patterns further influence the simple "ease-difficulty" premise of prosthetic utilization. Though the true state of affairs in any particular case is a highly complicated one, there can be little doubt that the inherent "usefulness" of the prosthesis is one of the prime factors in determining the number and kinds of purposes to which an artificial arm will be put. This first series of studies was therefore designed to discover the activities for which prostheses are used by amputees with unilateral arm loss at various levels and to delineate any changes in use patterns properly attributable to the new types of prostheses fitted during the NYU Field Studies.</p> <h5><i>Eating</i></h5> <p><i>Usefulness</i>. As regards eating, unilateral below-elbow amputees generally thought well of their old prostheses, above-elbow subjects had a considerably lower opinion of their arms, and shoulder-disarticulation amputees viewed their prostheses as being of relatively little value. In almost all cases, the amputee rated the new prosthesis more useful than the old in eating. For all types of amputees, there were fewer opinions that the prosthesis was of "no use" or "a hindrance" and a greater number of opinions that it was "very useful" or "essential." While this shift in opinion was characterized primarily by a considerable decrease in the proportion of unilateral amputees (of all types) who considered their prostheses of "no use" or "a hindrance," there was also an increase in the number of those considering the prosthesis "very useful" or "essential."</p> <p>Of major significance is the fact that even with the newer arms the majority of unilateral amputees (58 percent of the below-elbow amputees, 83 percent of the above-elbow amputees, and 96 percent of the shoulder-disarticulation subjects) felt that the prosthesis was of limited use or no use in eating. Since only 41 percent of the below-elbow amputees, 15 percent of the above-elbow amputees, and 4 percent of the shoulder-disarticulation subjects considered their new prostheses essential or very useful in eating activities, it must be concluded that, although there was some increase in usefulness in the "program" prostheses, considerably greater improvement is necessary if the artificial arm is to have a significant influence upon the eating activities of the majority of unilateral arm amputees. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. Reports from all unilateral amputee groups indicated that the number of eating activities increased for a significant number of amputees while very few subjects experienced a decrease. The increase in usage was greatest for shoulder-disarticulation amputees (45 percent), less marked for the below-elbow group (34 percent), and least for above-elbow amputees (28 percent). <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. As might be expected from the foregoing, a significant number of amputees of all types reported that eating activities were easier with the new prosthesis than with the old, although the increase in facility for the below-elbow and above-elbow groups was less marked than for the shoulder-disarticulation amputees. <b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 1</b>, based on responses from 168 below-elbow, 158 above-elbow, and 23 shoulder-disarticulation ampu- tees, presents a composite picture of the specific eating activities for which unilateral amputees of various amputation levels said they used their prostheses. Since the list of activities was compiled from amputees' responses to the unstructured request <i>List activities for which you use your [new] prosthesis</i>, and since in the experience of the authors arm amputees commonly use their prostheses more extensively than they can recall, it may be assumed to be minimal both with respect to number of activities and to incidence of performance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prime significance of these responses lies in their indication of use potential of the prosthesis. For example, the fact that in opening a soda bottle some below-elbow, above-elbow, and shoulder-disarticulation amputees can and do hold the bottle with their terminal device suggests that this activity is not particularly difficult and that it could be performed by most amputees. Why, then, do some amputees prefer to use one hand only or to hold the bottle between the knees to take off the cap? Such questions are worthy of more intensive investigation than was possible in the NYU Field Studies.</p> <h5><i>Dressing</i></h5> <p><i>Usefulness</i>. Amputees' opinions concerning the usefulness of the prosthesis in dressing show a pattern somewhat similar to that found in eating. There is a general shift of opinion toward the positive end of the scale, but the extent of the change varies with amputee type. It is slight in the below-elbow group, somewhat greater in the above-elbow group, and most marked among shoulder-disarticu-lation amputees. When the percentage of amputees who considered the prosthesis essential or very useful is employed as the basis of comparison, the data for new vs. old arm were: below-elbow, 63 percent vs. 59 percent; above-elbow, 24 percent vs. 14 percent; shoulder disarticulation, 17 percent vs. zero. Although because of the small number of subjects involved the data on the shoulder-disarticulation group must be interpreted cautiously, there are definite indications that a significant number of amputees considered the new prosthesis more useful than the one worn previously. It is also apparent that most groups consider a prosthesis <i>more useful for dressing than for eating</i>. The comparative percentages of amputees who considered the new prosthesis either essential or very useful were—below-elbow: dressing, 63 percent, eating 41 percent; above-elbow: dressing, 24 percent, eating 15 percent; shoulder disarticulation: dressing, 17 percent, eating 4 percent. These differences may be attributable to the larger number of discrete tasks involved in dressing as compared with eating. Despite the improved sentiment toward the usefulness of the program arms, however, a considerable proportion of unilateral amputees of all types (below-elbow, 37 percent; above-elbow, 76 percent; shoulder disarticulation, 83 percent) still considered these prostheses of limited use, no use, or a hindrance. Again it is obvious that much room for improvement still exists, particularly for the more severely handicapped above-elbow and shoulder-disarticulation groups. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. An increase in the number of dressing activities performed with the prosthesis was reported by all amputee groups. The proportion of amputees indicating increased use of the prosthesis ranged from 28 percent of the below-elbow category to 38 percent of the shoulder-disarticulation sample. An insignificant number reported decreased usage. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. Since extent of use is undoubtedly related to ease of use, it is not surprising to find that a high proportion of the amputees considered dressing activities easier to perform with their new prostheses than with their old. Easier operation was reported by 52 percent of the below-elbow, 42 percent of the above-elbow, and 55 percent of the shoulder-disarticulation subjects. Very few subjects at any amputation level reported greater difficulty of operation with the program prosthesis, although almost one in twelve below-elbow amputees fell into this category. The use of more complex terminal devices and the change from soft (leather) to hard (plastic) sockets may in some cases have contributed to this minority opinion. <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 2</b> presents a tabulation of specific dressing activities in which unilateral arm amputees reported performance with their prostheses. Since this listing is based upon the responses of the subjects to open-end questions, it should be considered minimal and indicative rather than comprehensive.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major significance of the data in <b>Table 2</b> lies in their indication of the use potential in existing prostheses. Equally important, however, is the corollary question, <i>Why is this potential not fully utilized by amputees? </i>For example, 88 below-elbow, 51 above-elbow, and 5 shoulder-disarticulation amputees claimed that they held one end of a necktie with the prosthesis while they tied the knot with their "good" hand. This circumstance would suggest that the activity is perfectly feasible for all three amputee types and that it might almost be considered a "typical" or "normal" prosthetic activity. Nevertheless, the fact remains that a considerable number of amputees tie their neckties using the "good" hand alone. Presumably it is "easier" or more convenient for them to employ the one-handed method, but whether the reason is related to prosthetic difficulty, lack of motivation to use the prosthesis, or prior habit pattern is not readily apparent. More intensive study in this area might be extremely fruitful in gaining deeper insight into the problems of prosthetic utilization.</p> <h5><i>Work</i></h5> <p><i>Usefulness</i>. As a result of the research program, all amputee types except the below-elbow showed an increase in positive attitude toward the usefulness of prostheses in their work. The shift in opinion was quite marked in the shoulder-disarticulation group but less apparent with the above-elbow subjects. Although the below-elbow amputees as a whole indicated little change in usefulness between the old and the new prostheses, their opinions of both prostheses were generally high.</p> <p>In spite of apparent improvement with the new prostheses, many of the amputees (below-elbow, 24 percent; above-elbow, 40 percent; shoulder disarticulation, 55 percent) felt that their prostheses were of little or no value to them on the job. Since, however, these percentages are much lower than the corresponding ones for the two activities previously discussed, it would appear that amputees consider their prostheses more useful for work than for either eating or dressing. The reason may be that eating and dressing involve a relatively small number of activities, many difficult to perform with a prosthesis, while vocational activities present a much broader variety of tasks of which perhaps many can be performed better with a prosthesis than without one. <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. Sixty-eight percent of the shoulder- disarticulation subjects reported that they performed more work activities with the new prosthesis. So did 41 percent of the above-elbow and 29 percent of the below-elbow participants. <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. A major proportion of the amputees believed that the new arm made work activities easier. Holding this opinion were 63 percent of the be-low-elbow subjects, 75 percent of the above-elbow amputees, and 76 percent of those with shoulder disarticulations. Although this result represents a more uniform and significant "positive shift" than that found for either eating or dressing, one in eight of the below-elbow amputees felt that work activities were harder to perform with the program prosthesis. The basis for this minority opinion was not apparent from the data. <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. The specific work activities that amputees can perform with their prostheses, and the kinds of jobs they can hold successfully, are of considerable interest from the viewpoint of vocational re- habilitation. <b>Table 3</b> presents a listing of vocational activities reported by the 168 below-elbow, 158 above-elbow, and 23 shoulder-disarticulation amputees involved in the study. Activities reported by the subjects have been classified arbitrarily as light work {i.e., activities typical of white-collar workers), medium work {i.e., activities typical of artisans and mechanics), heavy work {i.e., farming and other heavy manual occupations), and miscellaneous. Although this listing does not reveal the full story of the employability of unilateral arm amputees, it does indicate trends. While a detailed analysis of the subject is not possible at this time, it is apparent that unilateral arm amputees are capable of a wide variety of work activities and are employable in a wide range of occupations.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An additional interesting aspect of the relationship between vocation and amputation was provided by amputee responses to two questions asked at the conclusion of the study. These questions and the answers provided by 349 subjects in the study were: <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>From these data it is evident that, while one in five amputees changed jobs during the course of the study, few of the changes were attributed to the new prosthesis. Of the total number of subjects in the study, therefore, very few felt that the new prosthesis affected their employment. Consideration of the type of job change made by the amputees also fails to reveal any significant trend. None of the changes reported (student to farm hand, post-office clerk to wholesale manager, hospital attendant to repairman, unemployed to guard, janitor to stock clerk) indicated any marked shift in vocational status, either positive or negative. It must be concluded, therefore, that the prostheses provided in the study had little apparent effect on the employment status of the participants.</p> <h5><i>Recreational and Social Activities</i></h5> <p><i>Usefulness</i>. All amputee groups reported that in recreational and social activities the program prosthesis was an improvement over the old prosthesis. As with the activity areas previously discussed, improvement was least marked in the below-elbow subjects, but even this group showed a change for the better. For example, 72 percent of the below-elbow sample considered that their new prosthesis was either essential or very useful as against 60 percent for the old prosthesis. Shoulder-disarticulation amputees reflected a greater degree of improvement, 33 percent reporting essential or very useful for the new prosthesis as compared with 19 percent for the old. Above-elbow amputees appeared to obtain the most benefit from their new prostheses, the proportions rating their prostheses in the upper two categories of the scale being: new arm, 69 percent; old arm, 33 percent. The proportion of amputees reporting that the prosthesis was of little or no use or was a hindrance in leisure-time activities (below-elbow, 28 percent; above-elbow, 31 percent; and shoulder disarticulation, 67 percent) was greater than for vocational activities but less than for eating and dressing. <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. A significant number of amputees used their new prostheses for additional leisure-time activities. One third of the above-elbow and shoulder-disarticulation subjects and one fourth of the below-elbow subjects had found new uses. A very small proportion of above-elbow and below-elbow amputees reported decreased usefulness (3 percent and 5 percent respectively). <b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. More than 50 percent of all the amputees felt that the performance of social and recreational activities was easier with the new arm. A small number of below-elbow (7 percent) and above-elbow (3 percent) subjects felt that activities in this area were harder to do. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 4</b> presents a listing of leisure-time activities performed by unilateral arm amputees using a prosthesis. Some of the pursuits listed are performed vocationally also, but the subjects in the study mentioned them more frequently as a hobby than as a vocation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While an amputee's social or hobby interests are perhaps not of the same level of importance as eating, dressing, and working, they are nevertheless quite significant in his total pattern of living. It is apparent that to many arm amputees a major value of the prosthesis in leisure-time activities resides in its cosmetic contribution, this factor being mentioned most frequently by all types. In addition, many found their prostheses useful in a variety of sports and hobbies, including such relatively active endeavors as hunting, fishing, golf, and baseball.</p> <h5><i>Home Tasks</i></h5> <p><i>Usefulness</i>. Use of a prosthesis at home encompasses a wide variety of tasks, from washing dishes and sweeping floors to gardening, painting, and electrical and plumbing repairs. Some of these activities are, of course, basically of a vocational nature but are performed as avocations on a part-time or intermittent basis. As for improvement in the usefulness of the prosthesis in home tasks, the shift in opinion was relatively small in below-elbow subjects but quite pronounced in above-elbow and shoulder-disarticulation amputees. In home tasks, as in other activity areas discussed previously, a high percentage of below-elbow subjects (70 percent) considered their old prostheses either essentia] or very useful, and this opinion was maintained for the new prosthesis (73 percent). It would appear that for this type of amputee there was less margin for improvement and hence less was achieved, or, the other way round, the old arms available for below-elbow amputees were relatively more satisfactory than were those available for other amputee types. <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. Nearly 45 percent of the above-elbow and shoulder-disarticulation cases and a smaller proportion of the below-elbow amputees (28 percent) found new uses in the home for their program prostheses. A small minority of the below-elbow group (6 percent) found fewer uses for their new prostheses. <b>Fig. 15</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. The proportion of amputees reporting greater ease in performance of home tasks with the program prostheses ranged between 64 and 75 percent. Shoulder-disarticulation amputees (75 percent) were most favorably impressed, followed by above-elbow (66 percent) and below-elbow (64 percent). A few below-elbow (9 percent) and above-elbow (3 percent) subjects found home tasks more difficult than before. <b>Fig. 16</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 5</b> indicates the types of home activity for which unilateral amputees used their prostheses. From the scope of activities listed, it is apparent that unilateral amputees find a wide range of uses for their prostheses in the home. While the rate or quality of performance is not indicated by the data, several of the tasks performed imply a high degree of dexterity. For example, a number of amputees undertook automobile and electrical repairs and various types of carpentry, and they made use of a wide range of tools, including power equip- ment. Since, as mentioned earlier, many tasks performed in the home by choice or necessity are vocational in nature, a more intensive investigation of this performance pattern would throw further light on the employment potential of arm amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bilateral Subjects</h4> <p>In the performance of bimanual activities by unilateral arm amputees, the prosthesis serves primarily, as has been seen, to assist the remaining good hand. Similarly, and for various reasons, unilateral arm amputees not infrequently perform with the one remaining hand activities ordinarily bimanual. Bilateral arm amputees quite obviously are faced with an entirely different situation. Since more or less of both upper extremities is lacking, at least one prosthesis must assume more than an assistive role, and one-handed performance of tasks normally two-handed cannot be substituted for use of a prosthesis. Manual activities required of bilateral arm amputees must therefore be done prosthetically if done at all. In a very real sense, then, the performance problems and the adaptations of bilateral arm amputees are quite unlike those of any type of unilateral amputee, and they therefore warrant separate discussion.</p> <p>In the Upper-Extremity Field Studies, data were collected on 10 bilateral arm amputees (7 bilateral below-elbow, 3 bilateral above-elbow/below-elbow). Five of these subjects (4 bilateral below-elbow, 1 bilateral above-elbow/below-elbow) were wearing prostheses bilaterally when admitted. The other five had either one prosthesis only or none at all. Thus, although information as regards program prostheses was obtained on all 10 subjects, comparative data on new vs. old arms are available on only five subjects.</p> <h5><i>Experienced Wearers</i></h5> <p>Although the five amputees who had worn prostheses bilaterally prior to the NYU Field Studies rated their old arms quite useful in all five of the activity areas, they considered the new prostheses equally useful or slightly better than the old ones (<b>Table 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As shown in <b>Table 7</b>, four of the five experienced wearers of bilateral prostheses indicated equivalent or increased use of their new prostheses as compared to the old, while one reported decreased use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As might have been anticipated, the pattern of amputee responses concerning ease of use (<b>Table 8</b>) of the new prostheses as compared with the old was quite similar to that concerning extent of use (<b>Table 7</b>). In general, the evidence indicated somewhat easier operation of the program prostheses, although the improvement was by no means universal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those bilateral arm amputees who reported easier operation and more extensive use of their new prostheses attributed the improve- ments primarily to the more secure grasp permitted by the terminal devices prescribed in the Field Studies. Neoprene-lined hook fingers and the heavy-load feature of the Northrop-Sierra two-load hook contributed greatly to this improved grasp security. Other favorable aspects of the new arms, mentioned by different subjects, were lighter weight and better control (faster operation and lower force requirement). The one subject fitted with an above-elbow arm indicated that operation of his new elbow lock was simpler and more efficient.</p> <h5><i>New Wearers</i></h5> <p>The five amputees who had not worn prostheses bilaterally prior to the Field Studies rated their program prostheses quite useful (<b>Table 9</b>). For some reason, however, their ratings showed less enthusiasm than did those of the patients who had previously worn prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Specific Activities Performed</i></h5> <p>At Evaluation II (new prostheses), information on the specific uses to which bilateral arm amputees put their prostheses was obtained from all 10 subjects for each of the activity areas under study. The activities reported by the individual amputees were given as "free responses" (i.e., unprompted and unstructured), and hence the listings may be considered more representative than complete.</p> <p>The available data on the 10 bilateral subjects indicate that they used their prostheses extensively in eating and attained a relatively high level of independence. Two mentioned specifically that they performed all eating activities with their new prostheses (i.e., were completely independent). <b>Table 10</b> presents specific eating activities reported to be performed by the bilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Only one of the 10 bilateral amputees claimed complete independence in dressing, although two other subjects reported the performance of all dressing activities except buttoning shirt sleeves. Two more persons performed all activities except fastening buttons, lacing shoes, and tying neckties. <b>Table 11</b> lists specific dressing activities reported as performed by the bilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The employability or vocational-placement possibilities of bilateral arm amputees always hold considerable interest. Although the sample was in this instance exceedingly small, it may be worth noting that five of the 10 bilateral amputees were self-employed, that four worked for others, and that only one was unemployed. Of the nine employed subjects, one was a lawyer, one an engineer, one a forester, and one a quality-control inspector. Two were filling-station attendants, and three were farmers. The quality-control inspector, unemployed at the beginning of the program, obtained his position after receiving his new prostheses, and he credited the functional qualities of the limbs for his new employment.</p> <p><b>Table 12</b> lists specific activities reported by the nine employed subjects as being performed with their program prostheses at work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A listing of recreational activities performed by the bilateral amputees revealed that with their new arms most were able to drive a car independently and that most engaged in some form of active or passive recreational endeavor. <b>Table 13</b> lists specific activities mentioned by the subjects as being performed with their prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The pattern of home activities performed by bilateral amputees (<b>Table 14</b>) does not differ greatly from that of unilateral except that among bilaterals there is a lesser tendency to undertake tasks requiring fine manipulation. Even allowing for the smaller number of subjects involved, it is apparent that the home activities of bilaterals run more to gross tasks, such as pushing a lawnmower or handling a broom, than to precision activities, such as electrical or radio repairing. Since the absence of "at least one good hand" would be a major handicap in work requiring manipulation of small parts, such a situation is quite understandable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In summary, the comparative data on five bilateral arm amputees whose preprogram prostheses were replaced by program arms appeared to indicate that:</p> <ol> <li>The five subjects thought well of their old prostheses and used them extensively.</li><li>In four of the five cases there was slight but definite evidence of functional improvement over that provided by the old prostheses. Contributing largely to this improvement appeared to be the better grasp furnished by the Dorrance 5X and Northrop-Sierra two-load hooks, partly because of the neoprene-lined hook fingers and partly because of the heavy-load feature of the Northrop-Sierra device. Other favorable features mentioned by some of the subjects were lightness and ease of operation. The one amputee fitted with an above-elbow prosthesis felt that his new elbow was much more dependable and much easier to operate than the one previously worn. One subject in the group apparently had a left prosthesis very poorly fitted and functionally inadequate, a deficiency which, in view of the rigorous checkout procedures and the close control of fittings by the clinic teams, is hard to explain. Nevertheless, that particular patient was obviously fitted unsatisfactorily, and this circumstance affected his whole reaction to the prostheses provided.</li></ol> <h4>Discussion</h4> <p>An outstanding characteristic of the data thus far presented is general consistency. For all categories of daily-living activities considered (eating, dressing, work, recreational and social life, and home tasks), and for all criteria applied (general usefulness, level of usage, and ease of use), the evidence strongly indicates that the prostheses provided in the program were more useful than those previ- ously worn. But the material also raises a number of interesting questions of which only some can be answered satisfactorily by the available data. For example, the extent of improvement provided by the new prostheses varied considerably from amputee type to amputee type. It was least for the below-elbow subjects, and some few members of this group even expressed a preference for the old prosthesis. For the unilateral above-elbow and shoulder-disarticulation subjects, the increased usefulness of the new prosthesis was considerably more marked and dramatic.</p> <p>When one speculates on the reasons for these differences, it must be borne in mind that the so-called "old" prostheses exhibited a wide range of quality from very poor to excellent. A number of the preprogram arms, particularly those for below-elbow amputees, were probably as good as, in some few cases even better than, those provided in the study. Moreover, some of the below-elbow subjects whose old leather-socket arms had some of the comfort qualities of old shoes or slippers reacted unfavorably to the new plastic sockets. Whatever the reasons, it was evident that some of the old arms provided below-elbow amputees with a relatively high degree of usefulness and that the impact of the research program on these subjects was relatively small. The reverse appears to have been true of above-elbow and shoulder-disarticulation prostheses. Taken as a whole, the old arms for these cases were of comparatively limited usefulness, and hence considerable improvement was effected by the new prostheses. Thus it may be said that the prostheses provided in the field program made the greatest contribution where improvement was most needed.</p> <p>Another thought-provoking finding of the study was that the usefulness of the prostheses obviously varied from one activity area to another, sometimes quite significantly. All three unilateral groups rated their prostheses as being about equally useful in home, work, and social activities but considerably less useful in dressing and of least use in eating. An explanation of these differences may lie in the fact that eating and dressing involve a limited number of specific activities, particularly those which require bimanual effort, and that the majority of these are quite difficult to perform with an arm prosthesis. It may also be conjectured that, in the sometimes quite lengthy time lapse between amputation and receipt of an arm prosthesis, patients build strong habit patterns of one-handed eating and dressing and that these habits carry over after the prosthesis has been supplied. Work, leisure, and home tasks present a much wider and more varied range of activities. Presumably more of these require bimanual performance in which the prosthesis is of definite assistance. Bilateral arm amputees gave uniformly high ratings to their prostheses in all activity groups, but their performance problems are quite different from those of unilateral arm amputees.</p> <p>A third area of interest involves the matter of basic reasons for use or nonuse of the prosthesis. In numerous instances, a particular activity was performed with the prosthesis by a considerable number of amputees of a given type. Why, then, do not all amputees of that type perform that activity with the prosthesis? Here is a question with many implications. It has been suggested that of the factors determining prosthetic usage-such as ease and convenience of performance, motivation, habit patterns-the first named is of basic importance. If, for example, we consider some specific activity such as tying shoelaces, which with prosthetic help apparently can be performed by some amputees of all types, even including a few with shoulder disarticulations, we may assume that this activity presents a certain level of difficulty and inconvenience. For below-elbow subjects the level may be low enough not to discourage more than a few from performing the task with their prostheses. But it must also be high enough so that others, by reason of habit or lack of motivation or some other influence, will tie the laces one-handed, wear loafers or buckle shoes, or in some other fashion avoid use of the prosthesis. For above-elbow and shoulder-disarticu-lation amputees, of course, the difficulty in performing the activity rises progressively and markedly, so that even though the performance potential be available with the prosthesis fewer amputees would be inclined to avail themselves of it. Obviously, then, further study of the factors affecting prosthetic utilization is highly desirable.</p> <p>A fourth area of interest has to do with the vocational potential of arm amputees. The number and variety of tasks that amputees can perform with the aid of an artificial arm is quite surprising. Extensive use of the prosthesis on the job, in activities around the house, and in hobbies suggests for arm amputees a much wider employment potential than is generally recognized. This subject too is worthy of further investigation on a more intensive basis than was possible in the NYU Field Studies.</p> <p>In general, the relation between the pre-treatment (Evaluation I) and post-treatment (Evaluation II) conditions of the five bilateral amputees was quite similar to the corresponding relation for the unilateral below-elbow amputees discussed previously. Since the bilateral sample included predominantly below-elbow fittings (4 bilateral below-elbow, 1 bilateral below-elbow/above-elbow), the similarity is not surprising. The over-all performance patterns of the 10 bilateral subjects would indicate that as a whole these patients achieved a high level of performance in a wide range of tasks. To a very considerable degree they appeared able to operate their prostheses effectively and to meet independently a substantial number of the requirements of daily living.</p> <h3>Extent of Use of Arm Prostheses in Twenty Selected Bimanual Activities</h3> <p>In the preceding section, the evaluation of the utility of prostheses provided arm amputees was based upon an analysis of their usefulness in five key activity areas, changes in activity level, and ease of use. To gain further insight in this matter, additional study was made of how amputees use their prostheses in 20 selected activities which were considered significant on the basis of four criteria:</p> <ol> <li>The activities should be important ones drawn from all five of the areas of daily living previously discussed (i.e., eating, dressing, work, social life and recreation, and home tasks)</li><li>The activities should call for a range of work levels from floor to head.</li><li>The normal performance of the activities should be bimanual.</li><li>Prosthetic performance of the activities should be possible for all unilateral amputee types.</li></ol> <p>The tasks selected were:</p> <ol> <li>Cut food with knife and fork</li><li>Sharpen pencil</li><li>Sweep up dirt with brush and dustpan</li><li>File and clean fingernails</li><li>Tie necktie</li><li>Use telephone (particularly when taking notes)</li><li>Assist someone with coat</li><li>Take bills out of wallet</li><li>Unbutton shirt sleeve</li><li>Carry several packages</li><li>Use "Flit" gun</li><li>Open bottles, jars, and tubes</li><li>Put on glove</li><li>Use paper clip</li><li>Carry cafeteria tray</li><li>Use can or bottle opener</li><li>Tie shoelaces</li><li>Play cards</li><li>Rewire electric plug</li><li>Use hammer and nails</li></ol> <p>With regard both to preprogram and to program prostheses, the subjects were asked concerning each of the selected activities five questions:</p> <ol> <li>How often in your routine of living does the occasion arise for you to perform the activity? (Daily, weekly, monthly, other)</li><li>How important is the activity in your particular pattern of living? (Very important, important, of little or no importance)</li><li>How often do you perform the activity with your prosthesis? (Daily, weekly, monthly, other)</li><li>If you do not perform the activity with your prosthesis every time the occasion arises, why not? (Write-in)</li><li>If you never use the prosthesis to perform the activity, how do you perform it? (Write-in)</li></ol> <p>The material that follows presents amputee responses to these questions and from these responses seeks to determine the extent to which prostheses were meeting amputee needs. In the main, attention is directed toward the new prostheses provided in the study, that particular data being considered as indicative of present status and hence more meaningful. Only in regard to Question 3, and then with respect to unilateral cases only, is a comparison made between old and new prostheses.</p> <p>The subjects in this study were the same as those making up the sample for the previous series of questions. Again, the data on the three unilateral amputee groups are presented first, with those for the bilateral subjects in a separate section following.</p> <h4>Unilateral Subjects</h4> <p>As we have seen, the problem of restoring function to unilateral arm amputees varies from amputee type to amputee type, the extent of restoration generally being related inversely to the degree of anatomical loss. But all three types of unilateral arm amputees usually have left one normal arm and hand, and accordingly the prosthesis needs for the most part only to assist the remaining natural member.</p> <h5><i>Frequency of Occasion to Perform Activities</i></h5> <p>The purpose of the question "How frequently does the occasion arise to perform the activity?" was to ascertain how often amputees were called upon, or had the opportunity, to perform each of the 20 selected activities, regardless of whether they used the prosthesis in the performance of the activity or whether they even performed it at all. For instance, the question "How often do you have occasion to cut food with a knife and fork?" was interpreted as "How often do you have food which requires cutting with a knife?" Responses relative to each of the 20 activities were tabulated in four categories-at least once daily; at least once weekly; at least once monthly; and less than once monthly, or never. Separate tabulations were prepared for below-elbow, above-elbow, and shoulder-disarticulation amputees. On the basis of these tabulations, there was calculated the percentage of amputees (of each type) who reported once daily or oftener as the frequency of occurrence of a particular activity. The percentage figures were then used to arrange the 20 activities in order from those occurring most frequently to those occurring least frequently. It should be emphasized that "most frequently," as used here, means occurring on a daily basis to the largest proportion of amputees.</p> <p><b>Table 15</b> presents the results for the three groups of unilateral amputees. Since these data are based on unverifiable amputee statements concerning their activities, the information in <b>Table 15</b> cannot be considered as presenting any absolute answer. Nevertheless, the data are quite consistent. Percentages for the first nine activities are of the same order for all groups, and that for the tenth shows a slight variation for the shoulder-disarticula-tion subjects only. The 10 tasks on the lower end of the table were performed daily by the least number of amputees. These data showed similar patterns of occurrence for each of the three types of amputees. Thus it would appear that some of the activities on the "selected" list confront a large proportion of all types of amputees on a daily basis. Other activities affect relatively few amputees as often as this.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>How often an activity should occur, or how many people it should affect to be considered "significant" in the lives of amputees, is a philosophical question. On an arbitrary basis we might say that the first nine activities in <b>Table 15</b>, which occur daily in the lives of more than about half of the amputee population, are "significant" activities. Yet who can say that tying a necktie (occurring to one third of the group daily) or even using a hammer and nails (less than one fifth of the population affected daily) are "insignificant" activities? Obviously such tasks could be highly significant to the particular amputees involved.</p> <h5><i>Relative Importance of the Activities</i></h5> <p>In addition to the frequency of occurrence, the degree of importance subjectively attached to being able to perform a specific activity is a second significant factor in determining the usefulness of a prosthesis to its wearer. Accordingly, the ten subjects were also asked to rate each of the 20 selected activities as "very important," "important," or "of little or no importance" to them in their regular activity pattern.</p> <p><b>Table 16</b> presents the percentages of amputees rating the respective activities as either "very important" or "important," the activities being arranged in the approximate order of importance on the basis of these percentages. For example, "cut food with knife and fork" was rated "very important" or "important" by more amputees within each of the three unilateral amputee groups than was any other of the 20 selected activities. Tying a necktie was second in importance to above-elbow and shoulder-disarticulation amputees but fifth in importance to the below-elbow subjects. Thus the ranking of activities in <b>Table 16</b> may be thought of as indicating the general level of importance attached to the activities by the unilateral amputee population as a whole.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In these terms the 20 activities fall rather obviously into three levels of significance. The first 10 tasks are rated as important by two thirds or more of the sample, cutting food being by far the most significant activity (about 9 out of 10 subjects). The next three activities may also be considered quite significant, almost one in two amputees designating them as important. The final seven tasks may be regarded as having lower general significance, no more than one in three amputees rating them as important. With the possible exception of using a "Flit" gun, however, even these low-ranking activities cannot be considered as completely insignificant. For example, rewiring an electric plug, nineteenth in order on the list, is rated as an important activity by one in five unilateral amputees of all types, a fairly substantial number of people. We may conclude therefore that, while according to the criteria used in this study the 20 selected activities vary widely in importance, all, or almost all, have value to some significant proportion of unilateral arm amputees.</p> <p>It is of interest to compare the data on the importance of activities with those on the frequency of occurrence discussed earlier. <b>Table 17</b> presents the 20 activities in approximate order of frequency of occurrence (from <b>Table 15</b>) and also lists the approximate order of importance for the 20 tasks (from <b>Table 16</b>). A fairly consistent relationship between frequency and importance is apparent at once. Seven of the nine most important activities occur very frequently.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It can be inferred therefore that, in general, activities which occur most frequently are likely to be regarded as being the most important, but the instances where this principle does not hold are also of interest. Two out of three shoulder-disarticulation amputees said they had occasion to use a paper clip daily, but only one out of three considered the activity important. Less than one in six below-elbow amputees reported that they had occasion to use a hammer and nails on a daily basis, yet two out of three considered the activity important. While only one in three of the below-elbow subjects reported tying a necktie daily, about three in four considered it important to be able to do so. Thus, some activities that occur frequently may be relatively unimportant; others may occur only infrequently but still have great personal significance.</p> <h5><i>Performance of Activities with the Prosthesis</i></h5> <p>Having considered the frequency of occurrence of the 20 selected activities and the relative importance of these activities in the lives of amputees, we come now to the frequency of use of the prosthesis in the performance of the tasks, the point being to evaluate both the extent of prosthetic use and the relationship between this utilization and the two factors previously presented (i.e., frequency of occurrence and importance).</p> <p>Data on use of the prosthesis in the 20 selected activities, obtained from all amputees in the study, were organized to show the percentage of amputees who always, regardless of frequency, used the prosthesis in the performance of a particular activity, the percentage who sometimes used the prosthesis, and the percentage who never used it, a small number of amputees who claimed that they never had occasion to perform a particular activity being excluded. <b>Table 18</b> presents the incidence of use of the program prostheses as reported by the unilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Analysis of <b>Table 18</b> shows that the prosthesis is used extensively by below-elbow sub- jecls in performing the 20 selected activities, all tasks save one being performed by more than 50 percent of the group every time the opportunity arose. With rare exceptions (e.g., carrying packages), the utilization of the prosthesis in performing activities dropped off sharply and progressively from the below-elbow to the above-elbow to the shoulder-disarticulation groups. An intriguing and somewhat unexpected finding is the relatively small percentage of amputees reporting occasional use of the prosthesis. It would appear that amputee use of the prosthesis tends to be on an all-or-none basis. If an amputee uses his prosthesis to perform an activity at all, he tends always to use it for that activity. Even when this general tendency is violated, there are interesting areas for speculation. For example, cutting food with knife and fork has a relatively high incidence of "sometimes" responses. Since we know that cutting food is relatively difficult at all amputation levels, it seems probable that some amputees ignore the prosthesis under some circumstances (e.g., eating at home) but use it on other occasions (e.g., eating out or when they have company) in spite of the difficulty. The fairly general always-or-never use of the prosthesis in the performance of specific activities reinforces a conclusion presented earlier-that there is for each activity a certain threshold, or tolerance, level of difficulty associated with prosthetic performance, that this threshold varies from amputee to amputee and from activity to activity, that if the performance difficulty is within the individual's tolerance limits he will tend to use the prosthesis consistently, and that if the level of difficulty is above his limit he will tend not to use the prosthesis at all.</p> <p>The data in <b>Table 15</b>, <b>Table 16</b>, <b>Table 17</b>, and <b>Table 18</b> may also be viewed as an index of the relative usefulness of the prosthesis in the performance of the 20 selected tasks and, conversely, as a measure of the relative difficulty of the several activities from the standpoint of accomplishment by means of a prosthesis. For instance, the activity "sharpen pencil" appears to be performed (with help from the prosthesis) by 90 percent of below-elbow, 76 percent of above-elbow, and 62 percent of shoulder-disarticula- tion amputees every time the occasion arises. It would appear, therefore, that sharpening a pencil is not too difficult an operation for any type of unilateral arm amputee. The corollary conclusion is that, in pencil-sharpening, the prosthesis is a highly useful assistive device. On the contrary, activities such as cutting food or holding a telephone with the prosthesis appear to be quite difficult for arm amputees at all levels, and the prosthesis is then obviously of less value.</p> <p>If we extend this index-of-usefulness concept to the entire list of 20 activities, we obtain the results shown in <b>Table 19</b>, which presents the percentage of amputees reporting use of the prosthesis every time the occasion arose for performing the activities. If, further, it is assumed that those activities in which there is the highest degree of prosthetic utilization are activities for which prostheses are most useful (or, more simply stated, easiest to perform with a prosthesis), then <b>Table 19</b> indicates that the below-elbow prosthesis is highly useful or well adapted to performance in most of the 20 activities. For above-elbow and shoulder-disarticulation subjects, the usefulness or adaptability of the prosthesis drops off sharply (i.e., the prosthesis has a high level of usefulness for considerably fewer activities). Nevertheless, some consistency in pattern is evident for the three unilateral amputee types in that activities for which the prosthesis is most useful for the below-elbow group tend also to be easiest for the above-elbow and shoulder-disarticulation subjects. Similarly, the activities that are most difficult for below-elbow subjects also present the greatest difficulty for above-elbow and shoulder-disarticulation amputees. Not readily explained is the fact that the activities for which the prosthesis is apparently most useful generally rank low in frequency of occurrence or importance or both, while activities for which the prosthesis is least useful generally rank high in occurrence and importance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Old Versus New</i></h5> <p><b>Table 20</b> compares reports by unilateral arm amputees as regards the extent of use of the old and the new prostheses. It reveals a consistent but by no means universal trend toward greater utilization of the new prosthesis as compared with the old. It is most apparent in the above-elbow subjects (increase for 17 of the 20 activities), less apparent in the below-elbow and shoulder-disarticulation amputees. As regards specific activities, however, there appears to be no systematic pattern of changes in degree of prosthetic utilization, and hence the general evidence here is rather inconclusive.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Reasons for Performing Activities Without Using the Prosthesis</i></h5> <p>In the foregoing material, consideration has been given to the matter of amputee utilization of prostheses in terms of their use always, sometimes, or never in performing each of the 20 activities under study. When an amputee always uses his prosthesis in the performance of a particular activity, some degree of adequacy of the limb for that task may be assumed. When, however, he "sometimes" performs a task without using his prosthesis, or when he "never" uses the artificial arm in the performance of that activity, prosthetic inadequacy to some degree would seem apparent. An understanding of the specific inadequacies of today's arm prostheses with respect to each of the 20 activities would be of great value in prescription and training as well as in planning research. Accordingly, each amputee who indicated less than full utilization of his prosthesis in a given activity was asked why he didn't use his prosthesis every time he had occasion to perform that task.</p> <p>The most specific, although not the most frequent, reason given for not using the prosthesis in the performance of particular activities was that the terminal device was inadequate. For instance, a given terminal device might be capable of holding a wallet or taking out bills but be ill-suited for holding a fork; it might be suitable for holding a necktie but not for handling a telephone. It may therefore be concluded that one major reason for not using the prosthesis in performing certain activities relates to lack of versatility in the terminal device.</p> <p>Another important reason advanced for failure to use the prosthesis was that the terminal device could not be brought to the appropriate functional position and operated there. Although the exact cause of this difficulty is not apparent from the data, it may be related directly to prosthetic inadequacies. As a matter of fact, not many amputees were able to give clear reasons for not using the prosthesis, so that it is possible only to speculate on the implications of the responses Some subjects stated simply that they "could not perform" the task in question. Since this kind of response may indicate either lack of training or genuine prosthetic deficiency or both, full interpretation requires further investigation. In the absence of a more complete examination, it may only be guessed that poor features in the available prosthetic equipment contributed in some way to its disuse.</p> <p>That an activity was "easier to perform without the prosthesis" was the reason given most frequently for failure to use an artificial arm. Although not especially revealing, such statements reaffirm the conclusion reached for other aspects-that for numerous amputees performance of certain activities presents such difficulty that it is "cheaper" in time, effort, and peace of mind to do without the prosthesis. A sharp rise in the number of "easier-without-prosthesis" responses was noted in the above-elbow amputees as compared with the below-elbow subjects-a result in keeping with earlier findings of decreasing prosthetic usefulness at the higher levels of amputation.</p> <p>A number of amputees reported that the prosthesis was not worn at the time a particular activity was performed. This circumstance may be considered as indicating either that the activity was easier to perform without the prosthesis or that performance without the prosthesis presented no particular problems. Were the prosthesis indispensable, it would be worn on almost all occasions when opportunity to perform the listed activities arose. Since it evidently was not, it must be assumed that some amputees could dispense with their prostheses without (to them) significant functional loss.</p> <p>Two other general observations can be made concerning the reasons for nonuse of the prosthesis. Both reinforce evidence presented earlier. One is that the number of "reasons" for nonuse of the prosthesis increased sharply for the above-elbow group as compared with the below-elbow subjects, which is only to say that more above-elbow amputees than below-elbow amputees report "sometimes" or "never" as regards use of the prosthesis. The other is that some "important" activities and some "occurring frequently" (such as cutting food, tying a necktie, using a telephone, taking bills out of a wallet, unbuttoning the shirt sleeve, tying shoelaces, and so on) are also reported by many amputees as being easier to perform without the prosthesis than with it.</p> <p>In summary, it would appear that in general the statements made by all amputee groups point, either directly or by implication, to functional inadequacies of the prosthesis as the basic reason for failure to make full use of it. The specific inadequacies, and the means of correcting them, are of course not directly or fully revealed by the present data. Even the seemingly straightforward problem of inadequate prehension in terminal devices cannot be solved simply by adding rubber bands or by providing a device with a stronger grasp. Experience has shown that for numerous amputees a lightly loaded hook is adequate for most needs and that they therefore prefer it. They object to the necessity for overcoming heavy resistance in every operation just to accommodate needs occurring infrequently. Nor is the voluntary-closing hook always the answer. Evidence presented in Section V of this series shows that such voluntary-closing devices as are currently available also are not without objectionable features. The solution of such problems must await further research into the total area of prosthetic utilization.</p> <h5><i>Manner of Performing Activities Without the Prosthesis</i></h5> <p>When, in a particular activity, an amputee regards the use of the prosthesis as either impossible or too difficult, awkward, or time-consuming, he is faced with the choice of excluding the activity from his routine of living or of finding some substitute means of accomplishing it. In the NYU Field Studies, those subjects who did not use the prosthesis in one or more of the 20 selected activities were asked what they did when confronted with the task or tasks concerned. By far the most frequent response by all classes of unilateral arm amputees was to the effect that they used the remaining hand, either alone or in combination with some other part of the body or some external object. About 3/4 of all responses told of one-handed performance, and the activities which are normally bimanual but for which performance was actually one-handed were essentially the same ones for all three classes of unilateral amputees. Moreover, activities so performed were for the most part the same ones as those reported to be "easier to perform without using the prosthesis" and also the same as those said to be most difficult to perform with a prosthesis (i.e., least facilitated by assistance from a prosthesis).</p> <p>A second alternative to use of the prosthesis, occurring in about 10 percent of the responses, was the use of substitute devices such as combination knife-forks, telephone holders, or playing-card holders-all simply aids to one-handed performance. As for other methods of accomplishing daily tasks without use of a prosthesis, some 15 percent of the subjects indicated that the services of another person were enlisted. Again, as in the case of one-handed performance, the activities most frequently cited were much the same ones for all three groups of unilateral amputees. Although there is no apparent reason behind the choice of activities for which outside help is to be sought, it is possible that the tasks selected are too difficult to perform alone, either with or without a prosthesis. But of course other factors-an overly solicitous wife, general dependency, lack of training- may well be involved.</p> <p>Two important goals in upper-extremity prosthetics are to help the amputee be independent in the performance of the tasks of daily living and to permit him to function bimanu-ally in as "normal" a fashion as possible. Obviously the final achievement level may be below that of a "normal" person, but nevertheless these goals remain the best standard of comparison. Prosthetic utilisation may be viewed as ranging from an optimum of complete independence and bimanual function to less independent performance with the sound arm alone, either with or without assistive devices, to a complete dependence on assistance from others. The employment of this scale of achievement along with additional measures of the quality or appearance of prosthetic performance should provide a useful basis for evaluating the degree of success obtained in amputee rehabilitation.</p> <p>From the material here presented, we may conclude that, in the 20 selected tasks, the most common substitution for prosthetic use involves use of the remaining "good" hand, either alone or in combination with some other part of the body or some external object. One-handedness, with or without the use of substitute devices, avoids the necessity of dependence on others, but it also leaves much to be desired from the standpoint of simulating "normal" performance. Moreover, one-handed performance of such activities as tying a necktie, or unbuttoning shirt sleeves with the teeth, is not easy. If these methods really are "easier" without a prosthesis, then prosthetic use must indeed be unattractive to the individuals concerned. The general findings of the whole study lead, however, to the obvious conclusion that a prosthesis is at best only a partial replacement for a lost limb. In unilateral arm loss, increased usage of the remaining arm and hand has unavoidably to make up, to greater or lesser degree, for existing prosthetic inadequacies.</p> <h4>Bilateral Subjects</h4> <p>As already pointed out (page 49), the 10 bilateral subjects in the Upper-Extremity Field Studies included 7 bilateral below-elbow and 3 bilateral below-elbow/above-elbow cases. Undoubtedly, the general performance level of the group as a whole was higher than it would have been had the sample included bilateral above-elbow and bilateral shoulder-disarticulation subjects. The extent of prosthetic utilization exhibited must therefore be interpreted accordingly. The responses of the subjects concerning frequency of occasion to perform the 20 selected activities, importance of the selected tasks, and frequency of actual prosthetic performance are presented in <b>Table 21</b>, <b>Table 22</b>, and <b>Table 23</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Frequency of Occasion to Perform Activities</i></h5> <p><b>Table 21</b> presents the responses of the bilateral subjects as to the frequency of occasions for performing the 20 selected activities with prostheses. It will be apparent at once that the activities for which opportunity occurred to the majority of bilateral amputees daily were for the most part the same ones occurring most frequently for unilateral subjects.</p> <h5><i>Importance of the Activities</i></h5> <p>The ratings of the bilateral group as to the significance of the 20 activities are presented in <b>Table 22</b>. On the basis of a composite of the two ratings "very important" and "important," the activities most significant to the bilateral amputees were, with the single exception of sweeping up dirt, the same ones that rated high in importance for the three unilateral groups, and more than half of these were among the ones occurring most frequently. Thus the general pattern of relationship between frequency and importance observed with the unilateral groups appears to apply to the bilaterals also. And again, as with the unilateral cases, the activities of bilaterals that apparently do not conform to this pattern give rise to speculation. A case in point is the matter of using the telephone. Ostensibly an activity which confronts bilateral arm amputees rather infrequently (<b>Table 21</b>), it is rated as significant by all of the ten subjects involved. Either the activity is considered important in spite of infrequent occurrence or, more likely, bilateral amputees avoid use of the telephone because of difficulty in handling it with their prostheses. Avoidance could explain infrequent occurrence.</p> <h5><i>Performance of Activities</i></h5> <p><b>Table 23</b> summarizes the responses of the 10 bilateral amputees as regards utilization of the program prostheses in the performance of the 20 selected activities. The always-or-never characteristic of prosthetic utilization, described earlier for unilateral amputees, is even more evident in the bilateral group. At Evaluation II, only one bilateral amputee reported "sometimes" use of the prostheses in any of the 20 activities. Judging from the proportion that never perform a given activity, the tasks that are the most difficult for bilateral amputees are also among those occurring most frequently for them, or rated most important by them, or both, so that the situation noted earlier for unilateral subjects again applies to bilaterals also. If we take as a basis of comparison the percentage of bilateral arm amputees who always use the prostheses to perform an activity, then as a group bilaterals use their prostheses more extensively than do any of the unilateral groups. The comparative figures, including the apparent anomalies, lead to the logical supposition that, if they can, bilaterals will perform the most difficult tasks in order to be independent but that some tasks may be too complex for them to manage in spite of a strong desire to do so.</p> <h5><i>Reasons for Not Using the Prosthesis and Alternative Ways of Performing Activities</i></h5> <p>Because of the small number of cases involved, and because of the variety of body movements used by bilateral arm amputees to accomplish tasks without prostheses, a detailed analysis of substitution techniques is not warranted, but two general observations may be made nevertheless:</p> <ol> <li>Prosthetic deficiencies related to nonperformance were concerned with inadequate grasp by the terminal device and inability to operate it at the appropriate level.</li><li>The chief remedy for such deficiencies was to have someone else perform the task. Use of substitute devices was confined largely to unbuttoning shirt sleeves, presumably by use of a special buttonhook held in a prosthesis.</li></ol> <h4>Discussion</h4> <p>The NYU Field Studies reveal a number of interesting highlights regarding the utilization of prostheses reported by upper-extremity amputees. With only minor exceptions, the 20 bimanual activities, chosen empirically, occurred in every case with sufficient frequency, and/or affected a large enough proportion of the amputee population, to be considered significant. Among the various amputee groups (unilateral below-elbow, above-elbow, and shoulder-disarticulation cases and bilateral arm cases) there was considerable agreement as to the relative frequency of occurrence of the activities. It must also be noted, however, that among the bilaterals the frequencies of occurrence were much lower than among the other groups. For example, only 10 percent of the bilaterals carried a cafeteria tray as often as once a week, and none of them used a "Flit" gun or rewired an electric plug as often as once a week. Finding such agreement supports the selection of these activities as being highly significant in the activity patterns of upper-extremity amputees.</p> <p>As judged by amputee opinions concerning the importance of the 20 selected activities, the level of significance attached to the individual tasks varied considerably. For unilateral subjects, 10 of the activities were rated as important by 2/3 or more of the group, five were rated as important by 1/3 to 1/2, and five were significant to less than 1/3. For the bilateral group, 11 activities were rated as important by 2/3 or more of the sample. For all amputee types, even those activities rated as important by the least number of amputees could not be regarded as totally insignificant. On the basis of amputee judgments of frequency of occurrence and of importance, therefore, the tasks selected appear to have •constituted a sound basis for study of the patterns of prosthesis usage among arm amputees. Although significant exceptions were apparent, in general the activities occurring most frequently were also rated as the most important.</p> <p>In sum, the data on amputee use of prostheses in performance of the 20 selected activities revealed a number of interesting, if occasionally unexpected, findings. Among these were:</p> <ol> <li>A sharp drop-off in prosthetic utilization from below-elbow to above-elbow to shoulder-disarliculalion amputees, found in an earlier investigation (page 32), was confirmed. While over-all utilization of the prosthesis by all amputee types, including the above-elbow and shoulder-disarticulation cases, was quite remarkable, improved utilization was most striking among the below-elbow and bilateral amputees. More than 50 percent of all unilateral below-elbow subjects reported that they always used the prosthesis in the performance of 19 out of the 20 selected activities (<b>Table 18</b>), and at least half of the bilateral amputees reported 100-percent use in 13 out of 18 applicable activities (<b>Table 23</b>).<br /> Because heretofore prostheses for above-elbow and for shoulder-disarticulation amputees have sometimes been regarded as comparatively useless, the data relating to these types of amputees are perhaps even more dramatic than are the corresponding results for the other two types. In the above-elbow group, 50 percent or more of the sample reported that for widely diverse tasks they always used the prosthesis. In a number of "important" activities, a smaller but still significant proportion of above-elbow subjects always used the prosthesis. If we focus attention on what was done rather than on what was not done, there is considerable evidence that the prostheses had real value even for the shoulder-disarticulation group. Some 50 percent or more of the sample reported that in performing 8 of the 20 tasks they always used the prosthesis. In almost none of the activities could the prosthesis be considered useless. Even for the shoulder-disarticulation amputee, to whom a prosthesis offers the least functional replacement, the fitting and use of a modern artificial arm seems worth while. And a similar conclusion may be drawn from the data presented earlier concerning use of the prosthesis in eating, dressing, and vocational, recreational, and home activities by all classes of amputees, including above-elbow and shoulder-disarticulation cases.<br /> There are, then, two sides to the coin of prosthetic usefulness. One points to the inadequacies of even the most up-to-date equipment and emphasizes the need for much improvement. The other shows that, despite prevailing inadequacies, present-day upper-extremity prostheses are quite useful devices, particularly in those cases once thought incapable of deriving much benefit from any arm substitute.</li><li>An "all-or-none" type of phenomenon in amputee use of prostheses was noted. In any given activity, an amputee tends either always to use his prosthesis or never to use it. While not absolute or universal, the inclination was considered strong enough to be viewed as a general characteristic of prosthetic utilization.</li><li>Paradoxically, the prosthesis was most useful for many activities which occurred less frequently, or which amputees rated as less important. Some of the more frequently occurring, and more important, of the 20 activities, such as "cut food with knife and fork" and "unbutton shirt sleeve," were less frequently performed with the prothesis. This may indicate that the difficulty of performing the task with prothesis influences frequency of prosthetic use more than does the frequency of occasion for use or the importance of the task.</li><li>Although there were definite indications that the program prostheses were used more extensively than were their preprogram counterparts, the increase in utilization was neither universal nor particularly striking. The reasons given by arm amputees for not using their prostheses in the performance of activities pointed generally to prosthetic inadequacies as the basic cause. While lack of a suitable all-purpose terminal device was the only specific item identifiable from the data, it appears that the whole area of amputee use or non-use of an arm prosthesis calls for further and intensive study. Where arm amputees did not use their prostheses in activity performance, the most common substitution among unilateral subjects involved use of the remaining hand, either alone or in combination with some other part of the body or some external object. One-handedness replaced what would normally be bimanual performance. Among bilateral arm amputees, "someone else does it for me" was the most frequent compensation for failure to use prostheses.</li></ol> <p>In the final analysis, the value of any particular set of principles or procedures in upper-extremity prosthetics is reflected by the degree of acceptance and utilization afforded the wearer by the prosthesis after the novelty has worn off and routine operation is expected. As part of the NYU Field Studies, therefore, the opinions of a large and diversified group of arm amputees were obtained on widely separated occasions in response to a series of open-end and multiple-choice questions relating to five key areas of activity considered more or less common to all persons. These reactions, classified and analyzed in terms of amputation type, were augmented by interviewing the same group of subjects with regard to 20 bimanual activities selected empirically as being important and of frequent occurrence in the course of daily living.</p> <p>These two inductive approaches were selected from many possibilities for investigation as being the most practical and appropriate for determining amputee opinions as regards the utility and general value of their prostheses. Though the answers obtained do not provide a completely definitive method for grading success or failure in the rehabilitation of arm amputees, they have nevertheless furnished much useful information on a number of the factors influencing acceptance of prostheses by their wearers.</p> <p>As might have been anticipated, amputees with the more disabling conditions (that is, with higher levels of amputation) were able to employ their prostheses over a smaller range of activities. On the other hand, the greatest increases in prosthetic utilization were found among these very groups. Not anticipated, however, was the indication that, in general, amputees tend to use their prostheses every time they do a given activity or not at all. The frequency of occurrence and the importance of an activity to an amputee were not always indices of the utility of the prosthesis in the particular task. While there were definite improvements in the utilization of program prostheses, a great deal of room for improvement remains, particularly in the bilateral group. Although deficiencies in the prostheses may be responsible, other factors such as training and motivation may also be involved. New studies focused on these questions will be required to illuminate the specific relationships.</p> <h3>Part 2. Amputee Performance With Arm Prosthesis</h3> <p>Since arm amputees, like most people, are not generally capable of a completely realistic self-appraisal, there is an inherent weakness in data which derive solely from verbal reports. For this reason, a second method of evaluation was devised with the purpose of assessing prosthetic use on the basis of more objective information. Based on the assumption that proficiency in use also reflects the value of the prosthesis to the amputee, two types of prosthetic proficiency tests were developed. The first was designed to measure the amputee's skill in prehension and accuracy in positioning the terminal device for prehension. The second was concerned with evaluating skill in performing a series of common daily activities.</p> <h4>Test Rationale and Test Development</h4> <p>Methods of evaluating human performance in physical activities vary from the simple, relatively objective timing of a footrace to the more subjective assessment of figure-skating or fancy diving. In the footrace, effectiveness of performance is determined solely by measuring time, since speed of performance is the main factor. In rating activities of the second type, consideration also is given to such subjective features as timing, rhythm, grace, and form because here both effectiveness and appearance are matters contributing equally to the overall result. Since the total value of performance with a prosthesis involves these two factors, efforts to analyze the quality of prosthetic use in the NYU Field Studies sought information not only on the effectiveness with which the amputee used his prosthesis in activities of daily living but also on his appearance while performing them. In this sense, "effectiveness" refers to the ability to complete a task in a reasonable time. "Appearance" has to do with the relationship between the performance of the amputee and that typical of a normal person.</p> <h4>Abstract-Function Tests</h4> <p>Considering the uses arm amputees make of the various functions provided by modern arm prostheses, it is clear that all artificial arms are employed primarily as prehensile tools. But the ability to grasp with a hook or artificial hand would be extremely limited were the terminal device restricted to one plane or to a single area of operation. The value of other prosthetic functions, whether passively or actively controlled, lies in their usefulness as a means of positioning the terminal device so that work can be performed throughout a large operating sphere. It may reasonably be said that all the motions that can be provided in an upper-extremity prosthesis are capable of classification into one of two functional categories-those involved in the act of prehension itself and those which are used to position the terminal device so that meaningful prehension may be performed. Recognition of these functional divisions led to the development of two tests of abstract function-the prehension test and the positioning test-designed to permit study of some of the factors involved in prehension and positioning. They are tests of "abstract function" in the sense that no purposeful activity is involved and that only the bio-mechanical functions of positioning and operating the terminal device are analyzed. Tests of abstract function were, then, used to assess the amputee's ability to:</p> <ol> <li>operate and control his terminal device in grasping, transporting, and releasing objects.</li><li>position his terminal device accurately and operate it effectively in various places in front and to the side of his body.</li></ol> <h4>Practical-Activities Tests</h4> <p>Tests of practical activities, used in an evaluation of how the amputees performed meaningful activities of daily living, were designed to provide information concerning the facility and appearance of a total performance in order to measure the functional value of the appliance. Selection of the performance tests of practical function was based on three prime criteria-that the activities concerned should normally require bimanual performance, that the activities concerned should be those performed frequently by the subjects being tested, and that performance of the activities should be important to the amputee.</p> <p>Tests of practical function were, then, used to rate:</p> <ol> <li>the effectiveness with which amputees perform common, everyday tasks.</li><li>the naturalness of appearance while amputees perform daily activities.</li></ol> <h4>Standards Of Performance</h4> <p>In the choice of a yardstick with which to measure the quality of prosthetic performance, consideration was given to the purpose of fitting an amputee with an artificial arm. Since the obvious aim is to restore as much as possible of the function lost through amputation, the desired outcome is that the amputee accept and use his prosthesis as naturally and as "normally" as possible. For this reason, normal, two-handed performance of tasks appeared to be a valid criterion. Because, however, it is commonly recognized that an amputee can never attain a completely normal, two-handed pattern of performance, it may reasonably be objected that such a standard is to some degree unrealistic and that the rating of amputee performance in relation to that of other amputees would provide a more reliable comparison. Perhaps it would. But the absence of norms or standards of amputee performance at the time the NYU Field Studies were undertaken precluded any choice in the matter. Consequently, the normal performance pattern was selected as the standard.</p> <h3>Sample</h3> <p>The numbers of below-elbow, above-elbow, and shoulder-disarticulation amputees available for these performance tests varied considerably. Participating in the pretreatment tests were 80 below-elbow amputees, 57 above-elbow amputees, and 4 shoulder-disarticulation amputees representing, respectively, 48 percent, 36 percent, and 17 percent of each amputation type in the sample. Attrition during the pretreatment evaluation was due to nonfunctioning or malfunctioning of arms, amputees appearing for evaluation without prostheses, and breakdown of prostheses during use with consequent inability to complete the test. Owing to the generally better functional condition of arms during the course of the program and to the increase in the number of shoulder-disarticulation and above-elbow amputees wearing arms, the number of subjects available for post-treatment testing was substantially higher: 115 (68 percent) below-elbow, 111 (70 percent) above-elbow, and 17 (74 percent) shoulder-disarticulation cases. To provide the most rigorous analysis that the data will permit, only the performances of the patients available for both pre- and post-treatment evaluations are presented. This restricts the total sample to 75 below-elbow, 51 above-elbow, and 4 shoulder-disarticulation cases. Because there are so few shoulder-disarticulation amputees, their performance ratings are not treated statistically but are described in terms of impressions and trends.</p> <p>All of these amputees took the prehension test, the first to be administered, but somewhat fewer completed the positioning test and the practical-activities tests, either because of breakdown of prostheses during the course of the tests or because of indisposition on the part of the patients.</p> <h3>Procedures</h3> <h4>Abstract-Function Tests</h4> <h5><i>Prehension Test</i></h5> <p>In utilizing his prosthesis in the activities of daily living, the amputee has occasion to grasp objects of various sizes, shapes, weights, textures, and degrees of fragility or hardness. This diversity was recognized by including, in the prehension test, objects which embody many of the variables normally encountered. Of the 12 objects used, six were of metal (five aluminum, one steel) and six of compressible rubber, and all were of one of four basic shapes-cylinders, spheres, prisms, and right-angled forms-in various sizes.</p> <p>In addition, the testing materials included a form board constructed of "Masonite" attached to a three-ply wooden board measuring 17 X 17 in. and into which were cut recesses corresponding to the shapes of the test objects but slightly (1/8 in.) larger. The test objects were arranged on a table near the board and in the same relative position as the recesses in the board so as to reduce the need to search for the proper recess. In the course of the test, the amputee transferred each of the objects from the table to the appropriate recess in the form board. Before the actual test, the amputee was given a trial run to familiarize himself with the objects and to give him an opportunity to decide upon the most efficient way to approach and grasp an object. The test was explained to the amputees as follows:</p> <p>"You are to place each of these objects in the appropriate recess in the form board. Start with the top row and work from left to right. Do each row in the same way.</p> <p>"Work as quickly as you can but also as accurately and neatly as you can; do not waste any time.</p> <p>"If you cannot handle any object after trying for 1 minute, leave it and go on to the next. You will be notified when you have been on any object for 1 minute.</p> <p>"Use only your prosthesis in handling the various objects.</p> <p>"Avoid compressing or distorting the shape of the rubber objects as much as possible.</p> <p>"You are being tested on your ability to grasp the objects and to release them into the recesses in the form board." <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the performance of these tasks, the terminal device is first brought into a position which allows for grasp of the object. The next step, concerned with the grasp itself, involves operation of the prehension mechanism, placement of the fingers to obtain a stable grasp, and control of finger pressures to provide appropriate prehensile forces. To complete the activity, the amputee must transport the object and then position the terminal device so that the object is released at the intended place. The general impression that an amputee's performance makes upon the observer depends upon the body move- ments employed, the number of errors made, and the appearance of the control motion. In addition to these factors, the appearance of the total performance is related to the general ease, grace, and accuracy of movement.</p> <p>In an attempt to appraise in each activity both the functional and the appearance value of the amputee's performance, the significant parts of the performance were rated with regard to positioning movements for grasp and release, appearance and effectiveness of control motion, and control of finger pressure. The ratings were then combined in an over-all score on the basis of the following 10-point scale:</p> <p>Excellent (10). Graceful, rhythmic, fast, accurate performance closely approximating the cosmetic value of a performance by a normal person.</p> <p>Good (8). Smooth, rapid performance involving one or two errors and some slight body and limb distortion in several positions.</p> <p>Average (6). Uneven, somewhat inaccurate performance with occasional errors, some effort, and some body distortion.</p> <p>Fair (4). Slow performance marred by errors and uncosmetic limb and body positions.</p> <p>Poor (2). Awkward, strained, slow performance with fumbling, excessive movement, and many errors.</p> <p>The observer interpolated ratings of 9, 7, 5, 3, and 1 when indicated.</p> <p>The ability of the arm amputee to grasp and hold objects securely with a prosthesis is dependent partly upon the amount of power the man-machine combination can furnish and partly upon the structure, size, and shape of the terminal device. The number of errors made during the test was recorded, two kinds of errors being considered-grasp errors and compression errors. A grasp error was counted when the amputee regrasped an object in an attempt to obtain a more secure grasp, when the object, once grasped, fell from between the fingers of the terminal device, or when the object slipped within the fingers to the extent that the amputee had to reduce his speed or otherwise interrupt his performance to avoid dropping it. The ability to control finger pressure was appraised by tallying the number of compressible objects distorted and judging the extent of the distortion.</p> <p>Considered alone, the time taken to perform a particular activity may not be a satisfactory indication of efficiency. When considered in relation to accuracy and appearance, however, it may be an important factor, particularly in view of frequent amputee complaints regarding inability to work rapidly. In the prehension test, the amputee stood at the table and began at his own volition, a stopwatch being started with his first movement. The watch was stopped as the last object was placed in the appropriate recess on the form board, and the elapsed time was recorded.</p> <h5><i>Positioning Test</i></h5> <p>Although prehension may be considered the primary function of both the normal hand and the prosthetic replacement, the ability to position the hand or its substitute in space is a key factor in utilization. The normal, two-handed person has occasion to reach for, grasp, and release objects in three planes. He commonly handles objects at the level of the mouth, the chest, and the mid-thigh, and objects at chest or waist level up to 1-1/2 feet on either side of him are usually within his reach. To study the ability of the amputees to employ their prostheses in these areas, use was made of the positioning test, which involved six common hand positions. The six exercises devised to assess the ability of an amputee to operate his terminal device at different positions required the subject to place a 6- X 3/8-in. dowel into a clip positioned on the wall and so arranged that release of the dowel was required in both vertical and horizontal positions. Before the actual tests, each amputee was given a trial run to familiarize him with the procedures and to let him decide upon the best approach to each of the test situations. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the performance of this test, the amputee was required to remain within a rectangle drawn on the floor 18 in. wide and extending 36 in. from a wall. He stood outside this restraining area until, on the signal to begin, he stepped into it. Although he was required to remain there while performing each of the tasks, he was permitted to reach over the restraining lines. The patient was told:</p> <ul> <li>"Hold this stick in your sound hand and stand behind the restraining line."</li> <li>"When I say 'go,' grasp the dowel in your prosthetic hand (hook), step into the restraining area, and place the dowel in the clip on the wall."</li> <li>"Do this as quickly as you can after you receive the signal, but do it as smoothly and as accurately as you can."</li> <li>"If you drop the stick while trying to place it in the clip, or at any other time, pick it up and continue the test."</li> <li>"You are being tested on your ability to place the stick in the clip as quickly as possible with the least amount of excessive movement."</li> </ul> <p> Proficiency in this test depended upon maintaining a relatively normal posture and appearance while operating the terminal device at varying distances and angles from the body. The cosmetic value of the performance was related to ease, grace, and smoothness of body movements and to associated characteristics in prosthetic control motions, while effectiveness was reflected in the speed and accuracy of positioning the dowel in the clip. Rated individually were body- and limb-positioning movements, appearance of prehension control motion, and appearance of elbow-lock control motion. These were then consolidated into a rating of total performance by use of the same type of 10-point scale as in the prehension test: excellent, 10; good, 8; average, 6; fair, 4; poor, 2. Again, ratings of 9, 7, 5, 3, and 1 were interpolated as necessary. The time required to perform each positioning test was recorded by means of a stopwatch. <b>Fig. 19</b>, <b>Fig. 20</b>, <b>Fig. 21</b>, <b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Practical-Activities Tests</h4> <p>The practical-activities tests called for each amputee to be tested in the performance of eight activities of daily living selected from the 20 common activities discussed heretofore. For each individual the activities varied in accordance with the criteria of frequency and importance previously mentioned (i.e., each amputee was tested on the eight activities he reported as occurring most frequently in his routine of living). In choosing between activities of approximately equal frequency, those regarded by the subject as of greater importance were selected for test.</p> <p>In the discussion of the temporal sequence of events during performance of the prehension test, it was pointed out that four phases of the performance could be isolated: the positioning movements for grasp, the grasp itself, the transporting of the object, and the positioning movements for release of the object. With one major exception, this breakdown served equally well as a guide to the more complex practical activities. Here, unlike the situation prevailing in the prehension test, the amputee must not only transport an object but must also make sure it arrives at a position where it can be used or manipulated purposefully. Moreover, the nature of the prehension test forced the amputee to pick up each object from the table without use of the sound hand, a feature that made it necessary to position the body and the prosthesis so that the object could be grasped with the terminal device. In routine practice, however, the amputee frequently picks up an object with his sound hand and places it in his terminal device, thus eliminating many of the positioning movements otherwise required for grasp.</p> <p>With special reference to practical-activities tests, therefore, we may speak of "positioning movements for use," as distinct from "positioning movements for grasp or release," to mean the sequence of motions adopted by an amputee to bring an object into position for the performance of a useful task. Each activity was rated according to the normalcy of the pregrasp positioning movements, the security of the grasp, and the adequacy of positioning for use. The first two were scored on the same basis as in the prehension test; the degree of awkwardness in the positioning movements was rated and the number of errors tallied.</p> <p>Positioning for use, however, refers to the manner in which an object is grasped as that relates to the intended manipulation or use of the object. For example, when the normal hand holds a telephone, both mouthpiece and receiver are positioned close to the face for ease and comfort in hearing and speaking. The artificial hand of an amputee may hold the telephone at some distance from the face, thus necessitating some undue amount of compensatory head-bending. Or the hearing end of the telephone may be held against the ear while the mouthpiece is at eye level rather than mouth level. Errors such as these in positioning an object for use may be due either to faulty judgment on the part of the amputee or to limitations inherent in the prosthesis. Whatever the cause, the adequacy of positioning in relation to ultimate use was rated in terms of the deviation from normal position and of the degree of compensatory movement necessitated by the position of the object in the appliance. These scores were then combined in an over-all rating of the functional and cosmetic value of the amputee's performance in each activity. Rating was accomplished on a 10-point scale as follows:</p> <p>Excellent (10). Object position does not deviate from position for normal use, nor are compensatory body and limb positions necessary.</p> <p>Good (8). Object deviates slightly from position in which the normal hand would use it; slight deviations in body and limb positions may also be present.</p> <p>Average (6). Object deviates somewhat from normal position, and some compensatory deviation in body or extremity position is necessary to use the object.</p> <p>Fair (4). Object shows marked deviation from normal position for use and necessitates somewhat awkward body and limb positions to accomplish the task.</p> <p>Poor (2). Object shows marked deviation from normal position for use, accompanied by strained, awkward, or obtrusive body and limb positions.</p> <p>The observer interpolated ratings of 9, 7, 5, 3, and 1 whenever it was felt to be necessary. In the accompanying annotated illustrations are depicted the materials, instructions, and procedures utilized in the administration of the 20 activities comprising the test series. Every time the amputee began one of the practical tests, he was first requested to perform the task in his customary way. He was told that the series of tests was a means of determining how he performed those tasks normally as part of his activity pattern. It was pointed out that he was being rated on how well he did the entire task regardless of the specific use he made of the prosthesis. The basis for rating the over-all appearance of the performance was the same as that for the prehension test, and the time taken to complete each test activity was recorded. <b>Fig. 23</b>, <b>Fig. 24</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Results</h3> <h4>Reliability And Validity</h4> <p>Fundamentally a test is an instrument for measuring the extent or absence of a trait or attribute. To be most meaningful, test results must be both reliable and valid.</p> <p>The reliability of tests which are scored by means of judgmental ratings depends upon the use of consistent standards in rating performances, and ordinarily precautions are taken to ensure a comparable frame of reference among the raters. During the course of these studies, the reliability of the raters' judgments was evaluated periodically and found to be reasonably satisfactory. A stringent statistical analysis at the completion of the studies (Appendix I) confirmed the reliability of the ratings on the abstract-function tests. But because too few practical-activity tests were scored by each rater, the reliability of the practical-activities ratings could not be assessed in the same way.</p> <p>The validity of a test rests upon the degree to which it actually measures what it is designed to measure. Selection of the abstract-function tests was based upon an analysis of the functional requirements of prosthetic utilization, the skills involved being those necessary to operate the prosthesis under any circumstances. Since these tests were designed to evaluate proficiency of prosthetic use by direct measurement of meaningful performance with prostheses, they have a certain amount of face validity. The validity of the practical-activities tests appears to be self-evident, since the amputee's ability to perform a given task was in this case determined by having him actually perform it in the presence of the raters.</p> <h4>Abstract-Function Tests</h4> <h5><i>Prehension Test</i></h5> <p>As might have been anticipated, the ratings of below-elbow and above-elbow cases in the prehension test clearly indicated that performance was related to amputation level. That is to say, the average below-elbow performance level was consistently better than above-elbow performance in both pre- and post-treatment evaluations (<b>Table 24</b>). An important point reflected by these data is that the discrimination of differences by the prehension test may be regarded as evidence supporting the validity of the test. Experience indicates that the below-elbow amputee generally accomplishes more with a prosthesis and performs in a smoother and easier way than does the above-elbow amputee. Since it distinguishes these two groups clearly, the prehension test may be said to measure those qualities which distinguish the adequacy of performance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Comparison of performance ratings in the pre- and post-treatment evaluations, presented in <b>Table 24</b>, reveals a definite but not always statistically significant improvement in prosthetic function. For the 75 subjects comprising the below-elbow sample, the mean for the new arms was 5.8 as compared with 5.5 for the old. Although this difference is not significant statistically, closer study of the scores made at the two evaluations indicates a small but definite improvement in performance, especially through the middle of the score range, where there was a marked decrease in the number of amputees receiving ratings of 4 and 5 and a sharp increase in those receiving ratings of 6. It appears then that, although the treatment program had little effect on below-elbow amputees who exhibited very poor or very superior skills with their old arms, it did improve the "low-average" performers. <b>Fig. 25</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As reported in Part 1 of this Section, the below-elbow group as a whole felt that their new arms were somewhat more useful and easier to operate than the old. But this improvement was less marked than that at other levels of amputation, and some below-elbow subjects even felt that the new prosthesis was inferior to the old. The data thus tend to corroborate an earlier conclusion that for the less severely handicapped below-elbow amputee the improvement in prehension skill was not outstanding. By contrast, the 51 above-elbow cases showed a decided improvement in prehension performance with the prostheses fitted in the Field Studies. Statistically, the 4.9 average achieved with the program prostheses was significantly higher than the 4.0 average attained with the old arms. A comparison of the scores at the two evaluations revealed a clear-cut and consistent shift in the direction of improvement of performance. There was a marked decrease in the number of amputees scoring below 5 and a sharp increase in those scoring above 5. It may therefore be concluded that there was a general elevation of the level of above-elbow performance, the greatest improvement being evidenced among those of low and low-average skills. With only four cases available for analysis, the findings for the shoulder-disarticula-tion amputees are of limited significance, although among the four there was also a definite trend toward improvement in post-treatment performance.</p> <p>In general, the results obtained in the functional tests of the above-elbow and shoul-der-disarticulation amputees correspond to the verbal reports, which strongly indicated that the program prostheses were more useful, easier to operate, and more extensively used. Improvement in these two groups was more marked than in the below-elbow group, and it may therefore be concluded that the more severely handicapped segments of the amputee population derived the most benefit from the program prostheses and that the benefits accrued principally to the poorer performers. <b>Fig. 26</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The speed with which amputees performed the prehension test was also related to level of amputation, the below-elbow subjects taking significantly less time than the above-elbow cases to complete the test at both pre- and post-treatment evaluations. For no group (below-elbow, above-elbow, or shoulder-dis-articulation) did the average amount of time taken to perform the prehension test decrease significantly after treatment. The data for the below-elbow and above-elbow subjects are presented in <b>Table 25</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>According to these findings, improvement in performance skill was not reflected in an appreciable increase in performance speed, but the reasons for this apparent inconsistency are not clear. One possibility has to do with the increase in the number of subjects using APRL terminal devices at Evaluation II as compared with Evaluation I (below-elbow, from 14 to 37; above-elbow, from 8 to 31). The "double-shuffle" control motion involved in this type of device, and the consequent increase in the time required to operate it, may account for the failure to increase speed along with skill and ease of operation. At the same time, however, there is a suggestion that slower operation with APRL devices is accompanied by smoother and easier prehension.</p> <p>Two kinds of errors, grasp and compression, were recorded. Grasp errors were counted when an object slipped or fell from the terminal device or when it had to be regrasped. Compression errors were scored when the rubber objects were distorted by poor control of finger pressure. On both pre- and post-treatment evaluations, the below-elbow cases made fewer grasp errors than did the above-elbow amputees (<b>Table 26</b>). The shoulder-disarticu-lation cases made substantially more grasp errors than did either the below-elbow or the above-elbow subjects. The below-elbow subjects made fewer grasp errors after treatment (average: 8.0) than at Evaluation I (average: 9.2), but the difference was not significant statistically. There was little difference in the number of grasp errors made by above-elbow amputees before (10.0) and after (9.7) treatment. While the shoulder-disarticulation cases showed a stronger trend toward improvement in grasp security than did either of the other two groups, the result should be interpreted cautiously because of the small number of subjects involved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Thus it would appear that, despite the changes made in terminal devices, harnessing, and control-system alignment, grasp security was not greatly influenced by the treatment process. Perhaps the principal limitation was the lack of "all-purpose" versatility in the hook, its rigid structure preventing it from being completely suitable for handling a variety of objects.</p> <p>Unlike grasp errors, compression errors decreased in frequency among both below-elbow and above-elbow cases after fitting with program arms (<b>Table 27</b>), and the shoulder-disarticulation amputees appeared to follow the same trend. Below-elbow and above-elbow cases made the same number of compression errors (6.2) in the pretreatment evaluations. After the treatment procedure, there was again little difference between the scores of the two groups, the averages being 4.5 and 4.8 respectively. As one would expect, the shoulder-disarticulation cases made more compression errors than did either below-elbow or above-elbow subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Better control of finger pressure may be explained by the large proportion of APRL devices fitted in the treatment program and also by the contributions from improved harness and control systems. The apparent influence of APRL terminal devices in improving control of finger pressure without also improving grasp security suggests a deficiency in hook size or shape and perhaps also a general lack of emphasis on training for the proper approach in prehension activities.</p> <h5><i>Positioning Test</i></h5> <p>Skill in performance in the positioning test, as in the prehension test, was related to level of amputation, the below-elbow amputees making consistently higher scores, and the positions in which the below-elbow subjects performed best differed from those in which the above-elbow subjects were most effective (<b>Table 28</b>). The below-elbow amputees were most effective at mouth and waist levels in the centerline (Positions 1 and 2); at chest and waist levels toward the prosthetic side (Positions 4 and 5); somewhat less effective toward the sound side (Position 6); and poorest at mid-thigh level in the centerline (Position 3). Above-elbow subjects were most proficient at two waist-level positions (Positions 2 and 5); somewhat less effective at waist level on the sound side (Position 6), at chest level toward the prosthetic side (Position 4), and at mid-thigh in the centerline (Position 3); and poorest at mouth level in the mid-line (Position 1), all of which suggests that the most efficient use of the above-elbow prosthesis is to be had at 90 deg. of forearm flexion and that less efficient operation occurs when the forearm is flexed appreciably more or appreciably less than 90 deg. Shoulder-disarticulation subjects were most proficient in handling objects at waist level, either in the mid-line or toward the prosthetic side (Positions 2 and 5).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Among both above- and below-elbow patients, skill in operating the terminal device in different positions improved significantly after treatment, a result more positive than that obtained from the corresponding prehension test, where improvement was statistically significant for above-elbow amputees only. Analysis of the pre-and post-treatment ratings of the below-elbow amputees revealed significant improvements (<b>Table 29</b>) in the ability to operate their terminal devices in three positions-at waist level in the mid-line (Position 2), at chest level toward the prosthetic side (Position 4), and at waist level toward the sound side (Position 6).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The time required by the amputees to complete each of the six tests did not appear to be related to the particular position involved, nor did performance time seem to be affected by the treatment process (<b>Table 30</b>). For the below-elbow cases, mean performance times for all six tests varied between 5 and 7 sec. in both pre- and post-treatment evaluations. Similarly, the above-elbow cases performed each of the six tests in approximately the same average time (10 to 16 sec. at Evaluation I, 9 to 14 sec. at Evaluation II).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although by definition the positioning test is "abstract," the level of performance in the several positions bears a relationship to the ability that may be expected in the performance of practical activities in the same positions. Improved performance in the test should be reflected either in greater ease in use of the prosthesis or else in the ability to perform more activities with it. Since in all cases there was an improvement in test performance after treatment, there is strong indication that treatment resulted in im- proved skill in utilizing a prosthesis in the positions required for the pursuit of the normal pattern of daily activities. While the available evidence is not wholly definitive, the distinct shift toward higher scores after treatment must be taken as indicating a general improvement in achievement level.</p> <h4>Practical-Activites Tests</h4> <p>In contrast to the abstract tests of prehension and of positioning a prosthesis, the practical-activities tests were designed to evaluate the amputees' ability to integrate the mechanical operations of prehension and positioning into the efficient performance of a complete and meaningful task. From the list of 20 tasks there were selected for each amputee eight specific test activities which, according to the subject's own statements, occurred most frequently for him in his normal activity pattern and to which he himself attributed the most importance. By virtue of these criteria some tasks were tested less frequently than others. The present analysis involves only those activities performed by 10 or more subjects.</p> <p>On this basis, the below-elbow subjects received substantially higher scores than did the above-elbow cases, a fact which only substantiates the superior ability of the below-elbow amputee in coping with daily needs. The average, weighted, pretreatment performance rating was 6.4 in below-elbow cases, 5.0 in above-elbow cases. After the treatment program, the corresponding figures were 7.0 for the below-elbow and 6.2 for the above-elbow patients (<b>Table 31</b> and <b>Table 32</b>). The scores of the few shoulder-disarticulation cases tested were far below those of either below-elbow or above-elbow amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If we consider that a score of 10 represents normal nonamputee performance, then the average score of 7.0 obtained by the below-elbow population for all 20 activities represents a creditable performance. For some tasks, of course, the average was higher than 7.0, and certain individual amputees consistently outperformed the average. It may thus be con- cluded that below-elbow subjects generally perform common daily tasks in a smooth, relatively unobtrusive, errorless manner. Although they never attain a level of skill equal to that of the nonamputee, they (and particularly the better performers in the group) tend to approach that level of performance.</p> <p>The post-treatment skill of the above-elbow group, represented by an over-all weighted-average rating of 6.2, indicates a relatively high level of performance. While the need for an elbow-lock control motion, together with the greater body distortion that results from the lack of an anatomical elbow, reduces the functional level of the above-elbow amputee to less than that of the below-elbow group, the above-elbow patient is nevertheless capable of more or less skillful use of a prosthesis.</p> <p>In the post-treatment evaluation, the below-elbow subjects generally performed better in all of the 15 activities studied. Increases in the ratings ranged from a low of 0.1 point to a relatively significant 1.5 points. Although the average increase (0.6 point) was not substantial, all of the changes were in the expected direction, an increase of a full point or more being achieved in five of the activities. A similar trend characterized the performance of the above-elbow subjects, where improvement (ranging from 0.1 point to 2.8 points) occurred in all 11 activities studied. In eight of the activities there was a gain of at least one full point, the average for all 11 being 1.2 points. The magnitude of the gains and the number of activities in which significant improvement occurred were both greater than in the case of the below-elbow subjects.</p> <p>It should be noted that most of the 20 shoul-der-disarticulation amputees taking the test at the post-treatment evaluation were capable of performing six to eight of the 20 activities. Apart from considerations of the quality of performance, this outcome represents a significant increase in the number of activities those subjects were capable of performing.</p> <h3>Discussion</h3> <p>Proficiency in the use of arm prostheses is clearly related to level of amputation. The performance of the below-elbow amputees in the NYU Field Studies was found to be consistently better and faster than that of the above- elbow amputees, who in turn performed better and faster than did the few shoulder-disarticu-lation amputees involved. Differentiation of performance was apparent in all tests, both before and after treatment.</p> <p>The most important single reason for the superior performance of the below-elbow amputee lies in his retention of the natural elbow. The above-elbow amputee is required to operate a mechanical elbow scarcely designed to provide all the functions of the natural elbow. Coupled with this mechanical limitation is the relatively high degree of skill required to operate present-day mechanical elbows smoothly and unobtrusively. Together these two factors impose upon the level of above-elbow prosthetic performance an insurmountable upper limit. The difficulty is only magnified in the case of the shoulder-disarticulation amputee, who must operate both a terminal device and a mechanical elbow by scapular abduction, a motion more gross and yet more limited than the humeral flexion normally available to both above- and below-elbow amputees. Further development and refinement of existing elbows and an increased emphasis on amputee training could conceivably elevate the level of above-elbow and shoulder-disarticulation performance to some degree. But radical changes to bring the above-elbow or shoulder-disarticulation amputee functionally up to par with the below-elbow case must await new concepts and designs in the development of components and control systems.</p> <p>As a result of the treatment program in the NYU Field Studies, the ability of all the amputee subjects to use their prostheses improved to varying extent. The superiority of the newer components and newer fabrication procedures, and the systematic training given to each patient as a routine matter, contrived to produce a general benefit differing only in degree from subject to subject and from amputation level to amputation level. That the improvement in performance among the below-elbow amputees was relatively small indicates that as a group they derived the least benefit from the new developments, for the obvious reason that their relatively high level of proficiency prior to the studies discounted their ability to profit greatly from the program. The more significant gains made by the above-elbow and shoulder-disarticulation amputees identified these groups as the major beneficiaries of the Field Studies. Although as a group the above-elbow subjects never quite attained the achievement level of the below-elbow amputees, the gap between them was significantly smaller after the treatment program, and as individuals the few shoulder-disarticulation cases improved markedly.</p> <p>The prostheses prescribed in the program were designed to provide maximum comfort, freedom of movement, and optimal replacement of lost function. The more significant improvements included higher, better-fitting, and better-appearing sockets; more useful and more easily operating elbows; improved efficiency of force transmission through better cable alignment and use of more stable materials; lighter, freer, and more comfortable harnessing; and a marked increase in the use of terminal devices offering improved control of grasp force. The advantages offered by these features were apparent in the prehension test, in which the objects to be manipulated remained stationary and the amputee was required to place himself and his terminal device in the best position for grasp and release. The need for compensatory body movements, which tend to lower performance ratings, was clearly reduced by the increased freedom and mobility of the new arms. The increased control of finger pressure offered by the new devices was reflected in the general and significant decrease in the number of compression errors made at the second evaluation.</p> <p>The value of the newer elbows seemed to be demonstrated by the improvement in performance of the above-elbow cases in the positioning test. The higher scores on the second test were based on more accurate positioning of the terminal device with lessened body contortion-a function of the elbow unit. It is interesting to note that, while performance ratings improved after treatment, speed of performance remained static. With the wider use of APRL devices on the second evaluation, an increase in the time required might have been expected. Since operating time did not increase, improved control of finger pressure was achieved without a concomitant slowing of performance.</p> <p>The similarity in performance patterns in the abstract-function and practical-activities tests may have important clinical consequences. Further study is warranted to see whether proficiency in the practical utilization of a prosthesis is related to, and perhaps reflected by, performance in abstract-function tests. Should such a relationship be found, it would be possible to convert the easily administered abstract-function test from a research tool to a clinical instrument. A combination of the more sensitive and selective elements of the tests could provide the foundation for a reliable system of measuring achievement and proficiency in amputee training.</p> <p>As a result of the Upper-Extremity Field Studies, it is now possible to establish a set of proficiency norms based upon amputee per- formance but retaining as its main criterion the skill patterns of nonamputees. The therapist who trains an arm amputee to use a prosthesis could thus have available a realistic and relatively objective standard against which to evaluate the progress and achievement of each patient, since she would be comparing his performance with that of hundreds of amputees of a similar type. The resulting improvement in the evaluation of training effectiveness should permit a judicious allocation of training time and services. Despite its inadequacies of crude-ness and of administrative difficulty, the performance-evaluation system described here established for the first time a logical plan for ascertaining the degree of functional restoration offered amputees by modern prosthetics services, a problem heretofore frequently bypassed for lack of reliable and valid methods.</p> <h3>Concluding Remarks</h3> <p>Refinement of the existing research tools on the basis of past experience, reapplication of these methods in the light of present knowledge, and the further correlation of results may well make it possible to predict the anticipated outcome when specific prosthetic components are applied to a particular arm amputee. Such an eventuality may lead to major changes in the principles of arm prescription and fitting as currently embodied in the art-science of upper-extremity prosthetics.</p> <p>The results of these studies, which have been analyzed and interpreted in the discussion sec- tions on pages 54-61, 99-103, and 143-149, are not resummarized here by way of concluding this article. It is perhaps sufficient to close with the remark that there has been presented in this article a large volume of information providing new insights-some clear, some tentative-into the over-all problem of evaluating arm prostheses. The surface of this broad field has been partially mapped along with some scattered probings of the substrate; but certainly the way has been opened for those who may elect to pursue this problem a little further.</p> <h3>Appendix I Reliability and Validity of the Test Methods</h3> <h4>Reliability</h4> <p>It is well known that test results are subject to a variety of influences and that therefore errors of measurement are to be expected under the best of experimental conditions. The tests used in the NYU Field Studies were at the time in a developmental stage, and in anticipation of errors tending to reduce reliability several precautionary steps were taken.</p> <p>Three measures were employed in scoring the performance tests-performance rating, number of errors, and time. The reliability of the last two is not open to serious question, since such errors as are likely to occur in counting errors or in reading a stopwatch are not usually of significant magnitude or of a systematic nature and can be expected to vary randomly and "average themselves out." Performance ratings, being based on judgment, are more variable, so that errors tending to reduce reliability are to be expected. Some of the principal sources of bias in this study may have been:</p> <ol> <li>Errors of Leniency. Judges tend to rate higher in the desirable traits the subject they actually know.</li><li>Errors of Central Tendency. Judges hesitate to give extreme ratings and so tend to displace subjects in the direction of the average for the entire group, thus misrepresenting the true variation in the group.</li><li>Halo Effect. We tend to judge in terms of the general mental attitude toward the test situation. Knowing, for example, that a subject is being tested for the second time, with an intervening period of fitting and training, a judge may tend to upgrade the performance unduly.</li><li>Normal Variation in the Attitude of the Judge. As individuals, we are continuously influenced by our physical environment and emotional status, and the net effect may produce variability in judgment.</li><li>Variations in Judges' Values. A judge's preconception about the relative difficulty of activities, or of the value to be placed upon efforts in relation to achievement, may bias his judgment.</li></ol> <p>During the course of the studies, 12 NYU Field Representatives conducted the performance tests over a 3-year period between 1953 and 1956. At no one time were all of the judges active in the work, and as a result they did not conduct equal numbers of tests. Nor was it always possible for the pre- and post-treatment evaluation of a patient to be judged by the same rater. Steps were therefore taken to maintain the reliability of the ratings by familiarizing judges with probable sources of error and by firmly establishing the judgment criteria. In addition, all judges were highly qualified members of the NYU staff, with previous research experience in testing and assessment. All were either graduates of the course in upper-extremity prosthetics at UCLA or else had been given similar instruction at New York University. Moreover, the criteria for evaluating performance were carefully studied in formal sessions by all the judges to aid in the development of consistent standards of judgment. The effectiveness of these steps in maintaining reasonable reliability was gauged by statistical analysis.</p> <p>Evidence of reliability was obtained by comparing periodically the independent but simultaneous ratings of a single performance as arrived at by several judges. The ratings thus obtained were evaluated by means of a statistical procedure involving Kendall's Coefficient of Concordance,<a style="text-decoration:none;">*</a> which indicates the degree to which a number of raters are applying essentially the same standard. Kendall's coefficient (W) is used to evaluate the difference between the variability in a set of ratings actually obtained and the variability to be expected in a hypothetical set of ratings if there were perfect agreement among all the raters. The resulting single measure of the extent of agreement among several judges is usually expressed as a chi-square function [x2 = p(m - 1) W, where m = number of judges and p = number of scores]. If the difference (in degree of variability) between the obtained and the hypothetical sets of ratings is significant (by statistical test), we may assume that not all of the raters were applying the same judgmental standard. Since of the original 12 raters in the Field Studies only eight rated enough cases for the results to be valid, only these eight were included in this and succeeding analyses of homogeneity. The statistical findings (x2 = 14.47; df = 7; P &lt; 0.05) indicated that a hypothesis of no relationship between the sets of ratings given by each rater is untenable. This may, therefore, be considered as indicative of a satisfactory degree of consistency in the judgments of the raters at those times. To test the reliability of the scores given by the judges during the entire test period, another technique, "analysis of variance," was used.</p> <p>"Analysis of variance" is a statistical procedure by which a number of independent samples or sets of scores may be tested simultaneously to determine whether or not they are sufficiently similar to be pooled. It is an efficient method for evaluating inter-rater reliability when more than two raters are involved. The test is expressed in terms of a ratio, F, which describes the relationship between the variability of the scores among the several raters (between groups) and the variability of each rater's scores from the mean of all raters (within groups). Simply stated, it is a test of a hypothesis that the scores given by any one rater did not vary significantly from the average of the scores given by all the raters. As shown in the relationship the larger the variance from one rater to another (between groups) as compared with a single rater's variance from the common mean (within groups), the larger the fraction (F). A large F signifies a great difference between the raters; an F of low value indicates homogeneity in the group. A low ratio therefore indicates that performances were consistently rated, that the raters are therefore interchangeable, and accordingly that all the ratings may be considered as having been given by the same rater. <b>Fig. 27</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because of the small number of cases involved, this technique could not be applied to the data from the practical-activities tests or from the abstract-function tests for the above-elbow sample at the pretreatment evaluation. It was applied to the ratings given the below-elbow cases on administration of both the prehension and the positioning test and to the ratings given the above-elbow cases at the post-treatment evaluations (<b>Table 1</b>). There were thus 21 tests in which individual raters had scored enough cases for reliability studies to be made by this means. Used were only those ratings given to subjects evaluated on both pre- and post-treatment tests by the same group of raters. Which is to say that, although an individual rater may not have scored the same subject on both evaluations, he was a member of a group of raters who had given all the ratings.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of the 21 tests, 17 were not significantly different (0.05 level). That is, the extent to which they varied is well within the relatively narrow limits of chance fluctuation, which indicates an acceptable degree of consistency and reliability among the raters. Four, footnoted in <b>Table 1</b>, were statistically significant beyond the 0.05 level of confidence (i.e., there was enough variation in the ratings in these tests to raise a question about the consistency of rating standards).</p> <p>Despite the significant F value obtained in the four questionable tests, all results were used in this report. While the lower statistical reliability of the four may indicate rater unreliability or instability due to smallness of the sample (which would suggest the possibility of eliminating either these tests or the extreme raters), they were retained because the results clearly followed the trend of those tests appearing more reliable statistically. Since, furthermore, all of the tests are, or were, in a developmental stage, no theoretical reason could be adduced for their low reliability. There seemed to be greater value in retaining all of the tests and analyzing the conditions affecting reliability than in discarding some tests on statistical grounds alone. Considering the implications of the findings from all 21 tests, the ratings seemed homogeneous enough to warrant pooling.</p> <h4>Validity</h4> <p>To establish the validity of a test on empirical rather than logical grounds requires a previously established independent criterion with which to compare the test in question. The degree of correspondence between the two (i.e., the extent to which the test measures the same variable as does the independent criterion) is the extent of test validity. External criteria usually are: a specific outcome or product of an activity (as, for example, the number of words typed by a typist in a specific time is a criterion of typing speed), or the activity itself (as illustrated by the speed of a runner as a criterion of fleetness of foot), or the judgment of persons qualified in a given field. The abstract-function tests-the prehension test and the positioning test-require activities which correspond closely to the skills being measured (i.e., to the ability to grasp a very wide variety of objects and to operate a terminal device in several useful planes). No other criteria appear more germane. The practical-activities tests derive their validity in the same fashion-each activity is a valid test since it is itself the skill being measured.</p> <p>To go a step further and to determine whether all or none of these tests are also useful measures of "prosthetic utilization" or of "extent of functional restoration" or of "rehabilitation" requires broader study and the use of other criteria. The presently available judgment of qualified clinic personnel may be the most useful criterion with which the tests may be compared. If, for example, the way in which amputees were classified on the basis of the test results was closely related to qualified judgment about amputee achievement, it would tend to establish the validity of the test as a measure of prosthetic utilization. Such an analysis is beyond the scope of the present work but remains as an interesting avenue for further study.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Siegel, S., Nonparametric Statistics for the Behavioral Sciences, McGraw-Hill, New York, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The five kinds of tasks selected were considered as encompassing the major undertakings in which an arm amputee might use a prosthesis in the course of daily living.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Director, Children's Prosthetic Study, Research Division, College of Engineering, New York University; formerly Field Supervisor, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Director, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Field Supervisor, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-027.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-029.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-030.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-028.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-031.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-032.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-033.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-034.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-035.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-036.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-037.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-038.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-039.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-040.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-041.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-042.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-043.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-044.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-045.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee VI. Prosthetic Usefulness and Wearer Performance Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/c0d0eca6feaf1da610d7cb20b544cd80.pdf 4ab0cc41972a01f65f7db078a1de828c https://staging.drfop.org/files/original/b6d2f7ed0ba556ec7090952c752fbbc5.jpg 41c792470fa9bf7060831ecdd6c6bebc https://staging.drfop.org/files/original/a3f76296fb4dd3889147b7e76d279fd1.jpg 7fdba66f3090467035423319664668ed DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_117.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 117 - 127 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_117.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_117.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee VIII. Research Implications</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It was the purpose of the NYU Field Studies to explore the matter of the upper-extremity amputee in a broad and comprehensive way. To this end there was devised a research program consisting of three phases-survey studies, clinical studies, and evaluation studies. The first of these consisted of the single examination of each of 1630 upper-extremity amputees for the purpose of developing normative, descriptive data concerning the status of the upper-extremity-amputee population at the beginning of the research program. Through the vehicle of an organized program of prosthetic management, 769 of the 1630 amputees surveyed were provided in the clinical studies with what at the time was a new type of upper-extremity prosthesis, the purpose being to study the varieties of prostheses provided, the prescription procedures used, the preprosthetic treatment employed, the adequacy of prosthetic fabrication and fitting, the effects of training, and the results of initial and final checkouts. Finally, in the evaluation studies, the prior status, mental and physical, of 359 individuals selected from the clinical study was compared with their corresponding status after participation and treatment. The procedures used in each of these studies, and the objectives sought in the work, have all been discussed in detail in Section I of this series (Artificial Limbs, Spring 1958, p. 4).</p> <p>While the variety, scope, and degree of completeness of the resulting data all increased as work progressed from the survey studies through the clinical studies and on to the evaluation studies, the size of the experimental sample decreased. The survey studies were limited to the normative data that could reasonably be gathered by means of a onetime interview and examination of the largest possible sample of upper-extremity amputees. The clinical studies supplemented the normative data with observational information concerning 769 amputees receiving prosthetic treatment. The evaluation studies included normative, observational, and research procedures. Only in the last series of studies did control of any research variables become possible. The major focus of the evaluation studies was, then, to obtain information on possible changes in the individual resulting from the application of new and experimental procedures in the management of the upper-extremity amputee.</p> <p>The types of information sought in each of the three phases fell into one or more of five broad categories:</p> <ol> <li><i>The physical and personal characteristics of the amputees.</i>Included identifying data (age, height, weight, residence, marital status); educational level; vocational, avocational, and recreational pursuits; amputation etiology; amputation type; and the strength, ranges of motion, and general characteristics of the stump.</li><li><i>The prosthetic components and fabrication techniques utilized.</i>Included information concerning the functional and mechanical characteristics as well as the advantages and disadvantages of each component of the artificial arm.</li><li><i>The treatment factors.</i>Included data concerning the frequency of prescription of various components, pre-prosthetic therapy, prosthetic training, and checkout.</li><li><i>Amputee performance.</i>Concerned with testing the individual's proficiency in accomplishing the basic activities of prehension, positioning, and release of objects from grasp and with amputee reports concerning the usefulness and importance of the prosthesis in various practical activities of daily living.</li><li><i>Psychological considerations.</i>Involved an assessment of amputee attitudes and personality factors as they affect reactions to prosthetic restoration as well as the social consequences of living with a disability.</li></ol> <p>While data within these five areas of interest were gathered in all three phases of the investigation, the comprehensiveness and sophistication of the measurement techniques varied from phase to phase. In view of the wide range of matters investigated, it is clear that the problems involved in their accurate measurement were considerable. Some factors <i>(e.g.,</i>mechanical characteristics of prosthetic components, results of checkout, certain personal identifying data, etc.) lent themselves rather conveniently to so-called "objective measurement," while in the light of presently available techniques other factors could be appraised only through subjective observation and rating by trained observers <i>(e.g.,</i>amputee performance, quality of prosthetic training, quality of prosthetic fabrication, etc.). Still other factors <i>(e.g.,</i>attitudes, personality factors, opinions concerning prosthetic components and treatment methods, etc.) could only be inferred from the verbal reports of the amputees themselves. As a consequence, the resulting data are of three kinds-objective measurements, observations and ratings, and amputee verbalizations. It should, however, be pointed out that no relationship necessarily exists between the significance and value of various data and their objectivity. Quite often the most objective data are the easiest to obtain but are also the least revealing. Yet certain data obviously subjective and barely capable of meeting any standards of precision provide the greatest insights and understanding.</p> <p>With several relatively minor exceptions, all five subject areas have individually been the topic for separate analyses and discussions and have culminated in five corresponding articles (Sections II, III, V, VI, and VII) in this series. Section II (Artificial Limbs, Spring 1958, p. 57) dealt with the descriptive characteristics of the sample. Section III (Artificial Limbs, Spring 1958, p. 73) was concerned with the evaluation of the treatment process. Section V (page 4) reviews the specific components and fabrication techniques that go to make up a prosthesis. Section VI (page 31) describes the performance or functional capabilities of the amputee subjects, while Section VII (page 88) analyzes the psychological attributes of the amputee group.</p> <h3>Studies Completed</h3> <h4>The Sample (Section II)</h4> <p>The initial point of interest is that there were in the nationwide, somewhat urban sample almost as many above-elbow as there were below-elbow amputees (41 percent as compared with 51 percent). The remaining cases consisted of shoulder-disarticulation amputees (5 percent) and bilateral arm cases (3 percent). Within each of these four basic amputee types, a further detailed breakdown is presented. For example, the below-elbow cases are classified and discussed as very short, short, medium, and long, and as wrist disarticulations. A similar breakdown is offered for the above-elbow and shoulder-disarticulation groups.</p> <p>It is important to emphasize that 73 percent of the participating subjects were veterans of military service who had lost limbs in World War II, a matter having a strong influence on the characteristics of the sample- on age, height, weight, educational level, and vocational status as well as on other physical characteristics.</p> <p>Although certain amputees continued to pursue agricultural and mechanically oriented occupations, amputation generally resulted in a shift away from agricultural, manual, and mechanical occupations toward clerical, sales, and managerial activities, and there was in addition a very significant increase in the extent of unemployment (from 1 percent to 19 percent). Such a finding raises the question whether these shifts are caused chiefly by the physical inability to perform and compete in certain activities or primarily by socioeconomic factors.</p> <p>An overwhelming majority of the subjects were found to have in their residual anatomy sufficient strength and sufficient range of motion to use an upper-extremity prosthesis. Despite this physical potential, 25 percent of the below-elbow, 39 percent of the above-elbow, and 65 percent of the shoulder-dis-articulation amputees were not wearing arm prostheses at the time of the survey studies. Typically, those who did wear prostheses used Dorrance hooks, Miracle or APRL hands, and friction-type wrist units. The below-elbow prostheses typically consisted of a leather socket, rigid metal elbow hinges, and a figure-eight harness. The above-elbow and shoulder-disarticulation prostheses had in general plastic or leather sockets, manually operated or harness-controlled elbows (in about equal proportions), and chest-strap harnesses with shoulder saddles.</p> <h4>The Treatment Process (Section III)</h4> <p>Before the advent of the Upper-Extremity Field Studies, only some 17 percent of the group had had arms prescribed for them by a clinic team consisting of a physician, a therapist, and a prosthetist. In the NYU program, where prescriptions were written and filled in this manner routinely, all the professional groups concerned and 94 percent of the amputee subjects heartily approved of the multidisciplinary, clinical approach.</p> <p>With respect to prosthetic components utilized there were several very significant shifts, such as the tendency toward the use of the APRL hook (from 12 percent to 61 percent of the sample) and toward the APRL hand (from 11 percent to 80 percent of the sample). There was also a marked increase in the use of positive-locking wrist units as compared with friction types, a strong shift toward the use of flexible hinges instead of rigid hinges for the below-elbow amputees, and an increase from 46 percent to 100 percent in the proportion of above-elbow amputees wearing harness-operated elbows. Plastic laminates were used exclusively for fabrication of the nonoperating parts of the prostheses, and the harness patterns tended to be of the figure-eight type. In point of fact, it may be said that the whole pattern of prosthetic prescription for the upper-extremity amputee was revolutionized in the course of the Upper-Extremity Field Studies.</p> <p>Introduction of the checkout procedures met with considerable success. Clinic personnel considered checkout a valuable management tool, and more than 90 percent of the amputees thought it useful. Whether initial checkout or final checkout, almost 70 percent of the arms passed on the first trial. The remaining cases required two or more visits to resolve all problems, the major deficiencies uncovered being in the areas of socket fit, harnessing, and alignment of control systems.</p> <p>Application of the training procedures was not nearly so successful. Some 40 percent of the group thought that the results of training could be improved by extending the instruction over a longer period and by including more and varied practice in the regimen. The finding that during the training period 54 percent of the sample needed adjustments or corrections in the prosthesis suggests the great value of supervised training-that is, of training in a situation so controlled that specific difficulties can be uncovered and resolved with a minimum of difficulty. Although the length of the training period was greater for bilateral cases than for shoulder disarticulations, greater for shoulder disarticulations than for above-elbow amputees, and so on, the time allotted for shoulder disarticulations and for above-elbow cases over that allowed below-elbow cases did not seem to be in keeping with the increase in operating difficulty known to accompany loss of the natural elbow.</p> <p>All in all, the system of amputee management introduced as part of the Field Study was accorded a high degree of acceptance both by the amputees and by the professional personnel charged with their care. Perhaps the strongest recommendation for the management procedures lies in the fact that, with appropriate revisions and variations, they are now in widespread use in amputee clinics throughout the country.</p> <h4>The Armamentarium (Section V)</h4> <p>The data concerning the prosthetic armamentarium tend to be encyclopedic and documentary. Each component of the upper-extremity prosthesis has been considered in terms of appearance, usefulness, ease of operation, and weight, and this information has been supplemented by data on the ranges within which the components functioned and on the magnitudes of the activating and resulting forces. The adequacy of the fabrication techniques utilized in making the upper-extremity prosthesis was also reviewed. These data provide the biomechanical basis upon which to revise a number of the checkout standards.</p> <p>Lastly, the new components that go to make up the present armamentarium (terminal devices, wrist units, elbow hinges for below-elbow arms, elbow joints for above-elbow arms, control systems, and harnessing equipment) have been compared with corresponding components in the prior art. Amputee reactions toward the conventional preprogram arms have been compared with the reactions toward the new program prostheses. The amputees felt that the program prostheses are characterized by:</p> <ol> <li>Higher, better-fitting, and better-appearing sockets.</li><li>More useful and easier-operating elbows.</li><li>Improved efficiency of force transmission reflecting better cable alignment and more stable materials.</li><li>Lighter, freer, and more comfortable harnessing.</li><li>A marked increase in terminal devices offering improved control of grasp force.</li></ol> <p>Of the 290 amputees who had an opportunity to wear both types of arms, 261 preferred the new, 25 the old, while 4 expressed no preference.</p> <h4>Amputee Performance (Section VI)</h4> <p>Section VI has been concerned with the functional value of arm prostheses, the uses to which they are put, and the skill and efficiency with which arm amputees can utilize them. From interrogation of the subjects, it became apparent that the usefulness of an arm prosthesis varied considerably from activity to activity in the five broad areas of daily living (work, home, recreation, dressing, and eating). In the numerous activities that go to make up work, recreation, and home life, prostheses tended to have wide applicability and to be most helpful to the wearer. As a matter of fact, use of the prosthesis in a variety of jobs and hobbies was much more extensive than is usually recognized, and we must therefore conclude that the functional potential of the upper-extremity amputee is also a good deal greater than commonly thought. But in the activities of dressing and eating, which for the most part involve a limited number of relatively difficult operations performed close to the body, prostheses tended to be considerably less useful. An interesting note is that, as regards the performance of any one given task, prosthetic usage tends to be on an all-or-none basis. Either the amputee uses his prosthesis every time he is confronted with a given task, or else he never uses it for that task. "Sometimes" usage is reported infrequently.</p> <p>To shed further light on the comparative values of below-elbow, above-elbow, and shoulder-disarticulation prostheses, 20 selected bimanual activities, considered both by the examiners and by the amputees to be significant in terms of frequency of occurrence and of importance, were used in an attempt to determine how widely prostheses were used. In summary, the results showed that:</p> <ul> <li>Over 50 percent of the below-elbow amputees always used their prostheses for 19 of the 20 tasks.</li> <li>Over 50 percent of the above-elbow amputees always used their prostheses for 13 of the 20 tasks.</li> <li>Over 50 percent of the shoulder-disarticulation subjects always used their prostheses for 8 of the 20 tasks.</li> <li>Over 50 percent of the bilateral arm amputees always used their prostheses to accomplish 15 of 18 tasks (two tasks not applicable).</li> </ul> <p>These and other data show clearly that the higher the level of amputation for which an arm prosthesis is intended the less the utility of the prosthesis. The sharp distinction between the usefulness of prostheses for below-elbow amputees and that of prostheses for above-elbow and shoulder-disarticulation amputees can be explained readily in terms of the limited function to be had from the mechanical elbow and the concomitant need for a comparatively high order of skill in order to use it properly. The difference in apparent usefulness is clearly due to the loss of the normal anatomical elbow. This circumstance re-emphasizes the need for more practically oriented and more extended training for above-elbow and shoulder-dis-articulation amputees.</p> <p>While contemporary below-elbow prostheses appear to be more useful than are the corresponding prostheses for above-elbow amputations and for shoulder disarticulations, arms for the higher levels of limb loss still offer a significant measure of utility. It should also be noted that not all amputees of a given type use their prostheses to the same extent or for the same activities. Obviously, then, the prosthesis varies in value and convenience for the individual wearer, and this factor also helps to determine the amount of use made of the limb by the individual wearer.</p> <p>Through a series of tests of abstract function (prehension and positioning viewed as ends in themselves) and of the performance of practical activities of daily living, a systematic, observational method of rating amputee performance was developed. Although the tests are not as precise as might be desired, an initial step in the measurement of amputee function has been taken. One direct result has been the establishment, for the upper extremity, of a set of norms which may be used as a point of comparison in evaluating amputee performance and in setting reasonable goals for prosthetic training.</p> <p>The data from these tests clearly indicate that, in general, more could be accomplished with the new arms than with the old and that more skillful and more natural performance with the new prostheses was usually obtained without any increase in performance time.</p> <p>The advantages of the experimental arms over the older, conventional arms were most noticeable in above-elbow and shoulder-disarticulation prostheses, less so in below-elbow prostheses. In the below-elbow case, apparently, prosthetic function is very much less dependent upon the quality or precision of arm fabrication, or on the specific components included in the prostheses, or both.</p> <p>While in general the results point up the inadequacies of even our most advanced devices and techniques and thus emphasize the continued existence of much room for improvement, they also show that present-day upper-extremity prostheses are quite useful devices despite the inadequacies, especially for those types of amputees heretofore thought incapable of deriving much benefit from any prosthesis. Since we seem now to have exploited the existing concepts of upper-extremity prosthetics, there would seem to be little more to be gained by continued redesign of current prosthetic equipment. Instead, there is now a need for dramatic, if not drastic, new concepts in approaching the problem of rehabilitating the upper-extremity amputee.</p> <h4>Amputee Attitudes And Reactions (Section VII)</h4> <p>Section VII attacked the problem of prosthetic restoration from the point of view of the psychological characteristics of the amputee and tried to evaluate the subjects on the basis of nine personality variables, to explore a number of factors influencing prosthetic wear and function in social situations, and to study the amputees' attitudes toward prosthetic wear before and aftei fitting with a prosthesis The predominant finding as regards the personality functioning of the amputees was that, no matter which aspect was studied, the subjects appeared to try consistently to maintain feelings of bodily integrity and adequacy by denying many of the personal, vocational, and social consequences of amputation. They consistently de-emphasized their physical difficulty, rejected notions of abnormality, and set their cosmetic and functional desires in line with those of normal people. Superimposed on this general positive tone of the amputees' statements concerning adjustment was the additional positive effect of the treatment program on many of the personality variables, as evidenced by consistent indications of some decrease in expressed feelings of sensitivity and frustration, increased feelings of functional and social adequacy, and greater acceptance of their disability.</p> <p>One problem associated with this aspect of the study was that, because of the limitations of the experimental design, the data were based entirely upon the voluntary expressions of the subjects themselves, who consistently tended to color their responses by hiding any attitudes which might be viewed as "negative." Aware of this difficulty in the measurement of the social and functional factors affecting prosthetic wear, the experimenters attempted a somewhat more indirect approach in the form of cartoons depicting a series of ambiguous, potentially sensitive, situations. The amputees were asked to respond to these situations, the expectation being that they would "project" their attitudes in a less inhibited form. Probably the major finding of this line of inquiry developed from the answers given when the amputees were requested to react to the cartoons as prosthesis wearers and then as nonwearers. The data show consistently positive attitudes toward prosthetic wear, the feeling being expressed that the prosthesis makes the amputee more effective and independent functionally, more self-reliant, more secure, more self-accepting, less shy, less easily embarrassed, and more adaptable. One may, of course, ask whether the amputees held these attitudes fundamentally or whether they were merely expounding an expected "cultural norm." On the basis of the available data it is not possible to answer the question.</p> <p>In a comparison of the preprosthetic expectations of amputees with the actual degree to which these expectations were fulfilled after fitting, it was concluded that:</p> <ol> <li>Normally, little prosthetic information is available to the new amputee, and this deficiency encourages the development of unrealistic expectations concerning prosthetic wear.</li><li>Anticipations which tended to be overly optimistic were in most cases modified downward (with considerable personal disappointment and regret) after the individual had an opportunity to wear a prosthesis.</li></ol> <p>The last question studied had to do with whether or not the postfitting behavior of the amputee toward his prosthesis is related to, and whether or not it can be predicted on the basis of, his prefitting attitudes, a matter that would seem to have significant practical implications. Should preprosthetic attitudes turn out to exercise a determining or controlling influence over later prosthetic acceptance, performance, and use, it would be desirable to attempt to influence early attitudes so as to obtain the best possible rehabilitation results. Investigation did indeed show that those amputees holding favorable attitudes before ever having had a prosthesis tended to maintain favorable attitudes after wear and use; those at first negatively disposed continued to react negatively after receiving a prosthesis.</p> <h3>Future Studies</h3> <p>Although the amputees in the NYU Field Study have thus far been assessed rather thoroughly in terms of five broad areas (physical and personal characteristics, prosthetic components and fabrication techniques, treatment procedures, prosthetic performance, and psychological orientation), little has yet been done toward exploring the relationships that may exist either within or between the several categories of data. As a matter of fact, the data reported and discussed here constitute a phenomenological picture of observed events and are therefore basically descriptive in nature. While data of this type are valuable in that they focus attention on significant occurrences and reveal what is taking place and what is changing during the period of observation, the reasons why the events occur, and the nature of the causal train producing them, can be learned only by more detailed and more definitive study.</p> <p>The only studies of this more detailed variety which have been performed thus far are as follows:</p> <ol> <li>A substantial segment of the findings concerning the unilateral amputees have been analyzed and presented in terms of the three basic amputee types- below-elbow, above-elbow, and shoulder-disarticulation amputees. But there is still a need for further analyses of this variety using finer categories in the amputee-type classification system (such as wrist disarticulation, long below-elbow, medium below-elbow, short below-elbow, very short below-elbow, etc.).</li><li>A number of attitudes toward prosthetic wear held by the amputees prior to prosthetic fitting have been studied and presented in relation to postfitting attitudes and psychological adjustment.</li></ol> <p>Whatever cross-correlations are attempted, however, it must be remembered that the subject matter deals with the complex interactions between a human being, the patient, and an involved environmental process, the treatment procedure. Man is not composed of a series of discrete traits and attributes, nor does he represent the simple sum of such features Taken as a whole, the configuration is more exponential that additive. Similarly, the treatment procedures at any given level of observation may represent a series of obvious events simply measured and simply described, or they may be seen more subtly as sets of behavior of professional people- physicians, prosthetists, therapists, others- directed toward another individual, the amputee. In this light, distinctions and comparisons drawn between the patient, the treatment process, and the restorative result are unavoidably arbitrary to the extent that they tend to be abstractions from the intricate network of human behavior. Since in practice, however, analyses must be performed at some level not fully reflecting the human interactions at work, attempts at further study require some kind of conceptual framework within which to consider the data.</p> <h4>A Conceptual Framework</h4> <p>When the mass of available data is reviewed,<a style="text-decoration:none;">*</a> the individual elements fall naturally into two groups-those which describe the factors contributing to the over-all result of prosthetic restoration and those which describe the result itself. The data in the first category, those dealing with the causal factors, seem in turn to constitute two separate subcategories-the individual characteristics, which the patient brings to the restoration regimen, and the treatment process, which describes the management procedures applied. Together the interaction of these two contributing factors (variables) produces the over-all result of prosthetic restoration. Thus:</p> <p>Amputee Characteristics + Treatment Process = Over-All Result of Prosthetic Restoration</p> <p>But each of these three broad factors consists, again in turn, of a number of more specific considerations that were the subject of investigation in the NYU Field Studies. It is therefore possible to recast the formula into somewhat more specific terms, whereupon the three factors in the original relationship are found to consist of seven different types of data. Thus: <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Further expansion of such a breakdown leads to <b>Table 1</b>, which reflects in greater detail the kinds of information available. All told there are some 60 variables on which data have been collected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The data having been thus classified, it is now necessary to find the means with which to develop whatever significant interrelationships may exist within and between the various categories. Analyses may be performed at any of the three levels of complexity, but those best undertaken first would tend to consider the segmented types of data listed in the lower portion of <b>Table 1</b>. Contrary to first impression, they are in reality by far the simplest to investigate. To study the earlier, more general, and apparently less complex relationships shown in the first two formulae will require the development of suitable means for consolidating individual sets of data in some meaningful way to describe the composite concepts utilized. Accordingly, analyses of the data will vary in complexity depending on whether we wish to study the relationships between discrete variables or those between increasingly composite, and therefore complex, conceptualizations. As the chosen formulation becomes clinically more meaningful, the complexity of the statistical analysis increases. Conversely, the simple selection of a pair of variables and the study of their interrelationship is easiest to effect statistically.</p> <h4>Two-Variable Analyses</h4> <p>When the available data are considered, the area of primary interest that comes at once to mind concerns the question of what factors in the amputee and/or in the treatment process tend to influence the over-all restoration result in a significant way, positively or negatively. Since the final level of prosthetic restoration is a composite measure made up of two different types of data, we can study various individual factors, one at a time, as they influence one segment of the rehabilitation result (use of the prosthesis by the amputee) or the other segment (the amputee's postfitting patterns of psychological adjustment). In the study of these relationships, the data concerning prosthetic performance (or those concerning amputee adjustment, one or the other) are organized and then compared systematically with data describing a variety of possible causal factors.</p> <p>Since any of some 40 individual factors may influence either segment of the final result of prosthetic restoration, it becomes a matter of judgment as to which of the many possible relationships are worth checking. On the basis of previous experience, the prefitting considerations which seem to have the greatest potential significance, and which would seem to be most worth while exploring in relation to each part of the prosthetic restoration result, are as follows:</p> <p>I. Personal characteristics: age, residence, education, marital status, vocation, hobbies, recreational activities.</p> <p>II. Psychological characteristics: acceptance of loss, identification with the disabled, functional adequacy, independence, sensitivity, acceptance by others, sociability, frustration, optimism, security, prosthetic expectations.</p> <p>III. Physical characteristics: etiology, dominant or subdominant loss, amputation level, stump strength, stump motion.</p> <p>IV. Prosthetic-component characteristics: voluntary-opening <i>vs.</i>voluntary-closing terminal devices, canted <i>vs.</i>lyre-shaped fingers, range of pinch forces, friction <i>vs.</i>locking-type wrist units, step-up <i>vs.</i>nonstep-up elbow hinges, single-axis <i>vs.</i>polycentric hinges, figure-eight <i>vs.</i>shoulder-saddle harnesses, quality of prosthetic fabrication (as revealed by checkout).</p> <p>V. Management procedures: extent of training, time lapse before training, extent of preprosthetic therapy, behavior and attitudes of clinic personnel (physician, therapist, prosthetist).</p> <p>In this analysis, the factors included under headings I through V may be considered "predictor" variables, while the data listed under headings VI and VII may be looked upon as "criterion" information. If firm relationships can be established between the data in the first group of categories (I-V) and those in the second group (VI-VII), the former information may be used as a basis for predicting the outcomes of the prosthetic restoration process. The choice of predictor variables to be studied depends, of course, upon the segment of the prosthetic restorative result (prosthetic use or psychological adjustment) selected for study. It is, for example, quite enlightening to relate stump factors to prostehtic usage, but there would be less reason to select stump factors when we are interested in predicting psychological adjustment. Whatever variables are ultimately selected for study, however, the basic analytic approach remains unchanged.</p> <p>A second important type of two-variable analysis can very well involve a study of what relationships exist between the two aspects of the post-treatment result itself (prosthetic use <i>vs.</i>psychological adjustment). Is there, for example, any relationship between an amputee's sense of independence and the extent to which he uses his prosthesis? Is the quality of prosthetic performance related to the individual's social sensitivity? Any number of relationships of this variety could be the subject of study, and the results would contribute to the solution of one of the problems of amputee rehabilitation. Does extensive prosthetic usage of high quality imply good general adjustment, or does good adjustment give rise to efficient prosthetic use? Or is there in fact no significant relationship between these two important aspects of successful amputee rehabilitation?</p> <p>A third variety of two-variable analysis stems from the fact that even within the individual areas of prosthetic usage and of amputee behavior there are important relations to be studied. How, for example, does the amputee's performance with a prosthesis relate to the importance which he attributes to a given activity? What is the relationship between the efficiency of prosthetic use as reflected by tests (actual usage) and the efficiency as reported verbally by amputees (reported usage)? In the psychological area, what is the relationship between an amputee's feelings of sensitivity and his sense of identification with the disabled? To what extent do feelings of frustration affect the amputee's sense of functional adequacy? All these are examples of significant relationships which may exist within the given segments of the prosthetic restoration result and which may very well be amenable to study.</p> <p>In addition to all these possibilities, there remains a fourth type of two-variable analysis, one concerned with the relationships between the various amputee characteristics and data concerning the treatment process. Do amputees with similar occupations, hobbies, and/or recreational pursuits receive similar prosthetic prescriptions, or is the prescribed prosthesis unrelated to these matters and more dependent upon the personal attitudes of the clinic personnel? Are the variations in prescription, training, and checkout procedures based on geographic factors, age of patient, etc.? Relationships such as these are also worth exploring.</p> <p>There is no question but that a considerable amount of knowledge is to be gained from the segmented type of analytic approach described. But a major limitation and a fundamental weakness is inherent in these techniques. When correlations are limited to no more than two factors at a time, the variables concerned are unavoidably isolated out of the large complex of continuously interacting forces known to exercise control over the final result of prosthetic restoration in any given case. In separating, out of the entire data, pairs of variables that may happen to interest us, we ignore the well-known clinical observation that the whole result of prosthetic rehabilitation is the consequence of a number of simultaneous, interdependent influences. In effect the other factors are treated as "constants" at any given time, an expedient admittedly not in keeping with the facts. Were the data made up of a large number of independent variables (factors independent of other influences in a situation), the difficulty would be less critical. But we find in fact that only comparatively few of the items are truly independent of one another.</p> <p>Although this limited analytical approach will not provide the ultimate in understanding of the prosthetic restoration process, it will provide information concerning the more salient relationships existing within the data. The technique of two-variable analysis can be carried one last step by combining selected distributions of data in order to develop indices of more general factors in the prosthetic-restoration complex. Data concerning performance on prehension tests, positioning tests, practical-activity tests, and reported use of the prosthesis may, for example, be combined to provide a composite measure of amputee performance. This combination factor may then be studied in relation to other discrete variables or other composite factors. But before one goes very far along this path he comes face to face with the desirability of attempting a "global analysis."</p> <h4>Global Analysis</h4> <p>In view of the weaknesses in the two-variable approach, it would seem desirable to be able to explore the interaction of all the various factors, each with the others. That is to say, it would be helpful to be able to gauge the extent to which each factor in the prosthetic-restoration complex affects the others and to determine to what extent the total pattern of interdependence affects the final result. In any such study of interactions of variables, we are of necessity drawn to relatively sophisticated methods in statistics, such as multiple correlation, analysis of variance, and possibly factorial analysis. That analysis by these methods would be completely fruitful is by no means assured. For unless the relationships within the data are reasonably clear-cut, the statistical procedure may not be discriminating enough to bring them to light. Deficiencies in the sampling, weaknesses in the measuring instruments, and other technical shortcomings would also tend to obscure the results.</p> <p>This known risk notwithstanding, such an effort is clearly worth while and will be undertaken in view of the <i>possibility</i>of approximating the significance to be afforded various considerations involved in the prosthetic-restoration potential of an individual. Success in this more ambitious approach would shed light on the relative influence that various factors, within the amputee and within the treatment process, have on the final result. Although it is well understood clinically that not all patient characteristics or all treatment methods influence the final outcome equally, no scientifically validated picture of the relative significance of the causal factors exists to date. From further studies, one might hope to learn what combinations of amputee characteristics and treatment procedures make for the best prosthetic-restoration results and, by the same token, what combinations dictate poor results. An understanding of these matters would permit reasonable predictions as to the probable success of the restorative effort, suggest modifications of the treatment process the better to fit the needs of the individual patient, and make it possible to identify and to grade "optimum" restoration results in any given case.</p> <h3>Conclusion</h3> <p>It is clear then that this presentation constitutes an overview of the information evolving from the NYU Field Studies and suggests that a considerable amount of additional data analysis will be required before the available material will have made its final contribution to the field of upper-extremity prosthetics. Many of the remaining analyses are already in process, and it is planned to publish these results as the work is completed. It must, however, be recalled that the NYU Field Study was essentially research "in breadth" and that this approach should not be expected to answer all questions relating to the upper-extremity amputee. For many of the issues needing resolution, research embracing the study of individual cases "in depth" will be required. Meantime, it is in order to express appreciation for the singular opportunity of studying such a large group of upper-extremity amputees. Because of the nature of the disability associated with arm loss, it usually is very difficult to gather large numbers of arm amputees in any one location, and it is almost impossible to be able to subject such a group to a systematic pattern of treatment. Although it would be gratifying if it could be said that the most had been made of the unusual opportunity afforded, afterthought and hindsight tell otherwise. Unfortunately the problems of research into the unknown do not cast their shadows before, and the path to discovery remains exceedingly narrow. Until better methods of dealing with the complicated manifestations of the human being become available, we must be content with studies and analyses that can shed even small light on the challenging problems of prosthetic restoration.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Almost all of the data developed during the NYU Field Studies have been codified and punched on IBM (International Business Machines Corp.) cards, and all of the major analyses presented in this (Vol. 5, No. 2) and the preceding (Vol. 5, No. 1) issue of Artificial Limbs have been performed through the use of IBM electromechanical data-sorting techniques. Any future analyses may be accomplished conveniently through the same means.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic Devices Study, Research Division, College of Engineering, New York University; Director, Prosthetics Education, NYU Post-Graduate Medical School; Adjunct Professor of Psychology, Fairleigh-Dickinson University, Rutherford, N. J.; member, Committee on Prosthetics Research and Development and Committee on Child Prosthetics Problems, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_117/aut1958-117-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_117/aut1958-117-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee VIII. Research Implications Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * https://staging.drfop.org/files/original/25d7008c03dbf5520812970f5e24a3b8.pdf 5e4f5d62d004e9714dae9287001a5288 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_088.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 88 - 116 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_088.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_088.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee, VII. Psychological Factors</h2> <h5>Jerome Siller, Ph.D. <a style="text-decoration:none;">*</a><br />Sydelle Silverman, M.A. <a style="text-decoration:none;">*</a><br /></h5> <p> With the possible exception of the introductory Section I (Artificial Limbs, Spring 1958; Vol. 5, No. 1), the foregoing presentations in this series have in general been concerned with the biomechanical aspects of the man-machine entity in prosthetic restoration. If, however, our understanding of amputee needs and limitations is to be comprehensive, we must inquire also into the mental and emotional characteristics of the man served by the machine. Consideration of the psychological factors in amputee rehabilitation was therefore an important aspect of the Upper-Extremity Field Studies, and the results of these investigations are summarized in this three-part article. The first part, <i>Personality Dynamics of Amputees,</i> discusses a number of the psychological variables that are relevant to amputation. The second deals with <i>Social and Functional Factors in Prosthetic Wear.</i> And the final one, <i>Attitudes Toward Prosthetic Wear, Before and After Fitting,</i> describes the attitudes shown toward arm prostheses by amputees who had never before worn an artificial arm. The rationale of the study, and the data-collecting instruments here referred to as "appendices," are all to be found in Section I (Artificial Limbs, Spring 1958; Vol. 5, No. 1; pp. 46 through 56). </p> <h3>Personality Dynamics of Amputees</h3> <p>At present no single theory, or combination of theories, encompasses all the central problems arising in man from the loss of a limb. One reason for this circumstance is that the special problems and needs of the amputee have never been defined adequately. What does an amputation mean to the amputee? What does it mean to his family, friends, and co-workers? What reaction does the amputee have to his loss? How is he affected socially, vocationally, emotionally? Does his amputation cause basic psychological changes? What major needs are frustrated? What new needs arise? Does prosthetic restoration affect personality restoration? These are but some of the questions that seem pertinent and to which answers were sought during the NYU Upper-Extremity Field Studies.</p> <p>A probing of specific amputee problems was considered to be the most fruitful approach, and accordingly a set of questions was designed to elicit information about areas in which the amputee might be expected to have significant problems. By means of a 57-item, multiple-choice questionnaire (Appendix IIIE), supplemented by a 9-item instrument calling for narrative answers (Appendix IIIF), nine personality variables (acceptance of loss, identification with the disabled, functional adequacy, independence, sensitivity, appraisal of acceptance by others, sociability, frustration, and optimism) were identified and defined. Of 359 adult male amputees who responded in this phase of the investigation, all but 55 were currently wearing prostheses or had worn one in the past.</p> <p>Each of the nine personality variables has many ramifications, and it was possible to investigate a limited number only. Moreover, a preliminary analysis indicated that the data did not differ significantly for different levels of amputation, and accordingly the responses of the three groups (below-elbow, above-elbow, and shoulder-disarticulation) were combined. The results therefore represent only an early exploration of the field with two principal purposes-first, to stimulate further inquiry, and, second, to build a more general awareness of the psychological aspects of treating and dealing with amputees. While the central concept of each variable is discussed here, emphasis has been placed on principles of theoretical and practical interest to those concerned with the management of amputees. Whenever possible, the interrelationships between a particular concept and other variables are examined, and an effort is made to bring out implications for research and practice. Vocational attitudes provided an additional area of interest, as did also the shifts in the valuation of prosthetic service.</p> <p>The data presented are chiefly those gathered after the period of treatment and fitting. Although the treatment procedure produced few measurable changes of any consequence, where such changes were observed they are also discussed.</p> <h4>Acceptance of Loss</h4> <p>"Acceptance of loss" refers to the amputee's ability to accept the physical limitations that result from his injury, to avoid depreciating or pitying himself, and to recognize the social implications of his loss without exaggerating or denying them. This matter was explored by means of questions relating to the amputee's adaptation to his loss, his wishful thinking about the lost limb, and his reaction to the artificial one.</p> <p>When the treatment period was over, most of the subjects claimed to be adapted to their loss:</p> <table> <tbody><tr> <td> <p><b> To what extent do you feel that you have become adapted to the loss of your limb?</b> </p> </td> </tr> <tr> <td> <p>Completely</p> </td> <td> <p>42%</p> </td> </tr> <tr> <td> <p>Almost completely</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Considerably</p> </td> <td> <p>16</p> </td> </tr> <tr> <td> <p>Somewhat</p> </td> <td> <p>5</p> </td> </tr> <tr> <td> <p>Slightly</p> </td> <td> <p>5</p> </td> </tr> </tbody></table> <p>Before the treatment period, only 35 percent of the amputees said that they felt completely adapted to their loss. The increase to 42 percent after completion of the treatment program would seem to indicate that the fitting of the artificial limb had a strong positive effect upon the adaptation of at least a small number of amputees.</p> <p>Although 90 percent of the amputees claimed either complete, almost complete, or considerable adaptation to their respective losses, it is doubtful that so many had really achieved it. While some may truly have accepted their physical loss and its implications, there were surely many who were trying to maintain feelings of bodily integrity and adequacy by denying the personal and social concomitants of amputation. Clearly, they preferred to de-emphasize regret and any hint of abnormality and difference. In keeping with this feeling, 86 percent of the amputees said that they rarely, very rarely, or never felt sorry about their loss:</p> <table> <tbody><tr> <td> <p><b> Do you feel sorry that you're an amputee?</b> </p> </td> </tr> <tr> <td> <p>Most of the time</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>13</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>12</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>33</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>41</p> </td> </tr> </tbody></table> <p> But it should be noted that many amputees <i>do</i> admit that they have fantasies about the matter: </p> <table> <tbody><tr> <td> <p><b> Do you find yourself wishing you were a two-handed person?</b> </p> </td> </tr> <tr> <td> <p>Much of the time</p> </td> <td> <p>8%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>45</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>28</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>10</p> </td> </tr> </tbody></table> <p>A second question also explored this phenomenon :</p> <table> <tbody><tr> <td> <p><b> Do you ever think of how much better off you would be if you had not lost an arm?</b> </p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>6%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>16</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>14</p> </td> </tr> </tbody></table> <p> Thus it appears that, although most amputees try to avoid thinking about themselves as amputees, regrets over their loss <i>do</i> come out in fantasy. Other indications of this subconscious process can be seen in the contradictory data resulting from different avenues of questioning. About half of the amputees indicated that they frequently tried to perform with their prostheses tasks which they knew would be difficult, and approximately the same number said that what bothered them most was "the inability to perform as I used to." Both of these reactions, which persisted throughout the entire period of participation in the program, seem to represent the amputee's attempt to retain his status as an active, competent, and self-sufficient person. But an amputee who frequently tries to use his artificial arm for a task that he knows will be difficult must have an unrealistic attitude toward his physical limitation. He is evidently demonstrating an unwillingness to accept the full implications of his loss. </p> <p>Among the many considerations involved in the loss of an arm, the most obvious is the inability to perform at one's previous level. Others are the loss of normal appearance and the thought of not being like other people. Although 57 percent of the amputees said that performance was their most bothersome problem, while only 15 percent mentioned the other two considerations, it is difficult to accept such a response at face value. It is likely that the loss of normal appearance and the thought of not being like other people bother amputees far more than they are willing to admit.</p> <p>Two factors lead us to this belief. First, we are convinced that people (and men in particular) hesitate to admit that they are concerned over their appearance or over the thought of not being like other people. An amputee probably finds it much more acceptable, both personally and socially, to seize upon the very real functional and vocational problems caused by his amputation and to use them as the "real" causes of his distress. Secondly, an amputee who admits to being bothered by his inability to perform is really also saying that he is concerned about being different from others, since performance difficulties as well as altered appearance make one "different."</p> <p>Amputation has also other, less obvious aspects that are even more difficult for the amputee to accept. These involve the subconscious effects of the loss, such as the thwarting of life goals, threats to masculinity-femininity identifications, and the arousal of latent fears of castration. Although the reality and importance of these problems have repeatedly been demonstrated clinically, controlled investigation designed to explore them is exceptionally difficult and has not yet been undertaken. Hence most of the subconscious effects of amputation cannot yet be evaluated systematically, even though it seems clear that they exert a great influence upon the amputee's acceptance or nonacceptance of his loss.</p> <p> In general, it may be concluded that an amputee's acceptance of loss depends upon many factors, the most important usually being beyond his own control. His ability to accept depends upon his conscious and subconscious interpretation of his status. If he feels that his amputation has relegated him to an inferior social and vocational status, that he can no longer achieve his principal goals, that he is inferior, and that he has been reduced in functional and sexual potency, he will naturally attempt to reject the implications of his loss. If he looks upon his amputation as a means of escaping from the competition of everyday life, he may accept his loss. If it justifies catering to his need to feel dependent, he may even derive satisfaction from it. But when the amputee is able to look upon his experience as primarily a major frustration that must be overcome-and that <i>can</i> be overcome by his own efforts, in cooperation with family, friends, and rehabilitation personnel-then the stage is set for a real acceptance of loss. </p> <p> Although it seems clear that when first seen many of the participating amputees had not achieved full acceptance of their loss, experience shows that, after the early postamputa-tion period of readjustment, and after satisfactory prosthetic fitting, most amputees <i>do</i> accept their loss to a significant degree. </p> <h4>Identification with the Disabled</h4> <p>"Identification with the disabled" refers to the degree to which the amputee considers his abilities, general appearance, and personality similar to those of other persons physically impaired. To a great extent this factor serves as the basis for his interaction with others.</p> <p>The basic question exploring this matter was:</p> <table> <tbody><tr> <td> <p><b> I think of myself as a:</b> </p> </td> </tr> <tr> <td> <p>physically abnormal person....</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>normal person except for a major physical defect....</p> </td> <td> <p>18</p> </td> </tr> <tr> <td> <p>normal person except for a slight physical defect....</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>normal person except for a very slight physical defect....</p> </td> <td> <p>24</p> </td> </tr> <tr> <td> <p>completely normal person...</p> </td> <td> <p>28</p> </td> </tr> </tbody></table> <p>Obviously the subjects tended to describe themselves as normal persons and to de-emphasize their physical defects. Of particular interest are the 28 percent who described themselves as completely normal, not even conceding a "very slight" defect.</p> <p>Few of the subjects admit that amputation is of considerable consequence:</p> <table> <tbody><tr> <td> <p><b> Do you think being an amputee makes:</b> </p> </td> </tr> <tr> <td> <p>a considerable difference?</p> </td> <td> <p>7%</p> </td> </tr> <tr> <td> <p>some difference?</p> </td> <td> <p>31</p> </td> </tr> <tr> <td> <p>a slight difference?</p> </td> <td> <p>19</p> </td> </tr> <tr> <td> <p>a very slight difference?</p> </td> <td> <p>26</p> </td> </tr> <tr> <td> <p>no difference at all?</p> </td> <td> <p>17</p> </td> </tr> </tbody></table> <p>In keeping with their expressed tendency to place the fact of amputation in the background, and to consider themselves physically normal persons, most claimed that they often forgot about their amputations:</p> <table> <tbody><tr> <td> <p><b> I forget that I am an amputee:</b> </p> </td> </tr> <tr> <td> <p>never.</p> </td> <td> <p>7%</p> </td> </tr> <tr> <td> <p>rarely.</p> </td> <td> <p>4</p> </td> </tr> <tr> <td> <p>sometimes.</p> </td> <td> <p>21</p> </td> </tr> <tr> <td> <p>most of the time.</p> </td> <td> <p>61</p> </td> </tr> <tr> <td> <p>all of the time.</p> </td> <td> <p>7</p> </td> </tr> </tbody></table> <p>Still tending to play down any differences, 67 percent of the subjects said that they thought amputees had about the same number of personal problems as did nonamputees. At the start of the treatment program, only 57 percent of the amputees felt that way. But even then a sizable minority (30 percent) believed that amputees did have more personal problems than nonamputees. In any case, it is noteworthy that, in an area where one might reasonably expect some expression of difference, so large a percentage of the subjects denied any difference at all. A strong tendency to reject any hint of abnormality or "difference" appears throughout the study.</p> <p>In setting goals and evaluating achievements, most of the amputees would like to be considered as nondisabled persons:</p> <table> <tbody><tr> <td> <p><b> In deciding what you should be physically able to do, do you compare yourself with:</b> </p> </td> </tr> <tr> <td> <p>very active nonamputees?</p> </td> <td> <p>16%</p> </td> </tr> <tr> <td> <p>active nonamputees?</p> </td> <td> <p>53</p> </td> </tr> <tr> <td> <p>inactive nonamputees?</p> </td> <td> <p>2</p> </td> </tr> <tr> <td> <p>active amputees?.</p> </td> <td> <p>28</p> </td> </tr> <tr> <td> <p>inactive amputees?</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p>Over two thirds seem to feel that their physical abilities should be comparable to those of active or very active nonamputees. In short, amputees want to be considered normal and would like to discount their physical defects. Since most arm amputees can function in society without serious disadvantage, they would seem to have a sound basis for de-emphasizing their handicaps.</p> <p> There is, of course, a stigma attached to those who are "different," and this circumstance also gives the amputee a strong reason for rejecting identification with the disabled. Thus he tends to maintain that being an amputee does not really "make a difference," although what is certainly implied is that he feels it <i>should not</i> make a difference. It is difficult to believe that so many can forget a fact of such consequence as amputation. But obviously they would <i>like</i> to forget it, and many <i>do</i> forget it, at least intermittently. For them to repress the amputation completely would be to deny the loss rather than to accept it, and this would be an equally unrealistic type of adjustment. From clinical observation, we have the impression that few amputees wear their loss as a badge, but the fact of amputation does seem to underlie a good part of their behavior. Whether this results in a neurotic fixation or is viewed as one more of life's frustrations to be overcome depends upon the individual. </p> <p>The fact that 30 percent of the amputees seem to feel that they have more personal problems than do nonamputees should not be taken as showing that amputees are more poorly adjusted than nonamputees. Other studies on physical handicap and amputation have indicated that, although particular problems of adjustment differ, there is generally no marked difference in adjustment between those who are handicapped and those who are not.<a></a></p> <p>An amputee has mixed conscious and subconscious identifications both with disabled and with nondisabled groups. Whichever group he primarily identifies with provides the basis for his concept of himself, the goals he sets, the aspirations he has, and the way he interacts with others. The amputees in the NYU Field Studies overwhelmingly elected a non-amputee, nondisabled frame of reference. In such a course lie dangers for them-dangers of self-deception, of denial and distortion of reality. Yet advantages follow too. Identifying with the nondisabled provides stimulation and drive to actualize the potential that each amputee has. It helps to combat defeatist attitudes and withdrawal into lethargy and invalidism. The amputee who is able to recognize and accept his identifications with both the disabled and the nondisabled groups maintains the soundest approach to personal adjustment.</p> <h4>Functional Adequacy</h4> <p>"Functional adequacy" refers to the amputee's estimate of his level of competence in performing physical activities. Questions were asked exploring the amputee's evaluation of his physical abilities. As has already been seen, over two thirds of the amputees seemed to feel that their physical abilities should be comparable to those of active or very active nonamputees. How well did they think that they met this exacting standard? Generally speaking, they said that they were able to achieve their high goals:</p> <table> <tbody><tr> <td> <p><b> As compared to nonamputees, I am generally able to do:</b> </p> </td> </tr> <tr> <td> <p>much less.</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>somewhat less.</p> </td> <td> <p>35</p> </td> </tr> <tr> <td> <p>as much.</p> </td> <td> <p>49</p> </td> </tr> <tr> <td> <p>somewhat more.</p> </td> <td> <p>14</p> </td> </tr> <tr> <td> <p>much more.</p> </td> <td> <p>0</p> </td> </tr> </tbody></table> <p> Only about one third conceded that they could not do as much as nonamputees. Furthermore, 68 percent of the amputees said that "very little effort" or "a little extra effort" was required to keep up with nonamputees. Ten percent even claimed that <i>no</i> extra effort was required. But 21 percent did admit that "a lot of extra effort" was necessary to keep up with others. </p> <p>In response to other questions, 92 percent said that they believed their work to be as good as or better than that of their nonamputee co-workers, and 66 percent said they felt they could be employed in jobs requiring "almost as much use of the prosthesis as of the normal hand."</p> <p>Comparing their present abilities with those had before amputation, 83 percent said they found doing things only "slightly more difficult now." Speaking of the things they could do before their loss, 96 percent said that they could still do "many," "almost all," or "all" of them. Only 8 percent said that being an amputee restricted their capacities "considerably." But 97 percent believed that they could do as much as, or more than, most other amputees.</p> <p>Here again the optimistic responses show some increase after the treatment period, and there are still other indications that the amputee's feelings of competence are related to the use of the new type of prosthesis. After treatment, 81 percent of the amputees said that they were "very much; or ;completely" satisfied with their prostheses, whereas at the beginning of the treatment program only 58 percent said so. Improved prosthetic equipment and better management procedures seem largely responsible for the favorable results.</p> <p>Generally speaking, we may describe the picture as follows. The amputee sets high limits to his physical accomplishments, most often aiming to equal the nonamputee. He will sometimes concede that he can do less than a nonamputee, but more often than not he will claim that he can do as much or more. While he almost never admits to a substantial inferiority, he will acknowledge that it takes a little extra effort to keep up with nonamputees. He feels competent to handle the daily routine of living, and he expresses no deprivation associated with his functional limitations. Finally, his estimate of his own abilities increased as a result of participation in the research program.</p> <p>Taken at face value, this self-picture by the amputee seems a blissful one. But experience indicates that, while some amputees do approach the ideal state, the average patient is far more concerned about his functional adequacy than the responses show. Some of the amputee's description of his high level of competence must certainly be the result of wishful thinking. Concerned with maintaining his self-esteem and confidence, he surely must often distort reality so as to diminish the gap between what he imagines he can do and what he actually can do. And his feelings of great competence may also reflect certain changes in his habits since his amputation-changes that have brought his activities more into line with his new physical abilities.</p> <p>Complete analysis of functional adequacy requires both objective and subjective estimates of competence and a study of the effect that the difference between the two has upon the amputee's adjustment. In the absence of such an investigation, the data presented are best considered as the responses of people who are concerned with maintaining their self-esteem, their feelings of confidence, and their sense of adequacy. The responses show what the amputee subconsciously desires in the way of treatment from nonamputees. In effect, what we have here is the collective mask that amputees present to the public-and often to themselves. The extent to which we can accept this mask, or how we need to modify it, is a clinical problem that can be resolved only when the amputee's real and fancied achievements are considered in the light of his basic needs.</p> <h4>Independence</h4> <p>"Independence" refers to the extent to which the amputee can make a reasonable effort to be self-sufficient while still feeling free to call for assistance or to use help that is offered. It has been seen that the amputees in this study tend to characterize themselves as self-sufficient. When the amputee knows himself to be capable of handling a situation, he usually declines offers of help:</p> <table> <tbody><tr> <td> <p><b> When I know that I am capable of handling a task, I:</b> </p> </td> </tr> <tr> <td> <p>never accept help.</p> </td> <td> <p>28%</p> </td> </tr> <tr> <td> <p>very rarely accept help.</p> </td> <td> <p>34</p> </td> </tr> <tr> <td> <p>rarely accept help.</p> </td> <td> <p>12</p> </td> </tr> <tr> <td> <p>sometimes accept help.</p> </td> <td> <p>22</p> </td> </tr> <tr> <td> <p>frequently accept help.</p> </td> <td> <p>4</p> </td> </tr> </tbody></table> <p>In keeping with this desire for self-sufficiency, almost three quarters of the amputees said that they rarely or very rarely solicit help:</p> <table> <tbody><tr> <td> <p><b> How often do you call for help from others?</b> </p> </td> </tr> <tr> <td> <p>Never.</p> </td> <td> <p>5%</p> </td> </tr> <tr> <td> <p>Very rarely.</p> </td> <td> <p>57</p> </td> </tr> <tr> <td> <p>Rarely.</p> </td> <td> <p>14</p> </td> </tr> <tr> <td> <p>Occasionally.</p> </td> <td> <p>23</p> </td> </tr> <tr> <td> <p>Frequentrly.</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p>Two facts are of particular interest here. First, the course of treatment provided by the program increased from 49 percent to 57 percent the proportion of those who claimed they very rarely called for help. Secondly, none of the most physically disabled patients (bilateral and shoulder-disarticulation cases) reported frequent calls for help. In answer to other questions, only 1 percent of the amputees said that they refuse help under any circumstances. More than half said that they accept help only when it means the difference between success or failure. About one quarter said they accept help if it makes the task easier. And 14 percent said they accept help even if it does not make the task easier.</p> <p>It is clear that the amputee is vitally concerned about his sense of independence. He tends to depict himself as a self-sufficient individual who rejects offers of help whenever he can and who asks for help only occasionally. Despite the stress he places on self-sufficiency, however, the amputee almost always accepts the fact that complete independence is impossible. But he will be practically certain to reject any suggestion of serious dependence.</p> <p> Why does the amputee value his independence so highly? The answer seems to lie with our society, which places a high premium on personal competence and achievement. The dependent person often finds himself assigned an inferior status in his group. The amputee, constantly faced with this prospect, feels a strong need to prove that he is self-sufficient and that he does not differ from other people. In any case, a handicapped, dependent person is seriously restricted in his ability to reach simple goals that are easily achieved by others.<a></a> </p> <p> Before the amputee can judge the extent of his handicap, he must go through an extensive trial-and-error period, particularly in the early stages of his loss. Depending on how realistically he views his limitations, dependency will or will not become a critical problem. At this point, three kinds of reactions are possible: he may appraise realistically his functional capacities and limitations; he may partly deny his limitations, at the same time often attempting to compensate for them; he may deny his limitations completely. <a style="text-decoration:none;">*</a> Underlying all three of these reactions is the basic need of all persons to maintain feelings of self-sufficiency-if necessary, by distorting reality. Thus an amputee may distort the extent of his dependence on others and exaggerate his abilities to fulfill society's demands for independence. Conversely, some amputees may distort reality in the other direction, emphasizing their loss in order to help them think of themselves as dependent, affection-seeking persons. In general, however, the amputee's ability to make a realistic appraisal of his capacities, to recognize a certain amount of dependency where it is inevitable, and to ask for help when necessary will depend above all on his feelings of basic security. The amputee who is insecure will be more likely to seek help indiscriminately or to reject it unreason-ably.<a></a> </p> <p> To avoid overdrawing the negative effects of reality distortion, a distinction must be made between extreme distortion of reality and its temperate shaping. We tend to admit into our perceptions things in line with positive self-feelings and to eliminate or modify those which might cause anxiety. This is a form of adaptive, nonpathological distortion involving control of situations so that, when reality must be faced, it may be done despite the temporary pain associated with the process. Some avoidance of harsh reality is sometimes necessary in order to preserve equanimity in the face of many daily frustrations. In some cases, however, the amputee displays an extreme form of dependence that has been called "invalidism."<a></a> When this happens, the amputee exploits those about him by harping on his incapacities more than his injury warrants. He uses his handicap to avoid responsibilities. While it is true that anyone might be tempted to plead illness to avoid an unpleasant experience, in invalidism the individual employs his loss as a constant way out. Invalidism can also be an attention-getting device as well as an attempt to obtain love that the amputee is not sure of having otherwise. It is used to threaten and control other persons and sometimes provides the disabled person with the means of taking revenge upon others by limiting their freedom of action and making them anxious and guilty. </p> <p> Whatever the reaction, the family plays an important role in the amputee's attempts to achieve self-sufficiency and yet to fulfill his needs for dependency. The attitude of the family is often thought to be at least as important as the physical injury itself in determining the amputee's reaction to his disability.<a></a> The amputee's attitude toward his family is a combination of a drive for independence and a plea for aid, explicit or implicit. In the ideal family relationship, both needs will be satisfied. But the stress should be upon helping the amputee to take his place in society as a self-respecting, adequate person. </p> <h4>Sensitivity</h4> <p>"Sensitivity" refers to the amputee's subjective appraisal of the effect of his physical condition on others and to the feelings of self-consciousness he experiences as a result of this appraisal. Sensitivity about disability may therefore be related to two sources: perception of the negative appraisals of others, and the individual's own self-rejection. These two factors are of course not entirely independent, since an amputee's notions of what others think of him may largely determine what he thinks of himself.</p> <p>The majority of the amputees in the study readily admitted concern about the opinion of others, but it is noteworthy that almost a fourth of the group refused to admit anything more than a "little" sensitivity:</p> <table> <tbody><tr> <td> <p><b> How much do you care about what others think of you?</b> </p> </td> </tr> <tr> <td> <p>Considerably.</p> </td> <td> <p>53%</p> </td> </tr> <tr> <td> <p>Somewhat.</p> </td> <td> <p>23</p> </td> </tr> <tr> <td> <p>Little.</p> </td> <td> <p>8</p> </td> </tr> <tr> <td> <p>Very little.</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Not at all.</p> </td> <td> <p>7</p> </td> </tr> </tbody></table> <p>The clinical treatment program had the effect of reducing the self-consciousness admitted. Amputees who said that they never, rarely, or only sometimes felt self-conscious about their personal appearance went from 59 percent before treatment to 72 percent afterward. But 28 percent still said they felt self-conscious most of the time or almost always.</p> <p>Twenty-one percent of the amputees said that they felt they looked "the same as most people," and 62 percent answered "almost the same as most people." In keeping with this attitude, most of the amputees claimed that they did not feel themselves to be conspicuous. But a significant 22 percent confessed that the idea occurred to them with some frequency:</p> <table> <tbody><tr> <td> <p><b> The idea that people are looking at me:</b> </p> </td> </tr> <tr> <td> <p>is almost always on my mind.</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>sometimes occurs to me.</p> </td> <td> <p>20</p> </td> </tr> <tr> <td> <p>rarely occurs to me.</p> </td> <td> <p>17</p> </td> </tr> <tr> <td> <p>very rarely occurs to me.</p> </td> <td> <p>38</p> </td> </tr> <tr> <td> <p>never occurs to me.</p> </td> <td> <p>23</p> </td> </tr> </tbody></table> <p>The majority of the amputees said that they expected other people to discuss the disability. Only a few believed this occurred frequently, and even fewer denied its existence:</p> <table> <tbody><tr> <td> <p><b> Do you think that people talk about your disability?</b> </p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>3%</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>30</p> </td> </tr> <tr> <td> <p>Occasionally</p> </td> <td> <p>57</p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Always</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p> Most amputees (67 percent) denied that they felt any resentment over the curiosity of other people. The rest maintained a ratio of three positive reactions <i>(e.g.,</i> pride in demonstrating the prosthesis, appreciation of interest) for every negative reaction <i>(e.g.,</i> self-consciousness, resentment, nervousness). In all, reactions of annoyance caused by people's curiosity decreased significantly by the end of the treatment period. </p> <p>Although 99 percent of the amputees said that they seldom or never tried to hide the fact of their amputation, the overwhelming majority said they would not tell a new acquaintance about it unless asked.</p> <p>The question of whether to fit a hook or a hand is often decided on the basis of the amputee's sensitivity. Those particularly sensitive about their amputation might be expected to reject a hook because of its appearance. The majority of the amputees in this study (61 percent) said that they believed hooks to be mechanical-looking but not unsightly, while a significant additional number (25 percent) expressed a more negative attitude concerning their appearance. But only 1 percent said they would not use one under any condition:</p> <table> <tbody><tr> <td> <p><b> I think that a hook is :</b> </p> </td> </tr> <tr> <td> <p>so ugly I would never wear one...............................</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>so ugly I would never wear one when I'm with other people...</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>unsightly but not enough to prevent me from wearing one...</p> </td> <td> <p>23%</p> </td> </tr> <tr> <td> <p>mechanical looking but not unsightly..............................</p> </td> <td> <p>61%</p> </td> </tr> <tr> <td> <p>as natural looking as any artificial hand........................</p> </td> <td> <p>13%</p> </td> </tr> </tbody></table> <p>The composite data indicate that, although the amputees showed considerable awareness of their appearance, they did not brood about it. When asked directly, they were much more likely to deny being sensitive than to admit being preoccupied with their condition. They were well aware that amputations and prostheses arouse curiosity, but they maintained that they (the amputees) were "normal" and so did not feel resentful toward these attentions. Amputees who do acknowledge self-consciousness are most likely to do so in situations where there is no social pressure against displaying sensitivity.</p> <p>On the basis of other evidence, there seems to be considerably more indication of sensitivity and of hostility toward the curious person than is revealed by the questionnaire. This is to be expected, for clinical situations induce greater rapport and permit the amputee to express hostile feelings with less fear of social criticism. Thus, it is quite likely that the amputee's sensitivity is much greater than he is willing to admit.</p> <p> The universal unwillingness of amputees to admit that they differ from others rests in part on the fact that in many respects they are indeed no different from other people. But it also may represent a "whistling-in-the-dark" attitude, an attempt to deny something that the amputee really believes to be true <i>(e.g.,</i> that he <i>is</i> handicapped or inferior), and may reflect the amputee's resistance against the social consequences of being "different." </p> <p>As has already been mentioned, amputees are likely to incorporate the negative attitudes of others into their own self-concept. Most amputees recognize that nonamputees are more comfortable when the fact of amputation is not conspicuous, and they will attempt by various means to "spare the feelings" of others by trying to reduce the visual "shock" for the nonamputee. Many of the subjects are not, however, merely responding appropriately to social cues but rather are using this explanation as a rationalization for their own self-rejecting thoughts. The same self-rejection may be responsible for the denial of sensitivity, which the questionnaire data show to be characteristic of a sizable minority of the sample.</p> <h4>Appraisal of Acceptance by Others</h4> <p>Appraisal of acceptance by others" refers to the amputee's evaluation of the effect his disability has on the approval others may give him. Less than 5 percent of the amputees said that they felt they were being treated any way different from that in which they had been treated before amputation. Almost all of the subjects claimed that their amputation had had little or no effect upon their acceptance by others. They rejected overwhelmingly the suggestion that their amputation merited them either special treatment or discrimination in their job, family, or social relationships. Most of them said they did not feel that people paid them undue attention. In general, the data indicate that amputees feel they receive sufficient but not excessive attention in social situations. A small percentage admit that some sympathetic behavior is displayed consistently in their job and family relationships.</p> <p>The amputee claims to be accepted by others on the same basis as anyone else, and he rejects strongly the suggestion of "different" treatment. But he will more readily admit to being favored than to being rejected. The treatment program seemed to bring a slight increase in the number of those who felt they were accepted on the same basis as other people. But little change was noted among those who claimed to be the recipients of either favoritism or antagonism. The data suggest that the treatment program was psychologically beneficial to those who were "uncommitted" on the first testing but that it had no effect on those who were convinced of their "different" status.</p> <p> The cumulative evidence about the social position of the disabled person strongly suggests that the results of the survey again represent the amputees' <i>wishes</i> rather than the actual situation, a finding supported by the fact that, when asked indirectly how they thought amputees should be treated, the majority revealed that they preferred to have little made of their physical handicap: </p> <table> <tbody><tr> <td> <p><b> If you were a nonamputee, how would you react to an amputee?</b> </p> </td> </tr> <tr> <td> <p>I would ignore the fact that the person is an amputee</p> </td> <td> <p>16%</p> </td> </tr> <tr> <td> <p>I would treat him as a normal person who just happens to have lost an arm or hand</p> </td> <td> <p>72</p> </td> </tr> <tr> <td> <p>I would expect less from him physically</p> </td> <td> <p>6</p> </td> </tr> <tr> <td> <p>I would be more kind and thoughtful of his feelings</p> </td> <td> <p>5</p> </td> </tr> <tr> <td> <p>I would know that, as an amputee, he requires special treatment</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <h4>Sociability</h4> <p>"Sociability" refers to the extent to which the amputee seeks, and derives pleasure from, social relationships. In this connection, the subjects said that they looked forward to social functions and enjoyed them. The treatment program had the effect of increasing by about one fourth the number of amputees who said that they "always" enjoyed these functions. All but a very few of the subjects said that they had greater social confidence with their new prostheses. Neither before the treatment period nor after, however, did more than S percent confess to any lack of social confidence. Over three quarters of the amputees said that neither their amputations nor their prosthesis-wearing had caused any change in their social relationships. Those who did report changes were almost unanimous in claiming that the changes were toward greater sociability.</p> <p>These results reaffirm the earlier observations that the amputee tends to deny he has any major problems of acceptance. He usually claims that he engages in social activities eagerly and freely and experiences no prejudice because of his disability. But here again it is possible to read these results as expressing not so much the real facts as the wishes of the amputee to be accepted fully into the nonamputee world. Nevertheless, the indications are clear that the amputee tends to have more social confidence after suitable prosthetic fitting and treatment, the implications being that superior prosthetic equipment provides the basis for the ability to meet others with less trepidation and with greater feelings of personal adequacy. It also confirms indirectly the significance of feelings of functional adequacy and of ability to be independent.</p> <h4>Frustration</h4> <p>"Frustration" refers to the amputee's experience resulting from his inability to achieve personal, social, and vocational goals because of his amputation. The term refers both to whatever blocks or interferes with the amputee's strivings and to his subjective feelings of annoyance, confusion, or anger when he is thwarted. While 58 percent of the amputees said they rarely or never were prevented from achieving their goals, the other 42 percent claimed to feel frustrated from time to time as a result of amputation:</p> <table> <tbody><tr> <td> <p><b> Does being an amputee prevent you from doing things you really want to do?</b> </p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>20%</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>27</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>11</p> </td> </tr> <tr> <td> <p>Someties</p> </td> <td> <p>37</p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>5</p> </td> </tr> </tbody></table> <p>When, however, absence of a limb prevented performance of a task, a considerable proportion of the amputees (86 percent) felt annoyed. They almost unanimously (98 percent) said that they did not give up trying to do something because it was difficult, or that they gave up only after repeated failures.</p> <p>As for vocational goals, a majority of the amputees refused to admit more than slight difficulties. Some 40 percent indicated that there was some substantial interference:</p> <table> <tbody><tr> <td> <p><b> Do you feel that your amputation interferes with your getting a job?</b> </p> </td> </tr> <tr> <td> <p>Not at all</p> </td> <td> <p>27%</p> </td> </tr> <tr> <td> <p>Very slightly</p> </td> <td> <p>15</p> </td> </tr> <tr> <td> <p>Slightly</p> </td> <td> <p>18</p> </td> </tr> <tr> <td> <p>Somewhat</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>Seriously</p> </td> <td> <p>11</p> </td> </tr> </tbody></table> <p>Here the fact that the more seriously disabled (bilateral and shoulder-disarticulation cases) responded as did the other amputees seems to suggest that the results do not accurately reflect the real situation.</p> <p>The relatively small degree of frustration the amputees reported is surprising in view of the many frustrating situations they encountered. It suggests that many of the responses were given because they seemed socially desirable and because the test situation did not encourage the amputee to express freely his aggressive or negative feelings. But it is also possible that repeated experiences of frustration, together with the strong motivation to be "like anyone else," which is so characteristic of the subjects studied, can produce in many amputees a truly high level of frustration tolerance. To this must be added the active efforts to avoid situations potentially frustrating.</p> <p>Any interference with goal-directed activity constitutes a frustration. But interpreting frustration in others has certain dangers because what frustrates one individual may not frustrate another. The nonamputee who fails to consider this circumstance is likely to make toward the disabled person unnecessary offers of help. The amputee may take such overtures as indicating that people believe him to be incompetent and may, consequently, feel downgraded in his status as a functioning person. In a sense, the real frustration in this particular situation is the nonamputee's lack of awareness of the amputee's competence.</p> <p>The intensity of an amputee's frustration depends upon how important his thwarted goals are to him. And while he may not feel seriously deprived if he cannot accomplish some trivial task, his frustration may be great if the particular failure happens to symbolize his inability to reach some more important goal. A minor frustration may assume importance if it symbolizes a general downgrading of status. Furthermore, when frustration is chronic the setting is ripe for the development of neurotic symptoms that represent the amputee's attempt to escape from an intolerable situation. It is considerably easier for anyone to deal with a short-term frustration than to adapt to a long-term one. Amputation is permanent and hence can lead easily to chronic frustrations and to neurotic solutions for the frustrations.</p> <p>The amputees in question showed two general types of reaction to frustration. One was concerned with overcoming the obstacles that interfere with the attainment of goals. In the other, the concern had more to do with preserving self-esteem and warding off anxiety than with achieving thwarted objectives. The first, or goal-directed, reaction to frustration is characterized by the amputee's ability to accept the reality of his amputation with a minimum of self-deception. In this type of reaction, the amputee seeks goals that are in line with his reduced capabilities and takes whatever steps he must to overcome the barriers imposed by his amputation. When questioned, he admits to being frustrated sometimes, but he shows a high toleration for frustration and tends to give up only when a task is clearly beyond his abilities, at which time he is willing to accept appropriate help. Besides, he will probably accept himself as a person and neither brood over nor resent his situation.</p> <p> In the second, or "ego-protective," reaction to frustration, the amputee refuses to accept reality. Instead, he distorts it and tries to create situations in which he can be at ease and relatively free of anxiety. If necessary, he will go so far as to deny his disability. He tends to set such low limits for achievement that he can avoid frustration, and he often sharply restricts his involvement in life as he seeks to eliminate opportunities for frustration. Such protective action is likely to lead to neurotic symptoms-to hypersensitivity, invalidism, defeatism, somatic complaints, anxiety, social withdrawal, and so on. In an earlier publication, Siller <a></a> observed that amputees who achieved good adjustment were often strongly oriented toward compensating for their loss. They were, in other words, showing a goal-directed reaction to frustration. It was also observed that amputees who adjusted poorly often directed their efforts toward avoiding the implications of their loss, thus showing an ego-protective reaction to frustration. </p> <p>As a result of the treatment program in the NYU Field Studies, there was a small increase in the number of amputees who reported a moderate degree of frustration tolerance combined with the ability to recognize their limitations clearly. While in answering the test questions the amputees undoubtedly had a tendency to deny unfavorable feelings and behavior, the subjects as a whole still showed a rather high tolerance for frustration.</p> <h4>Optimism</h4> <p>"Optimism" refers to those feelings of adequacy, of self-confidence, and of positive future outlook that the amputee experiences. The negative aspects of this personality variable are pessimism, depression, and feelings of inadequacy and inferiority. While the subjects in the study tended to stress their positive feelings of optimism and to de-emphasize their pessimistic feelings, few denied that they experienced depression at times:</p> <table> <tbody><tr> <td> <p><b> How often do you feel "down in the dumps" or "blue"?</b> </p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>3%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>21</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>39</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>8</p> </td> </tr> </tbody></table> <p>The treatment period had the effect of increasing from 33 percent to 39 percent those amputees who answered "very rarely," and in general the fitting of new prostheses increased slightly the claims of optimism. Most of the amputees professed to be very optimistic about their future prospects, and none at all said that they expected to be unsuccessful:</p> <table> <tbody><tr> <td> <p><b> Does your future promise to be:</b> </p> </td> </tr> <tr> <td> <p>extremely successful?</p> </td> <td> <p>14%</p> </td> </tr> <tr> <td> <p>moderately successful?</p> </td> <td> <p>66</p> </td> </tr> <tr> <td> <p>slightly successful?</p> </td> <td> <p>11</p> </td> </tr> <tr> <td> <p>neither successful nor unsuccessful?</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>unsuccessful?</p> </td> <td> <p>0</p> </td> </tr> </tbody></table> <p>Throughout the questionnaire, the subjects tried to avoid responses indicating pessimism, depression, and feelings of inadequacy or inferiority. They were more likely to admit feelings of superiority than of inferiority, but in general they avoided admitting extreme feelings in either direction:</p> <table> <tbody><tr> <td> <p><b> Do you ever have feelings of:</b> </p> </td> </tr> <tr> <td> <p>Inferiority?</p> </td> <td> <p></p> </td> <td> <p>Superiority?</p> </td> </tr> <tr> <td> <p>38%</p> </td> <td> <p>Never</p> </td> <td> <p>29%</p> </td> </tr> <tr> <td> <p>28</p> </td> <td> <p>Very rarely</p> </td> <td> <p>22</p> </td> </tr> <tr> <td> <p>12</p> </td> <td> <p>Rarely</p> </td> <td> <p>15</p> </td> </tr> <tr> <td> <p>20</p> </td> <td> <p>Sometimes</p> </td> <td> <p>30</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>Frequently</p> </td> <td> <p>4</p> </td> </tr> </tbody></table> <p>The amputees tried of course in their answers to place themselves in a socially favorable light-to shun answers with negative implications. But we may still estimate the feelings of the average amputee. He resists, rejects, and resents any suggestion that as a person he differs from anyone else; at the same time he acknowledges some (but not too much) physical difference and handicap. If he senses that the nondisabled people about him consider him "different" because of his loss, he may often go to extremes to deny pessimistic feelings which in a more relaxed environment he might well acknowledge.</p> <p>Amputees are not alone in their desire to be placed in a favorable light. The tendency to respond in a socially desirable manner seems to be characteristic of all groups when tested under conditions similar to those of the present study. Nevertheless, when we consider the very real handicaps amputees must face, we may conclude that those studied here are for the most part maintaining an optimistic outlook.</p> <h3>Social and Functional Factors in Prosthetic Wear</h3> <p>The attitudes of amputees toward prostheses have in the past received little systematic study. The amputee's preferences in artificial limbs, and his habits in using them, are evidently not based entirely upon his objective assessment of his functional and social needs. They are influenced also by emotional factors arising from the meanings he attaches to the wearing of artificial limbs. Little organized information is available about these attitudes, whether rational or irrational, and we know little as yet about the specific effects that an amputee attributes to his prosthesis once he has accepted and worn it. What difference does he think it makes in his daily life?</p> <p> The prosthetic-reaction test (Appendix IIIG), designed to explore in a systematic way some of the attitudes and reactions underlying prosthetic wear, attempted to gauge, in various situations, the amputee's response, both when he is considered to be <i>wearing</i> an artificial arm and when he is considered <i>not</i> to be wearing one. In a series of nine different pictures, a fictitious amputee, "John," was shown in some everyday situations-some in which his sensitivities as an amputee might be expected to be aroused. Below each picture were from five to nine statements indicating possible responses that John, the amputee in the picture, might make to the situation depicted. The subjects under test were asked to select the statement most nearly describing what John might say, feel, or do in each case. The assumption, of course, was that the amputees would attribute to the imaginary John some of their own feelings and reactions. It was thought that, as the amputees thus responded to specific life situations through the medium of this other person, their attitudes might be expressed more freely than they would be through direct questioning. </p> <p> The test was administered to each of the amputees three times, once at the beginning of the research program (Evaluation I) and twice at the end of the studies (Evaluation II). In Evaluation I, and at the first administration during Evaluation II, the subjects were asked to select John's response <i>"if he were wearing a prosthesis as he usually does."</i> Immediately after the amputees had completed the test for the first time during Evaluation II, they took it again but now were asked to select John's response <i>"if he never wears a prosthesis."</i> For convenience, we shall refer to these three administrations of the test as El, E2a, and E2b. Together, the three provide data for the study of three major questions: </p> <ol> <li>In the difficult social situations that an amputee faces daily, what are his most frequent responses and his most commonly held attitudes?</li><li>What changes, if any, in his attitudes and reactions came as a result of his being fitted with a new prosthesis and taking part in the research program?</li><li>In these difficult social situations, how does the wearing of a prosthesis affect the amputee's responses?</li></ol> <p>Each of these problems shall be taken up in turn.</p> <p>The prosthetic-reaction test touches upon a number of aspects of an amputee's performance. Foremost is the general area of "security," which involves the amputee's basic acceptance of himself and others, particularly his personal adjustment to the loss of his arm. Included within the concept of security were such constructs as self-acceptance (the ability to view the loss without self-pity, exaggeration, or denial, and without resorting to maladaptive means of defending self-esteem) and reality-facing (the ability to appraise environmental situations as they are). In addition, there was evidence that several of the cartoons strongly measured a second variable, "independence," which describes the amputee's motivation to be self-sufficient and to function adequately with a minimum of assistance.</p> <p> Psychologically, strivings for independence are likely to stem from the individual's feelings of security, and as such the two must be considered related phenomena. But since the need to be independent is a major concern of amputees, separate analyses of the data concerning independence were made whenever appropriate. Each statement in the test was therefore rated first for "security" and, when indicated, for "independence." Four psychologists ranked from 1 to 5 all possible responses according to the extent that the individual variables were reflected therein. <a style="text-decoration:none;">*</a> Personal differences in ranking were resolved through mutual discussion among the four. </p> <p>Responses rated 1 or 2 were considered "high." A rating of 3 was considered "intermediate," a rating of 4 or 5 as "low," and the terms "high," "intermediate," and "low" were used as relative terms to describe the individual's position along the "security" and the "independence" scales. For example, Picture VI (Appendix IIIG) showed an amputee in a restaurant with a steak that seemed too tough for him to cut. The seven statements given beneath the picture were ranked and judged as shown in the following tabulation:</p> <p>The prosthetic-reaction test, then, tells us how amputees appraise various social situations and what they think about the worth of artificial arms in these situations. It also gives us some indication of their feelings of independence and security, both when they are wearing prostheses and when they are not. What light does this information shed upon the three major problems already mentioned?</p> <h4>Amputee Responses to Everyday Social Situations</h4> <p> The most outstanding finding of this study was that the amputees overwhelmingly-in fact, almost invariably-selected the most positive responses to the situations depicted in the cartoons, particularly when the amputee was assumed to be wearing an artificial arm. For almost every situation of the series, the statement most frequently chosen was one extremely high in both independence and security. Moreover, for most of the pictures well over half the sample responded with statements that were judged "positive" <i>(i.e.,</i> high in security or independence). Even in E2b, where positive responses were considerably fewer, they still accounted for a large segment of the sample. Typical percentages of amputees showing high, intermediate, and low "security" and "independence" responses to each cartoon are shown in <b>Table 1</b> , where the data are derived from E2a (post-treatment) and refer to circumstances in which John was supposed to be wearing a prosthesis. For the sample as a whole, there were negligible differences between the El (pretreatment) and the E2a (post-treatment) data. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 1</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> For every situation, more than 60 percent of the sample chose positive responses, and in only one instance did more than a negligible proportion choose a statement reflecting definite insecurity. As for that item, many of the respondents had not correctly interpreted the other person to be the amputee's wife. Even more striking is the fact that from a fourth to a half gave as their response the single most positive statement. It is clear, then, that the majority of the amputees wished to be viewed as functionally independent, having confidence in their ability, with a desire to demonstrate their functional achievements, and willing to accept some aid if it is found to be needed. The vast majority of the responses expressed an acceptance of the loss of the limb, a willingness to discuss the amputation with others, and a general self-assurance in social situations. ( <b>Fig. 1</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In general, the most popular responses were those which emphasize functional effectiveness, self-confidence, and lack of sensitivity about amputation. Reactions suggesting any admission that the amputee considered himself at all "different" from anyone else were extremely rare. It seems clear that the subjects readily recognized the socially desirable responses and favored them overwhelmingly. To what extent this eventuality represents the true feelings and behavior of the group, and to what extent it represents wishful thinking, cannot be determined from these data-a situation that reflects a weakness in the prosthetic-reaction test as currently conceived. Evidence indicates that amputees are very much concerned with conforming to the important cultural values of self-reliance and self-confidence and that they abhor any suggestion of a departure from complete normality. <b>Table 1</b> </p> <h4>Changes in Responses as a Result of Fitting</h4> <p>For the group as a whole, there were virtually no significant differences between El and E2a, even though the latter was administered after a considerable period of time had elapsed. This result would suggest that the treatment program had little or no effect on the expressed attitudes of the group. But when we consider separately those amputees who were being fitted for the first time and those who had worn prostheses before, some changes can be detected among the new wearers. Since the number of amputees being fitted for the first time was small (only 55), no extensive quantitative analysis can be made. Nevertheless, a few general conclusions can be drawn.</p> <p>First of all, the responses after fitting indicated that new wearers were slightly disappointed in the functional efficacy of their artificial arms. While initially (on El) a large number of these amputees revealed expectations that the prosthesis would enable them to do "almost everything," particularly in their occupational roles, the E2a responses indicated more modest attitudes. But these changes were not toward more negative responses. Rather, they reflected the fact that the amputees concerned had indulged in unrealistic expectations for the prostheses and then had adjusted to a more realistic view after some experience with their new arms. There were, moreover, indications of a greater degree of security in social situations. After fitting, some of the new wearers indicated an increased acceptance of their amputation-a greater ability to talk about it, less tendency to withdraw from situations revealing the disability, and less expectation of pity from others. Besides this, they expressed a greater readiness to ask for help without apology or embarrassment.</p> <h4>Effects of Fitting Upon Responses to Everyday Situations</h4> <p> As has already been indicated, the primary aim of the prosthetic-reaction test was to evaluate the amputee's feelings about the part that an artificial arm plays in the common difficult situations of his life. The statements the subjects chose as describing John's behavior may therefore be taken as reflecting aspects of their own behavior. Consequently, if we compare the results of E2a (in which John is considered to be <i>wearing</i> a prosthesis) with those of E2b (in which he is considered <i>not</i> to be wearing one), both tests having been administered at the end of the studies, we discover some of the effects that wearing an artificial arm has on the daily life of an amputee. Toward this end, the two personality variables, independence and security, were considered. In separate analyses of the data from the "nonprevious prosthesis wearers" (referred to as NPPW's) and the "previous prosthesis wearers" (PPW's), it was found that the two groups did not differ in their responses except as discussed specifically hereafter. <a style="text-decoration:none;">*</a> </p> <p> A review of the E2a (prosthesis worn) and E2b (prosthesis not worn) responses follows: <b>Fig. 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Greater tolerance of curious strangers is exhibited when a prosthesis is worn. In E2a the amputees appear better able to view the situation without misinterpretation, to be more sure of themselves and less likely to pity themselves or to expect pity from others. The PPW's are somewhat more secure in the E2a situation than are NPPW's, even though both groups were wearing prostheses at the time of the tests. The most reasonable explanation for this difference would seem to he in the fact that the period of prosthetic wear for the NPPW group was insufficient for feelings of conspic-uousness to disappear.</p> <p> <b>Fig. 3</b> , <b>Fig. 4</b> , <b>Fig. 5</b> , <b>Fig. 6</b> , <b>Fig. 7</b> , <b>Fig. 8</b> , <b>Fig. 9</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Differences between the E2a (with prosthesis) and E2b (without prosthesis) responses were considerable throughout the entire test, both for amputees who were being fitted for the first time and for those who had previously worn prostheses. We may thus conclude that the positive acceptance of prostheses reflects not merely the enthusiasm of new wearers but rather the genuine value of prosthetic wear in its own right.</p> <p>The indications are clear that amputees regard a prosthesis as a definite asset in functionally demanding situations and that they think of it as something enabling them to be more independent, more secure, and more willing to accept their condition. In the potentially threatening situations that an amputee must face from time to time, a prosthesis contributes to his ability to handle himself easily and self-confidently, even in cases where the prosthesis does not have immediate functional value.</p> <p>The data for "emotional" situations indicate that the amputees' positive expressions of security were definitely greater when the protagonist was wearing a prosthesis than when he was not. An artificial arm apparently gives many amputees an increased confidence in their functional adequacy. This in turn helps them to achieve a greater self-acceptance, enables them to face their disability more realistically, and lets them view the reactions of others without feeling quite so threatened.</p> <p>Of the two personality variables considered, independence and security, independence appears to be the more strikingly affected by prosthetic restoration. The subjects tend to expect that the amputee who wears a prosthesis will be more effective functionally, more self-sufficient, and generally more adaptive than the nonwearer. When the matter of security is concerned, the role of the prosthesis is less pronounced. Still, most of the amputees think of prosthesis wearers as more self-accepting, less shy, and less easily embarrassed than non-wearers.</p> <p>The responses to the prosthetic-reaction test strongly indicate that amputees feel there is both functional and psychological advantage in the wearing of a prosthesis. They consistently attribute more positive responses to the amputee wearing an artificial arm than they do to the nonwearer in the same situation. But of course all of these findings are merely projections upon a fictitious amputee pictured in a cartoon; we do not yet know the precise extent to which these projections reflect the actual responses amputees make in life situations. Nevertheless, it is clear that the wearing of a prosthesis has a positive effect upon the way an amputee perceives and reacts to many social situations in his daily life.</p> <h3>Attitudes Toward Prosthetic Wear, Before and After Fitting</h3> <p> The discussion thus far indicates that the amputee believes strongly in the importance of wearing an artificial arm. He tends to feel that a prosthesis increases his functional capabilities and helps him to cope with social situations. He retains these beliefs, even reinforces them, after participating in the research program. To analyze still further amputee attitudes toward the wear and use of a prosthesis, additional studies were designed to seek answers to the questions <i>Are the expectations of nonprosthesis wearers fulfilled by a prosthesis?</i> and <i>Can the postfitting attitudes of amputees toward their prostheses be predicted on the basis of their prefitting expectations?</i> </p> <p>As for the first of these queries, the amputee who does not wear a prosthesis holds certain preconceived opinions about the value of an artificial limb before he ever undertakes to wear and use one. If these expectations are fairly realistic, his experience with his prosthesis may be gratifying. But unrealistic expectations can interfere with the successful wearing of a prosthesis. For this reason, a study was made of the alterations in attitudes of nonwearers after they had used a new prosthesis. As for the second question, it is reasonable to expect that the opinion an amputee holds about prostheses before he receives one will be related to his opinion after he has been fitted. If these relationships are stable enough to be predicted, potential problems may be anticipated and perhaps avoided. It is well known that a negative attitude on the part of an amputee interferes with his wholehearted participation in the rehabilitation process and thus reduces the probability of success. Identifying such a situation is the first step toward correcting it.</p> <h4>Are the Expectations of Nonprosthesis Wearers Fulfilled by a Prosthesis?</h4> <p>Among the subjects for whom data were available in this aspect of the study were 45 amputees who had never worn prostheses before their participation in the research program. About half of them were relatively "new" amputees who at the time may not yet have had an opportunity for fitting. The other half consisted of persons who had been amputees for from one to 27 years and who were therefore considered to have had ample opportunity to obtain prostheses had they wanted to. Although it is possible that some in the latter group may have been discouraged long ago by the lack of adequate prostheses for shoulder disarticulation and for certain other types of amputation, some had stumps relatively easy to fit, and accordingly factors other than lack of prosthetic equipment seem to have been present.</p> <p>Because this study was only one phase in a more general investigation of the conditions underlying the wear or nonwear of a prosthesis, use was made of a broad approach in which was collected information generally related to amputation and to prosthetic restoration. Gathered by means of a questionnaire probing prior beliefs and attitudes on a variety of matters relating to prostheses (Appendix IIIH), the data sought included sources of prosthetic knowledge and an estimate of its extent, functional expectations, opinions of the appearance of prostheses, opinions of the comfort of prostheses, attitudes toward prosthetic training, attitudes toward the general value of artificial arms, and anticipated difficulties with prostheses. Approximately six months after the fitting of a prosthesis to these patients, the questionnaire was given again to obtain post-fitting attitudes.</p> <h5> <i>Sources of Prosthetic Knowledge and Estimate of Its Extent</i> </h5> <p> The extent of prosthetic knowledge claimed by the subjects increased only slightly after they had participated in the program. Before fitting, 95 percent said they knew little or nothing about artificial arms; after fitting 85 percent still said so. Even after some six months of having worn prostheses, only 14 percent said they knew "much" about the subject. These findings may of course only reflect restraint and modesty. If they reflect the situation accurately, the amputees are indeed poorly informed. To determine whether the sources of information had any bearing on the state of amputee enlightenment, the subjects were asked to name their principal source of information, As can be seen in <b>Table 2</b> , the answers were rather diverse. Mentioned were five major sources of information before fitting. Three of these (other amputees, friends, self) are generally unreliable in matters of prosthetics. Friends and one's own self are hardly qualified without special training, and other amputees, as has been indicated already, are not necessarily well informed. Medical personnel, including physical therapists, occupational therapists, and nurses, were cited by only one amputee as a source of information. But after the amputees had participated in the program, the picture changed sharply. Then most of them mentioned medical personnel as the main source of information, while "other amputees" were not mentioned at all. <b>Table 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 2</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the extensive list of pretreatment sources of information may indicate that the amputees were alert, receptive, and inquisitive, seeking information from all quarters, it may on the contrary mean that they used all these sources because they were not given information by those most competent to provide it. The general impression is that adequate information about prosthetics is not readily available to the average amputee and that there is therefore a real need for a more thorough prosthetics education of medical personnel. We might even suggest that more attention be given to improving knowledge of prosthetics among new amputees. One approach would be to furnish literature portraying different types of prostheses-along with a sober appraisal of the utility, as well as of the disadvantages, of current prosthetic equipment. Doing so would help the patient to acquire more realistic expectations, to eliminate some of his trepidation, and to fill his individual needs more successfully.</p> <h5> <i>Functional Expectations</i> </h5> <p> Experience tends to modify any overly ambitious ideas the amputee may have about the value of the prosthesis. Most of the amputees in the study had more realistic expectations after they had been fitted with their artificial limbs than before: ( <b>Fig. 10</b> ).The 73 percent who before fitting said they believed prostheses were essential included 21 percent who said they thought artificial arms were "as good as normal limbs." Among those who after fitting said they believed prostheses to be very important, there were still 10 percent who said they thought their prostheses were as good as normal limbs. Apparently the fitting of the prosthesis reduces the number of amputees who deny reality but does not eliminate that group completely.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Before they were fitted, the amputees tended to expect that artificial limbs would take a considerable expenditure of energy for effective operation, but experience showed them that these estimates had been too pessimistic: ( <b>Fig. 11</b> ), ( <b>Fig. 12</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those who deal with prospective wearers should make use of the general tendency among amputees to believe that prostheses are helpful. But unless the limitations as well as the advantages of artificial arms are explained, false hopes and unreasonable expectations will result.</p> <h5> <i>Opinions on the Appearance of Prostheses</i> </h5> <p>Judgment of appearance is a complex and subjective process. The phrase "acceptable appearance" means many things to many people because the component factors are not often defined. In this study, three factors were identified. The first relates to the appearance of the prosthesis itself-to the degree to which it resembles the natural limb. The second relates to the readiness with which the artificial limb is recognized by observers. And finally the third relates to the appearance of the prosthesis when it is actually in use by the amputee.</p> <p>Roughly 75 percent of the subjects said they believed that their prosthetic arms and hands closely resembled normal limbs. Although the remainder said they found no strong resemblance, it was clear that in general the amputees accepted the appearance of their prostheses. One patient alone gave "unfavorable appearance" as the reason for not wearing a prosthesis.</p> <p>At this point it is perhaps worth noting that medical personnel who see many varieties of prosthetic equipment tend to develop, out of their own experience, personal sets of standards about the appearance of prostheses and sometimes impose these standards upon an amputee. But the patient, having had very little experience with prostheses, bases his opinions on quite personal factors, and these may be at great variance with those which influence the judgment of the clinic team. We must therefore strive to fulfill the actual needs of the individual amputee rather than to satisfy our own honest but at times inappropriate standards.</p> <p> Initially, most of the amputees said they expected to be recognized as amputees even when wearing prostheses, an expectation apparently confirmed by experience: ( <b>Fig. 13</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These findings are especially interesting when we recall that about 75 percent of the amputees said they thought their prostheses closely resembled natural arms and hands. Yet only a few of the subjects, either before or after fitting, said that they believed they could be taken for nonamputees. It seems apparent, therefore, that more than just the physical appearance of the artificial arm was involved. A strong similarity may be thought to exist, but generally the amputee does not believe similarity alone will enable him to pass as a nonamputee.</p> <p> Data from studies by Dembo and Tane-Baskin <a></a> on the noticeability of a cosmetic glove indicate that noticeability depends upon the "intensity" of the situation, that is, upon the closeness of the amputee's social and physical contact with others at any particular time. In view of this observation, it is clear that the inability to discriminate between situations of varying intensity keeps us from interpreting the present data any further. The amputees' responses in the study came from their experiences in both casual and intense situations, and we cannot distinguish between the two. </p> <p>Ease and smoothness of operation constitute another important factor in the general appearance of the amputee. The well-trained, smoothly functioning amputee contrasts strongly with a less-trained, uncoordinated, and awkward one. Full evaluation of appearance must, therefore, also take into account the dynamic factor, the impression given by smooth, normal-appearing movement as contrasted with that given by halting, uncoordinated motions.</p> <p>We see, then, that there are at least three important considerations involved in any judgment of an amputee's appearance-the actual appearance of the prosthesis apart from its functioning (the "static factor"), the naturalness with which the prosthesis is used (the "dynamic factor"), and the intensity of the amputee's situation (the "situational factor"). Treatment personnel usually place greatest emphasis on the appearance of the limb itself; the amputee may base his impression more upon the other two considerations.</p> <h5> <i>Opinions on the Comfort of Prostheses</i> </h5> <p> The amputees' statements about the comfort of artificial limbs did not change very much with experience. Both before fitting and after some period of wear, about 25 percent of the subjects claimed considerable discomfort, while 50 percent or better had no complaints on this score: ( <b>Fig. 14</b> ). For three quarters of the prosthesis users, comfort does not appear to be an important problem, and expectations of comfort seem to be borne out by actual experience. But the 25 percent who complained about discomfort <i>do</i> represent a very significant problem because discomfort is a common cause for rejection or infrequent use of artificial limbs. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At present, research aimed at eliminating discomfort focuses on prosthetic and physiological factors, an emphasis that seems appropriate in view of the fact that the principal objective causes of amputee discomfort are related to fit of the socket and harness and to weight of the prosthesis. But the problem has several other aspects, and these might also be explored profitably. There is for example the question of education-of how to prepare the amputee to expect at least some degree of initial discomfort. Another possible factor relates to the early use of the new prosthesis unwisely and too well. The mere statement, "At first this may be uncomfortable," may be insufficient warning for the new user. This phase of orientation needs more emphasis. Otherwise there is always the danger that amputees not fully aware of the difficulty of initial adjustment may give up with the feeling that prostheses are not for them.</p> <p>In addition to all these matters, there are psychological problems related to the amputee's pain tolerance. The way the amputee reacts to pain is influenced by such psychological factors as his acceptance of the amputation and his unrealistic hopes for the prosthesis. Finally, there is a need to recognize the special social attitudes that an amputee elicits when he expresses discomfort.</p> <h5> <i>Attitudes Toward Prosthetic Training</i> </h5> <p> Training to operate a prosthesis effectively requires a period of time ranging from a few hours to many hours, as correctly anticipated by all but three percent of the subjects: ( <b>Fig. 15</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig.15</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As we have seen, the subjects of study generally knew little about the potentials of prosthetic restoration. When, on top of the amputee's functional disability, there is superimposed the unavoidably new and ambiguous situation, anxiety and feelings of dependency are created. Since at a number of points in the rehabilitation process the physical and occupational therapist is in closest contact with the patient and is offering direct functional assistance, he is one of the natural recipients of these negative reactions. It should be possible during training for the therapist to use these dependency feelings and other factors to instill in the patient an attitude of realistic independence. Moreover, the training situation offers the amputee opportunity to develop and to demonstrate his functional competence under professional guidance. Regulated training routines have many advantages. Learning is quicker and more efficient, and the number of successful experiences can be maximized while failures are held to a minimum. For the amputee, the training experience should result not only in proficiency with the artificial limb but also in a realistic functional independence and a general sense of adequacy and personal competence.</p> <h5> <i>Attitudes Toward the General Value of Artificial Arms</i> </h5> <p>In an effort to determine the significance that artificial arms had for the amputees, the subjects were asked to express their opinions in terms of three frames of reference the advantages of using a prosthesis, the general functional help of a prosthesis, and the importance of the artificial arm.</p> <p> <i>Advantages.</i> The overwhelming opinion among the amputees, both before and after fitting, was that artificial arms have more advantages than disadvantages: ( <b>Fig. 16</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>General Help.</i> The prosthesis enabled the amputees to get along better. Most of them maintained that they could get along <i>much</i> better. A few said that it hindered them slightly. No one said that it really interfered. But among the amputees who had expected to find extreme advantages, there were indications of marked changes of opinion. That the group with the highest expectations dropped from 78 percent to 59 percent illustrates the development of more realistic values through experience. The same kind of change is illustrated by the increase in the number of amputees who said they thought a prosthesis could help them to get along "about the same" or "slightly worse": ( <b>Fig. 17</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Importance.</i> Despite a drop of 9 percent in the two most favorable categories of response, over 70 percent of the amputees said after fitting that they still believed it "very important" or "extremely important" for them to wear artificial arms. There was, however, an increase from 4 percent to 12 percent in the number of amputees who said they thought their prostheses "not at all" or only "slightly" important: ( <b>Fig. 17</b> ) </p> <p>It seems clear that the amputees retain favorable attitudes toward their prostheses after a period of wear. They appear to consider prostheses generally helpful, to believe that the advantages far outweigh the disadvantages, and to be convinced of the importance of artificial arms.</p> <p>If these findings are accepted as showing the general feelings of the amputees, the next step is to relate these attitudes to the amputees' actual use of their prostheses. The relevant factors here are the amount and type of use, the situations in which prostheses are worn and employed, and the amputee's reasons for discarding a prosthesis.</p> <h5> <i>Anticipated Difficulties With Prostheses</i> </h5> <p>As regards the wearing of an artificial arm, the amputees foresaw certain difficulties. They anticipated problems in becoming accustomed to wearing the arm, in learning to operate it, in dealing with fatigue, and in avoiding awkwardness. With the exception of the second difficulty, learning to operate the arm, all of these turned out to be real problems, and some additional ones, such as mechanical failure of the prosthesis, stump pain, and excessive heat, developed.</p> <p>The difficulties that amputees experience with their artificial arms range from relatively trivial annoyances to serious complications. Most of them may be placed in either of two categories-problems related directly to mechanical, functional, or medical disorders, and problems related to emotionally based preoccupation with conditions otherwise insignificant. Those in the first category disappear when the relevant conditions are corrected. Those in the second category reflect personality variations. In the interests of clarity and emphasis, these emotion-laden complaints have been classified in accordance with six hypothetical kinds of personality. Although having no value in themselves the stereotypes thus created are not intended as "pigeon-holes," they serve nevertheless as organizing aids for identifying the problems.</p> <p> <i>The Unmotivated.</i> The unmotivated amputee does not expend the effort necessary to overcome obstacles in using a prosthesis. The person without drive wears and uses his prosthesis so long as everything operates smoothly, but when even slight difficulties arise he lacks the motivation to continue with the limb and to expend any extra effort needed to operate it. Wear and use are thus limited. In justification of his action in discarding the prosthesis, the amputee may present many rationalizations in the form of spurious complaints about comfort and effectiveness. </p> <p> <i>The Ghost Story.</i> Complaints derived from phantom sensation are likely to occur among amputees who are unaware of the common phenomenon and who consequently do not anticipate it. Still others, on experiencing the phantom, fall prey to misconceptions about it and fail to acknowledge the experience for fear of implying that they are disoriented or are suffering from mental disturbances. Through ignorance, such patients may attribute their phantom sensation or phantom pain to poorly fitting sockets or harnesses. Complaints usually disappear when the amputee has been well informed. </p> <p> <i>Mind Over Matter.</i> People vary in the amount of discomfort they can accept. Since it is probably impossible to eliminate discomfort entirely, some dissatisfaction is inevitable. But this common difficulty may be reduced to some extent if, before fitting, the amputee develops realistic attitudes toward whatever discomfort he cannot escape. Forewarning the amputee may help him to avoid disappointment and exaggeration of his discomfort. </p> <p> <i>The Exaggerators.</i> Some amputees tend to elaborate upon their complaints and to distort the situation out of all proportion to its real significance. They develop fixations about relatively unimportant details or symptoms, and they are not open to persuasion or logical argument. Most often such a complaint is based upon a personal need, as for sympathy or attention, perhaps only remotely related to the actual prosthetic condition. But until this personal need is satisfied, little success can be expected in handling the related prosthetic or medical conditions. </p> <p> <i>Motor Trouble.</i> Difficulties associated with the actual operation of a prosthesis result from two conditions-from poor neuromuscular endowment, or from tensions and anxieties producing awkwardness and lack of coordination. In the first condition, the amputee possesses in balance and coordination basic deficiencies which together operate to reduce his functional potential. Owing to the effects of banging and twisting in awkward and erratic movements, the prospects of prosthetic maintenance tend to increase. In such a case, faults that are apparently prosthetic are really human faults. </p> <p>The second condition typifies the anxious person who always anticipates something bad. He looks upon every squeak, every irritation, and every temporary malfunction as a sign that the prosthesis is falling apart or at least is in need of adjustment. He differs from the exaggerator in that his reactions are much more diffuse and not nearly so emphatic. Anxiety induces characteristic muscular tension, which interferes with function in much the same way as does an innate psychomotor inferiority. Since the latter condition offers a poorer prognosis and dictates a different course of care, it is necessary to make a distinction based upon etiology.</p> <p> <i>The Comparison Shopper.</i> Every prosthetist knows of amputees who are always looking for something better. Sometimes such persons channel their needs constructively and make a contribution by entering the field of prosthetics development. More often, however, they dissipate their energies going from limbshop to limbshop looking for satisfaction they probably cannot get. These amputees are apt to become a matter of professional concern, for they often tend to depreciate the efforts, skill, and integrity of the art. </p> <p> <i>Recapitulation.</i> It is likely that a single explanation runs through several of the foregoing categories, for the amputee's subconscious nonacceptance of his amputation may underlie lack of motivation, phantom sensation, over-reaction, and inability to be satisfied. The problems of phantom sensation and of low discomfort tolerance may be accounted for physiologically, and the conditions of over-reaction and constant apprehension may be traced to personality factors more general than refusal to accept amputation. In any event, the categories can be made more useful, or at least revised constructively, if conceptual and experimental analysis is undertaken to establish the extent of each category, the etiological backgrounds, and the best manner of treatment in each case. </p> <p>Two general considerations should govern the follow-up of complaints-improvement of undesirable conditions, and the identification and description of the "complainers." The first is limited only by the present state of technical knowledge and skill in the field of limb prosthetics. The second has received only casual attention in the past. Further work in this area of psychology could prove to be fruitful.</p> <h4>Can the Postfitting Attitudes of Amputees Toward their Prostheses be Predicted on the Basis of their Prefitting Expectations?</h4> <p> As we have seen, the attitudes held by the amputees before they had participated in the program were modified by their subsequent experience with prostheses. The shift was generally toward a more realistic opinion of the results that could be obtained with prostheses. In addition to these changes, however, the attitudes of the amputees both before and after fitting showed that they placed a great deal of importance on the desirability of wearing a prosthesis. The next step, then, was to study the relationship between an amputee's attitude before fitting and his attitude afterwards. Our aim was to determine whether or not it is possible to predict an amputee's postfitting adjustment from a knowledge of his expectations before he is fitted. To this end, the question was asked: <i>Are the prefitting attitudes of amputees toward prosthetic restoration related to the attitudes they hold after fitting and a period of usef</i> Or, to put the question more specifically, will the amputee who approaches the fitting with a positive attitude about prostheses tend to maintain that attitude after he has worn and used an artificial arm, and, conversely, will the amputee who starts with a less positive, ambivalent, or negative attitude toward prostheses persist in that attitude after wear and use? </p> <p> Appendix IIIH, used previously to determine the degree of satisfaction of amputee expectations, was now applied to test whether or not postfitting attitudes could be predicted from the corresponding prefitting attitudes. <a style="text-decoration:none;">*</a> Selected for this analysis were 42 amputees, none of whom had worn a prosthesis before participating in the program. They included 18 below-elbow, 18 above-elbow, and 6 shoulder-disarticulation cases ranging in age from 17 to 54 years, in education from none to postgraduate school, and in the year of amputation from 1916 to 1955. The group was, in short, highly diverse. According to their combined expectancy scores, the subjects were placed on a continuum ranging from high to low in prosthetic expectation and were then divided into three equal groups representing high, intermediate, and low prosthetic expectancy. For comparative purposes, only the upper third, representing high expectancy, and the lower third, representing low expectancy, are used in the following analyses. </p> <h5> <i>Combined Expectancy Score of High Group Compared With That of Low Group</i> </h5> <p>The first step was to determine whether the initial attitudes of the high-expectancy and low-expectancy groups were maintained after prosthetic experience or were modified by it.</p> <p> Accordingly, the attitudes of the high and low groups were compared before and after fitting, <a style="text-decoration:none;">*</a> as indicated in <b>Table 3</b> ]. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In both instances, the difference between the average combined expectancy scores of the high-expectancy group and of the low-expectancy group was found to be statistically significant (P 0.05). Moreover, the mean score for each group did not change significantly after fitting (P 0.05). Thus in general positive or negative attitudes within the group were maintained after fitting.</p> <p>The individual items of the questionnaire were studied in an effort to determine why within each group there was only insignificant change in the combined expectancy scores from before fitting to after fitting. Was this result owing to lack of systematic differences between evaluations? Or were gains in positive feelings toward some items canceled out by loss of positive feelings toward other items?</p> <h5> <i>High and Low Group Comparisons for Individual Items</i> </h5> <p> Within each group an analysis was made of the way in which the responses to individual questionnaire items changed after fitting. The opinions expressed by the high-expectancy group and by the low-expectancy group about each item before and after fitting are listed in <b>Table 4</b> , where it may be seen that the nine items originally used to differentiate high prosthetic expectancy from low continued to differentiate the two groups, the "high's" in every instance remaining more favorably disposed than the "low's." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Inspection of the data indicates that the lack of change from prefitting to postfitting evaluations, as measured by the combined expectancy score, does not result from the cancellation of negative changes by positive ones. The average score of both the high-expectancy and the low-expectancy groups increased (became less positive) on most items. The conclusion may thus be drawn that experience with prostheses led both groups to expect less in the way of functioning (items 1 and 2), to expect less resemblance between prostheses and natural arms (item 3), and to expect artificial arms to be more uncomfortable (item 5). On the other items, the average score either decreased or remained about the same. Both groups said that the artificial hand more closely resembled the normal hand than they had expected (item 4). The "low's" apparently found (more so than the "high's") that they had not sufficiently appreciated the advantages of wearing prostheses (item 8). Of considerable interest were the group differences in response to item 6 (the importance of wearing an arm). The "high" group showed a lessening of positive opinions, and this decrease corresponded to a decline in negative attitudes among the "low's."</p> <h5> <i>Certainty of Response</i> </h5> <p> Throughout the questionnaire, the amputees had been asked to indicate by code the degree of certainty they felt about each of their responses. After the initial investigation, a study was made of the certainty with which any particular response had been expressed. In the code <i>AS</i> (absolutely sure), <i>VS</i> (very sure), <i>FS</i> (fairly sure), <i>SU</i> (somewhat unsure), <i>VU</i> (very unsure), <i>AS</i> was arbitarily assigned a weight of 1; <i>VS</i> a weight of 2; <i>FS,</i> 3; <i>SU,</i> 4; and <i>VU,</i> 5. Thus was obtained an average certainty score for each person in each group. The mean certainty scores for each group, prefitting and postfitting, are shown in <b>Table 5</b> . </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 5</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputees with high expectancy express themselves as being a good deal more certain of their responses than do the low-expectancy amputees, although both are generally quite affirmative. Since in general the amputees admit to very little prosthetic knowledge, one may wonder about the basis for such certainty. After they had acquired experience with their prostheses, both groups became even more certain in their responses, as might have been expected. But the increase in certainty among the "low's" was considerably less than the increase expressed by the "high's." There would seem to be much value in further analysis of the relationship between attitude toward prostheses and certainty of response.</p> <h5> <i>Relationships Between Expectancy and Other Factors Related to Amputation</i> </h5> <p> In order to learn whether or not there were systematic relationships between prosthetic-expectation level and certain other factors, the "high" and the "low" groups were compared with regard to amputation type, hand dominance, marital status, age, educational level, and age at time of amputation. Analysis indicated no statistically significant differences<a></a> between the group with high expectancy and the group with low expectancy. <a style="text-decoration:none;">*</a> It would appear that, for this sample, the amputees who expect considerable returns from prosthetic service and those who do not expect very much are not greatly different in the factors of amputation type, handedness, marital status, age, education, and time since amputation. The suspicion that "attitudes held by amputees about prosthetic restoration before fitting are related to the attitudes they hold after fitting and a period of use" is therefore confirmed by the data. The findings also substantiate the more specific hypothesis: <i>The amputee who approaches the fitting with a positive attitude about prostheses will tend to maintain that altitude after he has worn and used one; the amputee who starts with a less positive, ambivalent, or negative attitude toward prostheses will persist in that attitude after wear and use.</i> </p> <p>It must be emphasized that these findings relate to the amputees' general attitudes toward prosthetic restoration. Any particular reaction will be a function of the general prosthetic attitude and also of the specific factor involved, whether it be that of appearance, of function, or of something else.</p> <h5> <i>Relationships Between High and Low Expectancy and Other Attitudes of Amputees</i> </h5> <p>In the course of the studies, information also was gathered describing the attitudes, experience, and expectancies of the subjects. Not all of these data were thought to be directly related to the question of what the amputees expected from prosthetic restoration. But in continuation of the study of amputee attitudes toward prosthetic service, they were examined anyway. A nonstatistical comparison, made between high-expectancy and low-expectancy groups to detect differences with respect to other reactions, uncovered the following distinctions:</p> <ol> <li>On the whole, the group with the high expectations reported a great deal of improvement in performance. But the low-expectation group said that performance of a number of activities was impaired after prosthetic treatment. The degree of negative change reported by the "low's" was not as great as the degree of improvement reported by the "high's." Activities showing the greatest amount of change were eating, dressing, driving, and participating in sports. The "low" group expressed the most disappointment about eating, dressing, and sports activities. The "high" group reported its greatest improvements in the areas of dressing and driving.</li><li>The "low's" expected more difficulties than did the "high's" (18 to 12), and in the evaluations after fitting they continued to report more difficulties (19 to 14).</li><li>More "high's" than "low's" reported having had favorable comments made to them about the appearance of their prostheses.</li><li>More "low's" than "high's" admitted to negative changes in feelings since amputation.</li><li>Before wearing a prosthesis, four "low's" felt resentful when new acquaintances asked about the amputation; none of the "high's" expressed any negative feelings. After wear, the "high's" still did not express resentment, although three "low's" did.</li><li> The most outstanding difference between the "high" and "low" groups was manifest in response to the question, <i>If you don't consider appearance, do you think that you could get along as well without a prosthesis as with one?</i> Before fitting, none of the 28 subjects responded in the negative (perhaps because they were getting a free prosthesis). Three of the "high's," however, gave extremely positive responses ("The prosthesis is like a part of my body; I cannot do without it."), while the rest of the "high's" and all of the "low's" answered more temperately ("It facilitates things, increases independence."). In the postfitting evaluation, one of the "high's" said that he could do without a prosthesis, as his was not too helpful; two of the "high's" gave extremely positive replies; and the rest were more moderately positive. The "low's" presented a much more negative picture in the postfitting evaluation. Four said that they felt they could do without a prosthesis, and only one expressed himself as being oriented very positively. </li></ol> <p>The validity of the group division appears to be supported by the sample findings from the rest of the psychological data. Although we are concerned at present with establishing points of difference between the "high" and the "low" groups, it is well to add that in many other variables, such as social sensitivity and reactions to frustration, use of these measuring instruments revealed no differences.</p> <p>In conclusion, then, the hypothesis was confirmed that the attitudes of nonwearers toward prosthetic restoration are related to their attitudes after they have worn prostheses. Through the use of a set of questions, it was found possible to differentiate between favorable and unfavorable attitudes. The division of the amputees on the basis of their general attitudes toward the usefulness of prostheses gave some indication of being related to other than prosthetic factors. But judging from the results, the establishment of predictive indicators of attitude toward prosthetic restoration appears to be feasible. It should be possible to develop a predictive scale which will have clinical and research utility and which at the same time can be administered and interpreted in a relatively simple way.</p> <h3>Summary</h3> <p> Throughout this section a number of recurrent themes have been encountered. Chief among these has been the amputees' need for unprejudiced recognition by nonamputees. In order to gain this recognition, the amputees consistently present themselves in a manner which only partially represents their true feelings. The interpretation of the data has therefore been that the amputees utilized the questionnaires more to express their feelings about how an amputee <i>should</i> be regarded than to state how he actually <i>is</i> treated. From this point of departure the information has been handled at two levels-the first involving the assumption that the data are valid and meaningful in themselves, the second based on the premise that the responses reflect the conscious and subconscious wishes of the subjects. </p> <h4>Personality Dynamics of Amputees</h4> <p>Although 90 percent of the amputees said that they were adapted to their loss, it is doubtful that so many had really achieved this result. Evidence seemed to indicate that many of the amputees were trying to maintain feelings of bodily integrity and adequacy by denying the personal and social concomitants of amputation. Any implication of abnormality was overwhelmingly rejected. Their physical defect was consistently de-emphasized, and their goals and values were those of the normal, nondisabled person.</p> <p>In almost all instances, amputees portray themselves as being as able an nonamputees. While almost never admitting to being substantially inferior to nonamputees, they do acknowledge that some extra effort is necessary to keep up with them. Other evidence confirms that amputees are, in the main, correct in stressing their ability. But their consistent refusal to acknowledge limitations reflects their own self-concern. Apparently they must exaggerate to maintain a social and vocational status equal to that of nonamputees.</p> <p>Considerable stress is placed upon self-sufficiency. Amputees say they resist accepting help because it is generally unnecessary. Unexpressed, but no less important, is the feeling that to accept help makes one dependent and lowers one's status.</p> <p>Sensitivity about physical prowess and appearance is one of the crucial influences in the psychological functioning of the amputee. The subjects in this study readily admitted their concern about the opinions of others, but few were ready to admit any considerable amount of sensitivity. They claimed not to resent curiosity about their appearance and to expect people to look at them. Clinical experience, however, indicates that amputees are much more sensitive and hostile toward the curious person than was indicated by the data. Not infrequently such sensitivity is denied not only to others but also to themselves.</p> <p>Amputees claim to be accepted by others on the same basis as anyone else, and they reject strongly the suggestion of "different" treatment. Mostly, the subjects did not feel that amputation had been a serious source of frustration. They felt they usually could do the things they wanted. When they were unable to perform because of the amputation, their usual reaction was to try all the harder.</p> <p>Finally, the general tone of the amputees is to give the impression of being optimistic about their abilities, acceptance by others, and future goals.</p> <p>The positive effect of the experimental treatment program on many of these variables was demonstrated. Although no radical personality changes were observed, there were consistent indications that some decrease in sensitivity and frustration resulted from the improved management procedures and from the improved prostheses. In addition, some degree of greater acceptance of loss, increased feelings of functional adequacy, and greater ease in social situations were noted.</p> <h4>Social and Functional Factors in Prosthetic Wear</h4> <p>The prosthetic-reaction test resoundingly confirmed the data from the questionnaires. It was clear that participation in the treatment program resulted in an increase in those responses indicating greater independence and increased feelings of security. The amputees believed there was both functional and psychological advantage in the wearing of a prosthesis. They viewed prostheses as providing the wherewithal for independent functioning. Increased confidence in their functional adequacy helped them to achieve greater self-acceptance, enabled them to face their disability more realistically, and let them view the reactions of others without feeling quite so threatened. They expected nonwearers to be more shy, more easily embarrassed, and less adaptive.</p> <h4>Attitudes Toward Prosthetic Wear, Before and After Fitting</h4> <p> In the final phase of the investigation two questions were asked: <i>Are the expectations of nonprosthesis wearers fulfilled by wearing a prosthesis?</i> and <i>Can the postfitting altitudes of amputees toward their prostheses be predicted on the basis of their prefitting expectations?</i> </p> <p>A number of avenues of approach were utilized to answer the first question. It was found that the extent of prosthetic knowledge claimed by the amputees was very small. The implications of the lack of information were discussed, with stress upon the opportunity ignorance presents for the development of unrealistic expectations (which may influence negatively future attitudes toward prostheses). Overly ambitious ideas as to the value of prostheses were modified with experience, and after being fitted most of the amputees had more realistic expectations of the advantages to be derived from prosthetic wear.</p> <p>General acceptance of the appearance of the prosthetic components was clear. There was little change in opinion regarding the extent to which prosthetic arms and hands resembled normal members. Three important constituents to the final judgment of amputee appearance were identified-the static factor of the cosmetic value of the prosthesis irrespective of function, the dynamic factor of natural appearance in use, and the situational factor of the intensity of the contact.</p> <p>Preconceptions regarding comfort did not change markedly with experience. Although comfort appears to be no important problem for three fourths of the amputees, the remaining one fourth found their prostheses to be uncomfortable.</p> <p>The amputees retained favorable attitudes toward the prostheses after a period of wear. Prostheses were considered to be generally helpful and very important to the amputees, the advantages far outweighing the disadvantages.</p> <p>With the exception of "learning to operate," most of the difficulties anticipated in wearing an arm actually developed. In addition, other problems evolved, such as mechanical failure, stump pain, and excessive heat. A number of hypothetical personality types were described to help identify complaints based upon emotional factors as contrasted with those directly related to prosthetic or medical problems. The second question was directed toward the idea that attitudes held before prosthetic fitting may influence the valuation of prosthetic usefulness regardless of experience. Tested and confirmed was the hypothesis that attitudes held by amputees about prosthetic restoration before fitting are related to the attitudes held after fitting and a period of use. Amputees holding favorable attitudes before using prostheses tended to maintain those attitudes after wear and use; subjects negatively disposed continued to be less favorably inclined.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, <i>Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability,</i> Social Science Research Council, New York, Revised 1953. </li> <li> Cameron, N, and A. Magaret, <i>Behavior pathology,</i> Houghton-Mifflin, Boston, 1951. </li> <li> Dembo, Tamara, and Esther Tane-Baskin, <i>The noticeability of the cosmetic glove,</i> Artificial Limbs, 2(2) :47 (May 1955). </li> <li> Dembo, Tamara, Gloria Ladieu Leviton, and Beatrice A. Wright, <i>Adjustment to misfortune - a problem of social-psychological rehabilitation,</i> Artificial Limbs, 3(2) :4 (Autumn 1956). </li> <li> Ladieu, G., E. Hanfmann, and T. Dembo, <i>Studies in adjustment to visible injuries: evaluation of help by the injured,</i> J. Abnorm. and Soc. Psychol., 42:169 (1947). </li> <li> Meyerson, L., <i>Physical disability as a social psychological problem,</i> J. Soc. Issues, IV(4):2 (Fall 1948). </li> <li> New York University, Prosthetic Devices Study, Report No. 115.07 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Social usefulness of the cosmetic glove: its notice-ability and appearance,</i> October 1949. </li> <li> New York University, College of Engineering, Research Division, Prosthetic Devices Study, Report No. 115.21, <i>Surveys of child amputees at the Mary Free Bed Hospital, Grand Rapids, Michigan,</i> Prepared for the Prosthetics Research Board, National Research Council, May 1957. </li> <li> Siegel, S., <i>Nonparametric statistics for the behavioral sciences,</i> McGraw-Hill, New York, 1956. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Kolmogorov-Smirnov and Fisher Exact Probability Tests (Siegel) indicated P&gt;0.05 in all instances.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall"> Siegel, S., Nonparametric statistics for the behavioral sciences, McGraw-Hill, New York, 1956. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be remembered that expectancy scores approaching 1 indicate favorable prosthetic attitudes, those approaching 5 indicate unfavorable attitudes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A measurement of prosthetic expectancy was obtained by a system of scores and ratings similar to that used in the analysis of the results obtained with Appendix IIIG. Each question in Appendix IIIH had five possible answers ranging from one that expressed very positive feelings to one expressing very negative feelings. The response reflecting the most favorable attitude was given a score of 1, that reflecting the least favorable attitude a score of 5. There was thus obtained a score for each item as well as an average score for the questionnaire as a whole (combined expectancy score). Each amputee was then assigned a rating which represented the direction and intensity of his feelings about prosthetic restoration and which was therefore a measurement of his prosthetic expectancy.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Dembo, Tamara, and Esther Tane-Baskin, The noticeability of the cosmetic glove, Artificial Limbs, 2(2) :47 (May 1955). </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall"> New York University, Prosthetic Devices Study, Report No. 115.07 [to the] Advisory Committee on Artificial Limbs, National Research Council, Social usefulness of the cosmetic glove: its notice-ability and appearance, October 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be remembered that on the average E2 was administered about six months after fitting. It is probable that, had this test been administered to the NPPWs before they received and used artificial arms, considerably greater differences between PPWs and NPPWs would have been found.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Six of the nine cartoons portrayed situations not relevant to independence and were therefore rated for security only. See Table 1, page 102.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall"> New York University, College of Engineering, Research Division, Prosthetic Devices Study, Report No. 115.21, Surveys of child amputees at the Mary Free Bed Hospital, Grand Rapids, Michigan, Prepared for the Prosthetics Research Board, National Research Council, May 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall"> Cameron, N, and A. Magaret, Behavior pathology, Houghton-Mifflin, Boston, 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> Dembo, Tamara, Gloria Ladieu Leviton, and Beatrice A. Wright, Adjustment to misfortune - a problem of social-psychological rehabilitation, Artificial Limbs, 3(2) :4 (Autumn 1956). </td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall"> Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The third reaction represents an extremely poor adjustment, for it leads to withdrawal from any situation that might point out the true extent of dependency. Typically, such amputees are characterized by sharply restricted behavior and a limited involvement in life.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall"> Meyerson, L., Physical disability as a social psychological problem, J. Soc. Issues, IV(4):2 (Fall 1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sydelle Silverman, M.A. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic Devices Study, Research Division, College of Engineering, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jerome Siller, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Research Scientist, Prosthetic Devices Study, Research Division, College of Engineering, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee, VII. Psychological Factors Creator An entity primarily responsible for making the resource Jerome Siller, Ph.D. * Sydelle Silverman, M.A. * https://staging.drfop.org/files/original/a6792a109f39ee50864e3cdc534b4712.pdf 9841f910ceaf33e1e3f1cc6914edbe70 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_03_008.pdf Text Any textual data included in the document <h2>Survey Results</h2> <p><i>Below are the summarized results of two questionnaires that appeared in recent issues of this publication. These results are important tools for observing, recording, and predicting trends within the Academy and the profession. Your responses are greatly appreciated, and we ask that you encourage your colleagues to send us their thoughts by answering the questionnaire in this issue (see p. 3), and those in future issues.</i></p> <h3>Scoliosis Orthoses</h3> <i>From the Summer, 1981 Issue, Vol. 5, No. 3</i> <p>A total of six responses have been received. Two respondents were institutional facilities and the rest were private. The six reported fitting a total of about 757 patients last year, an average of about 126 per facility. The maximum was 400 patients and the minimum was 8. Not too surprisingly, the maximum was an institutional facility (Newington Children's Hospital). The most commonly prescribed orthosis was the Boston System, and among four of the respondents it accounted for the majority of orthoses fit. One individual reported that the Boston System accounted for 100% of orthoses he fit for scoliosis (actual number, 13); however, two of these orthoses had been modified by the addition of a super structure, and 3 with anterior uprights. Only one respondent reported using more than 50% conventional Milwaukees (60%) and this individual, practicing in the Southwest, stated that all had leather girdles as plastic girdles were too hot. He also reported using 35% Orthomedics SOS Systems, the only mention of this style orthosis in the survey.</p> <p>Interestingly enough, one respondent reported that 36% of his scoliosis practice was comprised of Raney Flexion Jackets prescribed by a neurosurgeon for treatment of scoliosis and as positioning devices.</p> <p>Only one respondent, Richard D. Koch, CO of University Hospital, Ann Arbor, Michigan, reported using a preponderance (90-95%) of custom molded TLSO Body Jackets and Low Profile Orthoses combined (actual numbers fit 120-125). The rest of his scoliosis practice was comprised of conventional Milwaukee braces. Mr. Koch comments:</p> <p>"Through school clinics and early screening for scoliosis the range of curves have reduced in degree of their severity. Consequently, we find that TLSO Body Jackets and Low Profiles are in wider use than CTLSO's."</p> <p>Newington Children's Hospital, mentioned earlier, reported using 75% Boston Systems and 25% custom molded TLSO's primarily for treatment of non-idiopathic scoliosis secondarily to paralytic diseases.</p> <h3>Results of the Survey Concerning Endoskeletal Prostheses</h3> <i>From the Winter, 1982 Issue, Vol. 6, No. 1</i> <p>As of March 25, 1982: 27 responses</p> <ol> <li>How many definitive endoskeletal prostheses does your facility fit a year?</li> </ol> <ol> <li style="list-style-type: none;"> <ul> <li> <p>Total of 1,814 fit, an average of 67 per respondee</p> </li> <li> <p>Maximum of 380</p> </li> <li> <p>Minimum of 0, second lowest 5</p> </li> </ul> </li> <li> <p>Indicate the percentages of the type fit.</p> <p>While it is difficult to give precise figures, roughly speaking the same trend prevailed for all respond-ees. About 95-100% of Below-Knee prostheses fit were exoskeletal and 95-100% of Hip Disar-ticulation/Hemipelvectomy prostheses were endoskeletal. Above-Knee prostheses occupied some middle ground with many respondents reporting fitting more than 50% endoskeletal Above-Knee prostheses. Only four respondents reported fitting as many as 50% endoskeletal Below-Knee prostheses. These four tended to be among the most frequent users of endoskeletal prostheses reporting 380, 170, 75, and 50 respectively.</p> </li> <li> <p>Which Endoskeletal Prosthetic System was used most frequently?</p> <ul> <li> <p>Otto Bock 20</p> </li> <li> <p>AFP 2</p> </li> <li> <p>Both Otto Bock and AFP 2</p> </li> <li> <p>Both Otto Bock and USMC 2 IPOS 1</p> </li> </ul> </li> <li> <p>Do you consider endoskeletal prosthetic systems light enough?</p> <ul> <li> <p>11 said yes</p> </li> <li> <p>14 said no</p> </li> <li> <p>1 said yes to AK's and no to BK's</p> </li> <li> <p>1 said yes to AFP and USMC and no to Otto Bock</p> </li> </ul> </li> <li> <p>Do you consider them reliable enough?</p> <ul> <li> <p>19 said yes, one of whom qualified his response by saying for adults and geriatrics only</p> </li> <li> <p>7 said no</p> </li> <li> <p>1 said yes and no</p> </li> </ul> </li> <li> <p>Are cosmetic covers and skins adequate?</p> <ul> <li> <p>23 said no</p> </li> <li> <p>3 said yes, one qualified his answer by saying only the AFP system</p> </li> <li> <p>1 said yes and no</p> </li> </ul> </li> <li> <p>Do you consider it necessary to have full capability to modify alignment in definitive endoskeletal prostheses?</p> <ul> <li> <p>11 said yes, one stating that the need for making changes in alignment as the patient's condition changed was an indication for prescribing an endoskeletal prostheses. One specified the use in temporary prostheses.</p> </li> <li> <p>1 stated that he considered it desirable early in the patient's progress and unnecessary late</p> </li> <li> <p>14 said no, one of whom indicated that he used the AFP system exclusively and revised 380 of them</p> </li> <li> <p>1 ambiguous</p> </li> </ul> </li> <li> <p>How often do you make changes in alignment?</p> <ul> <li> <p>7 said never</p> </li> <li> <p>17 said occasionally, one of whom stated that he occasionally made changes early in the patient's progress and never in more advanced instances.</p> </li> <li> <p>3 said frequently. One was the individual in #7 who identified the need for alignment changes as an indication for prescribing an endoskeletal prosthesis.</p> </li> </ul> </li> <li> <p>Would you consider it satisfactory to trade alignment modification capability for lightness and durability?</p> <ul> <li> <p>22 said yes, one of whom qualified his position by saying not at the expense of the ability to interchange components.</p> </li> <li> <p>5 said no</p> </li> </ul> </li> <li> <p>10. What changes would you like to see made?</p> <ol> <li> <p>11 specified improved cosmetic covers</p> </li> <li> <p>4 specifically recommended a more durable cover at the knee, or a way to reinforce or prevent impingement at the knee.</p> </li> <li> <p>3 recommended more work on hydraulic and pneumatic knee control units, one of whom mentioned a hydraulic foot.</p> </li> <li> <p>2 mentioned a more secure system of maintaining alignment.</p> </li> <li> <p>2 mentioned waterproof skin for covers</p> <p>One each:</p> </li> <li> <p>lighter safety knee</p> </li> <li> <p>improved strengh</p> </li> <li> <p>easier to operate and more cosmetic knee lock</p> </li> <li> <p>interchangeability of knee units without necessity of altering pylon tube length.</p> </li> <li> <p>easier and better attachment of cover to foot and socket for improved cosmesis, yet allowing removal for adjustment of alignment.</p> </li> <li> <p>reduction in weight of single-axis feet and ankles</p> </li> <li> <p>modular, removable, hip joint and pelvic belt m. more versatile socket for geriatrics to accommodate weight fluctuation and vascular problems</p> </li> <li> <p>incorporation of cable systems in upper extremity prostheses.</p> </li> <li> <p>durable covers easily donned by the layman</p> </li> <li> <p>easier access to the adjustment screws on top of the foot of the Otto Bock system.</p> </li> <li> <p>Covers such as those used on Hydra-Cadence, but they must look better and last longer. Preferably in assorted sizes."</p> </li> <li> <p>noise reduction (spring squeaks)</p> </li> <li> <p>system for small girls</p> </li> </ol> </li> <li> <p>Additional comments:</p> <ol> <li> <p>"The Otto Bock System was the best of both worlds (lightweight and adjustable) until the alloys and tubing were changed for increased strength. A main selling point of the endoskeletal systems has always been improved cosmesis. This may be true for standing and during the first few months post-delivery. However, the common foam cover system deteriorates relatively rapidly-cuts, tears, folds, and compression of the foam remain common problems. Therefore, I feel the foam covers need refinement."</p> </li> <li> <p>"I want full adjustability while aligning. After alignment on definitive prostheses the adjustability doesn't have much value."</p> </li> <li> <p>"In regard to question #7. Depending on patient indications two systems would be desirable; one fully adjustable in terms of alignment, the other lighter and more reliable."</p> </li> <li> <p>"Most endoskeletal prostheses are for AK female amputees."</p> </li> <li> <p>"In reference to question #4 and #5 above, of course they could be more reliable and lighterweight if they could redesign the system (Otto Bock, Ed's note). As it is, they are doing the best they can with what they have to work with (design)."</p> </li> <li> <p>"It is a good unit but needs improvement."</p> </li> <li> <p>"Endoskeletal is a poor excuse to charge more money. Shell replacement is too costly too soon. I'm afraid the dollar sign prevails and not the patient's welfare."</p> </li> <li> <p>"For below-knee amputees, I do not feel an endoskeletal system is any advantage. For the young, active above-knee amputee, the foam cover is not durable enough. For the hip disarticulation of any age, it is usually preferred, except in special cases."</p> </li> <li> <p>"The endoskeletal system should only be used in those cases where lightness is desired and where changes in alignment are anticipated."</p> </li> </ol> </li> </ol> <h3>Questionnaire Summary Comments</h3> <p>The article on endoskeletal prostheses provoked an astonishing and gratifying response, something of a record in size, in the recent history of this publication. A surprising total number of prostheses are reported fit, and endoskeletal prostheses occupy a significant total in many individuals' overall practice. In assessing the results of this survey, it would do well to bear in mind, however, that according to the statistics, we are primarily talking about prostheses for the higher levels (Above-Knee, Hip Disarticulation, and Hemipelvectomy) fabricated with Otto Bock components. This fact is particularly interesting when considered in light of the fact that below-knee amputees are undoubtedly far more common in most practices.</p> <p>Despite the numbers fit, it is apparent that the re-spondees were less than totally satisfied with the components available. While somewhat ambivalent about weight, and in general satisfied as to reliability, they were almost unanimous in judging cosmetic covers inadequate.</p> <p>Taking questions 7, 8, and 9 together, it would seem that most of the prosthetists replying would feel comfortable using an endoskeletal system that did not have full indwelling alignment capability if it were clearly superior in other aspects. This is noted in light of the proponderent use of Otto Bock endoskeletal components.</p> <p>The written comments and suggestions for change are presented, with few exceptions, in toto to provide more than simple statistics, and some inkling of the thoughts of the respondees. Taken in conjunction with the rest of the survey, they should provide food for thought to all and stimulus to action for designers and manufacturers.</p> Page Number(s) 8 - 10 Year 1982 Volume 6 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Survey Results https://staging.drfop.org/files/original/bce63a5f984a2b7e266ad41c794457eb.pdf 3336381361b926e881b5e08b4d5a104f https://staging.drfop.org/files/original/8984ef005962175cd2cd9ca4c67dd953.jpg 27b4bfe13ac727d78e188ef5c0b67354 https://staging.drfop.org/files/original/abfa246572131fe9dd3cdcbd55538f20.jpg a393b0f058bc54700d9c3ab34b65c9f4 https://staging.drfop.org/files/original/b1236f8892840de73e07786a00477f27.jpg 17ad3bcf73e9cc611c2f726000e15585 https://staging.drfop.org/files/original/f423924d489cce78f8517b42ebf79aae.jpg da4e43f799a904dc23d6620dc6553989 https://staging.drfop.org/files/original/1605ed8928919d3ac2b4a9755e041d30.jpg 36995fceb11605d7162400a6c40443e0 https://staging.drfop.org/files/original/999e0f60cb6a02c2a0115145cf515482.jpg 1dad4baf20341bf6baeb1f03138e9898 https://staging.drfop.org/files/original/f6b705039b55b6defd8e13b6e9c13e02.jpg abe2f39e1bd4137970fc50bef98c633e https://staging.drfop.org/files/original/59c9f866e0c4115b40694ac727ab58e3.jpg 22142ed910fdea4adda64f3b92d3480d https://staging.drfop.org/files/original/c807f2e8e367587163feae6926ca1b81.jpg 5f9b6c07208aad1b7d1c8f17934ec314 https://staging.drfop.org/files/original/74e60652660a7f2fade6c3f7f604d916.jpg 4c8a84c66cf97e3b930c25c10fce434a https://staging.drfop.org/files/original/0422d5a84c721d8228bef8e3651da68e.jpg 4c29f85936b1ff8d7fde5e8a6c90e7a8 https://staging.drfop.org/files/original/9a2d677825dd94e876b15c4dd04e83bc.jpg e5ef2eba763449d1d7606f322f5ae139 https://staging.drfop.org/files/original/07ea344764325dbc83c30b93217adcb4.jpg a579c5f3e92ff8e9ead1a6975eb28f55 https://staging.drfop.org/files/original/a4abcb85f4dca41eb258db103a1b6758.jpg 33f7ded8889906f86c4011008830c2f7 https://staging.drfop.org/files/original/b37d8f6126d94e2d7899983c1a474c0f.jpg 1fe5f44a5993f642ec0619a7eab4ef46 https://staging.drfop.org/files/original/3af334d9f215fbfc19ea5de010c1cd7c.jpg f585c5ed5d6d36c905cf9769833bd923 https://staging.drfop.org/files/original/a4a20ebdca1ecd21eaae49d233d5ce56.jpg 63ada1bca5d0c342a0eb4a5ac485ec14 https://staging.drfop.org/files/original/766e46411ccd23ec701dab020f5f81ba.jpg 80998bfac3aa008d9f07c6c5a820fa6b https://staging.drfop.org/files/original/137b1d7a083dea7f124c935af402eed6.jpg 19c2b24e6295de60f62d98abb36ee83e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_005.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 5 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Suspension Casting for Below-Knee, Above-Knee, and Syme's Amputations</h2> <h5>Fred Hampton, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The suspension casting technique permits the casting of an amputee's lower-extremity stump while it is being held in an attitude simulating stance-phase weight-bearing in a prosthesis. This is accomplished through application of the principle of the Chinese finger trap; namely, when a cloth cylinder of suitable weave is stretched longitudinally, the circumference of the cylinder is decreased.</p> <h3>Suspension Casting of the Below-Knee Stump</h3> <p>In casting below-knee stumps, a cast sock clamped in a ring is the cloth cylinder. As the amputee bears weight on the suspended sock, the sock stretches longitudinally and constricts circumferentially, thereby firming the tissues of the stump during the application of the plaster wrap. The amputee is properly oriented in an upright position for casting and for producing accurate alignment lines on the cast. The tissues are firmly contained, edema is restricted, and bony prominences are emphasized. Distal redundancy is held firmly in the correct position by the suspension sock. While the stump is suspended, areas requiring relief can be definitively outlined and, if necessary, build-ups of appropriate thickness can be applied to the suspension sock prior to wrapping. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Equipment required includes:</p> <ol> <li>A ring, approximately 6 1/2-in. inside diameter.</li><li>A rubber gasket.</li><li>A hose clamp.</li><li>A VA or a Berkeley casting stand with vertical adjustment.</li><li>Bathroom scale and platform.</li></ol> <p><b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Data to be obtained and recorded are:</p> <ol> <li>The length of the normal leg from the medial tibial plateau to the floor, with the shoe off.</li><li>The shoe size.</li><li>The anteroposterior dimension of the stump, measured with a VA caliper while the stump is fully relaxed and supported by the prosthetist.</li><li>The mediolateral dimension of the stump just proximal to the tibial plateau, measured with a VA caliper.</li><li>The length of the stump, measured from the end of the stump to the level of the midpatellar tendon. A small square is used to obtain this measurement; the blade of the square should contact the crest of the tibia.</li></ol> <p><b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>PREPARATION OF MEDIAL TEMPLATE.</b> Because the medial flare of the tibial condyle is a particularly good weight-bearing area, it is desirable to construct a medium-weight cardboard template of the medial aspect of the stump for use as a guide in checking and maintaining the contours of the positive model in this important area. A cast sock is pulled over the stump and held with moderate tension by the amputee. To prevent bulging of the gastrocnemius during the tracing, the weight of the stump is supported by the prosthetist. The pencil is held vertically and slight pressure is exerted against the stump as the outline is drawn. The outline should extend from the proximal border of the femoral condyle to the midline of the distal aspect of the stump. After the medial tibial plateau is marked on the outline as an important landmark, the template is cut out and checked against the stump. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>PREPARATION OR RELIEF PATCHES.</b> Relief patches should be prepared prior to suspension of the amputee in the ring. Various materials may be used for the patches, such as 1/8-in. Kemblo rubber, 1/8-in. adhesive-backed felt, or any foam material 1/8-in. thick and of sufficient density for dimensional stability. Areas usually requiring relief are the tibial tubercle, the tibial crest, the distal end of the tibia, the leading edge of the lateral tibial condyle, and the head and distal end of the fibula.</p> <p>The patch for the head of the fibula should extend at least 1/4 in. beyond the bone area. If the head of the fibula is prominent, a double patch is sometimes indicated.</p> <p>The patch for the tibial crest should be 1-in. wide. This will allow 1/4 in. of plaster on each side for blending the edges of the positive stump model. The actual relief remaining is 1/2-in. wide, sufficient to cover the lateral edge of the tibial crest and blend into the medial tibial surface. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>SIZING THE CAST.</b> The dimensions of the negative cast produced are dependent upon the stump, the number and weight of the socks used, and the tension with which the plaster bandages are applied. One heavy cast sock is used to accommodate the fit of a stump wearing a three-ply wool sock in a hard socket. For a mature stump, two heavy cotton cast socks are used to accommodate a five-ply wool-sock fit in a hard socket. For a socket incorporating an insert, one light-weight cotton cast sock is used. Both socks and relief patches are removed from the negative cast before the plaster is poured to form the positive stump model. <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>ASSEMBLY OF EQUIPMENT AND SUSPENSION OF AMPUTEE.</b> Preparatory to taking the negative cast of the stump, the distance from the end of the stump to a point 4 in. above the proximal edge of the patella is marked on a heavy cast sock, the ring is mounted horizontally on the vertical stand, and the cast sock is centered in the ring with the mark showing. The gasket is then applied over the sock and secured with the hose clamp.</p> <p>Next, the ring is lowered on the easting stand to facilitate entry of the stump into the sock. Then the ring is raised until one-half of the body weight is borne by the stump sock, as indicated by the scale. Under these conditions, the suspension sock should contain the thigh to a point 3 in. above the superior border of the patella. The height of the ring should be adjusted until the amputated side is slightly high,so that further stretching of the suspension sock will be accommodated during the wrapping process.</p> <p>The amputee should be positioned so as to obtain a correct base of support and so that his thigh is vertically centered in the ring. The knee should be flexed so that the stump is approximately 12 deg. from the vertical, measured along the crest of the tibia. Excessive flexion will result in loss of support or cause bridging of the sock along the posterior aspect of the stump. The stump is palpated, and areas requiring relief are outlined. The relief patches are glued to the appropriate areas. and the flexion angle of the knee is checked. <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>WRAPPING THE STUMP.</b> Starting from a level just proximal to the top edge of the patella, four wraps of 4-in. plaster bandage are firmly applied. As noted previously, the medial flare of the tibial condyle is a good weight-bearing area. For emphasis, the plaster bandage is applied with firm tension diagonally upward in this area. The plaster bandage is then spiraled downward until the remainder of the stump is completely covered.</p> <p>Before the plaster begins to set, it is worked by hand to ensure an intimate contact between the wrap and the stump, to emphasize bony areas including the patella, to enhance the texture of the plaster, and to assist in obtaining a smooth inner surface in the cast.</p> <p>Several techniques and devices may be used when casting a below-knee stump to locate and define the patellar tendon and the support area posteriorly. Later in this article some of the variations will be presented.</p> <p>When the suspension casting technique was used initially, no attempt was made to deform the cast permanently at the patellar tendon or in the popliteal area. The patellar tendon was defined by a light massaging action on the cast, using the web of the hand between the thumb and index finger, and by applying a light counter-pressure posteriorly with the other hand. The hands were removed after the contouring, and the plaster was allowed to set. This method kept distortion of the tissues to a minimum and preserved the contours of the medial flare of the tibia.</p> <p>This technique has been modified to the extent that the hands are held in such a manner as to deform the cast permanently, producing a patellar-tendon bar anteriorly and a flattening of the popliteal area posteriorly. Any distortion of the contours of the medial flare of the tibia is corrected later by use of the template (previously discussed) when modifying the positive model of the stump. <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>ALIGNMENT LINES.</b> After the plaster has set, two vertical alignment lines are scribed on the cast with the use of a plumb bob while the amputee is standing in a position simulating stance phase in a prosthesis. Half of his weight should be borne on the amputated side. The pelvis should be level and at right angles to the line of progression. One line, scribed on the anterior aspect of the cast, will be used as a reference for the correct adduction or abduction angle of the socket during bench alignment. The other line, scribed on the lateral aspect of the cast, will serve as a reference for the flexion angle of the socket.</p> <p>In order to remove the cast, the hose clamp is released to allow rotation of the ring in the stand. After the ring has been lowered sufficiently to permit the amputee to sit down, the hose clamp, gasket, and ring are removed. Care must be taken to avoid distortion of the cast during its removal.</p> <p>Before plaster is poured to form the positive model of the stump, the cast socks and relief patches are removed from the negative cast, and the cast is oriented with the reference lines vertical. Orientation can be accomplished by setting the distal end of the cast in plaster and using a square to obtain the correct alignment. A Milmo vertical transfer jig is a useful device for this procedure and also provides a means for holding the pipe vertically in the cast until the plaster hardens. <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>MODIFICATION OF THE POSITIVE MODEL.</b> Modifications of the plaster model of the stump are made in accordance with the principles developed at the University of California Biomechanics Laboratory, Berkeley and San Francisco. <a></a></p> <p>An essential prerequisite to the modification of the plaster model is a complete examination and evaluation of the stump by the prosthetist. Variations in modification will necessarily be based upon this evaluation.</p> <p>An outline of the socket is drawn on the plaster model of the stump. This outline extends from the midpatellar level anteriorly to 2 1/2 in. to 3 in. above the midpatellar tendon level on the medial and lateral aspects of the model, down to a point 1/2 in. above the midpatellar-tendon level on the posterior aspect of the model.</p> <p>The anteroposterior dimension of the positive model will be determined by the type of socket to be fabricated. For a socket with a soft insert, the anteroposterior dimension of the model should be modified to that of the stump. For a hard socket, the anteroposterior dimension of the model should be 1/4 in. greater than the measured anteroposterior dimension of the stump; for example, if the anteroposterior dimension of the stump is 3 in., the anteroposterior dimension of the model should be 3 1/4 in.</p> <p>The following example is offered for guidance in determining the amount of plaster to be removed from the patellar-tendon area of the stump model as opposed to the amount to be removed from the popliteal area. Assuming that the anteroposterior dimension of the stump is 3 in. (to which 1/4 in. must be added for a hard socket) and that the anteroposterior dimension of the slump model is 4 in., it follows that 3/4 in. of plaster should be removed (that is, 4 in. less 3 1/4 in. equals 3/4 in.). Two-thirds of this amount, or 1/2 in., is removed from the patellar-tendon area (that is, 2/3 of 3/4 in. equals 1/2 in.). The remainder, or 1/4 in., is removed from the popliteal area (that is, 3/4 in. less 1/2 in. equals 1/4 in.).</p> <p>To prevent restriction of circulation in the stump, the plaster is removed posteriorly to produce a flattened surface rather than a bulge. The deepest removal of plaster is opposite from and just distal to the midpatellar-tendon level-thus creating the start of a radius proximally-and is continued downward to blend in toward the distal aspect of the stump model. <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>MODIFICATION OR THE POSITIVE MODEL.</b> Starting approximately 1/4 in. from the edge, plaster is removed from the reliefs to blend the edges into the contours of the stump model. Plaster is removed from the area of the medial shaft of the tibia to within 1 in. of the end. The angulation of the shaft must be maintained. The amount of plaster removed is dependent upon the amount of tissue covering the shaft. Approximately 1/8 in. to 1/4 in. of plaster is removed from the anterolateral aspect of the model, starting at the distal border of the relief for the leading edge of the flare of the lateral tibial condyle and continuing to within 1 in. of the end of the tibia. The template made from the stump is used as a guide in modifying the flare of the tibial condyle. The mediolateral dimension of the model should be reduced to within 1/8 in. to 3/16 in. of the measured mediolateral dimension of the stump. Usually, smoothing this area of the model with wire screening is all that is necessary.</p> <p>If warranted, 1/8 in. of plaster may be added to the relief of the anterodistal aspect of the tibia. The patella is smoothed by a wash of plaster rather than removal of plaster. Along the previously drawn posterior trim line of the socket, a build-up of plaster is applied to a height, of about 3/4 in. The build-up should be given a generous flare, and the distal border of the liare should be blended into the contours of the model, especially in the area of the hamstrings. Plaster should be added to eliminate any groove between the junction of the posterior plaster build-up and the medial or lateral side of the model. A piece of plastic screen or line sandpaper should be used to smooth the entire surface of the model. <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>BUILD-UP FOR RTV PAD.</b> When a Silastic RTV pad is to be used in the socket of the finished prosthesis, an additional plaster build-up about 3/4 in. high is formed on the distal aspect of the model. A piece of cardboard is applied to the cast to serve as a form for the plaster to be added. The form is sloped away from the distal anterior aspect of the tibia to provide any additional relief required. If the pipe is held vertically when the plaster is poured, a flat distal surface incorporating the correct angular alignment will result. All edges should be feathered into the contours of the model, especially in the tibial area.</p> <h3>Variations in Suspension Casting of the Below-Knee Stump</h3> <p>Since the introduction of the suspension casting concept, many variations have evolved in its use. These variations are mainly in the wrapping, the forming of the patellar-tendon bar, the modification of the wrap cast, and the modification of the positive model of the stump. <b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CALDWELL PROCEDURE.</b> In the procedure followed by Mr. Jack L. Caldwell,<a style="text-decoration:none;">*</a> gypsona plaster bandage is used in place of standard plaster bandage, a clamp (the Caldwell clamp) is used to measure the anteroposterior dimension of the stump and to contour the patellar-tendon bar and the popliteal area into the wrap cast, one heavy-cast sock is used during the wrapping procedure, the flare for the posterior proximal edge of the socket is formed in the wrap cast prior to pouring the plaster to form the positive model of the stump, and the distal portion of the stump is wrapped first for contouring purposes.</p> <p>In the Caldwell procedure, measurements are taken and recorded on a measurement chart before casting is begun. The patellar-tendon bar of the Caldwell clamp is pressed gently against the amputee's patellar tendon, and the reading made on the clamp scale is recorded. After the stump has been wrapped, the dimension should be approximately 1/8 in. greater than the measurement made on bare skin. Before the contouring clamp is applied to the gypsona-wrapped stump, the popliteal pad and the patellar-tendon bar should be greased with vaseline, since gypsona has an adhesive property not present in the ordinary plaster of Paris or elastic plaster. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CALDWELL PROCEDURE.</b> As soon as the wrap is completed, the clamp should be slipped onto the amputee's stump and the popliteal pad pressed into the proper area gently and correctly. With the contouring clamp in place, the wet plaster is worked into the medial tibial condylar shelf.</p> <p>A line is drawn circumscribing the wrap cast at the midpatellar-tendon level, also the socket trim line. <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CALDWELL PROCEDURE.</b> After the cast has been trimmed along the proximal trim line, several longitudinal cuts about 1/2 in. in length are made downward from the trim line in the area above the popliteal fossa. The cut area is reinforced with small strips of wet gypsona plaster. The use of warm water will reduce the time required to handle the plaster. The inside of the cast where the cuts were made is smoothed with a paste of warm water and plaster-of-Paris powder. <b>Fig. 15</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FOORT PROCEDURE.</b> In a procedure developed by Mr. James Foort,<a style="text-decoration:none;">*</a> one heavy cast sock is used routinely, no relief patches are applied to the suspension sock prior to wrapping, plaster is used to provide reliefs during modification of the positive model of the stump, the distance between the hamstrings is measured and used as a control for the posterior outline of the socket, the modification of the positive model under the flare of the medial tibial condyle is extended posteriorly to include the hamstring tendons, and the position of the posterior flare on the plaster model of the stump is located at the midpatellar-tendon level.</p> <p>A fixed ring holds the casting sock at the top, a clamp ring binds the sock against the fixed ring, a clamping screw is used to force the clamp ring out against the fixed ring, and a pin connects the ring assembly to the UCB stand.</p> <p>The distance between the outer edges of the tensed hamstring tendons is measured and recorded.</p> <p>After the plaster wrap has been applied to the stump, the patellar tendon is defined by pressing the thumb tips on either side of it. At the same time, light counterpres-sure is exerted with the fingers across the back of the stump. This procedure is similar to the technique described in <i>The Patellar-Tendon-Bearing Prosthesis </i><a></a> and subsequently modified as reported in <i>Air-Cushion Socket for Patellar-Tendon-Bearing Below-Knee Prosthesis. <a></a> - <b>Fig. 16</b></i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FOORT PROCEDURE.</b> When the plaster stump model has been cast, plaster is removed from the sloping surface of the medial flare with a curved l 1/2-in. rasp. The purpose here is to prepare the surfaces for supporting weight. Coupled with pressures from lateral surfaces, the medial flare helps to stabilize the stump mediolaterally in the socket. But very little adjustment of this surface is required. A 1/4-in. adjustment at the deepest part of the shelf, tapering off to nothing along the vertical portions, would be the greatest amount removed. If the model is of a seasoned stump, it is sufficient merely to work this area smooth with wire screening. The screening should be swept around the natural contours of the flare, into the posterior area, and over the hamstring tendons.</p> <p>Plaster is added to the stump model in bony areas to provide relief. In addition, a posterior flare is constructed on the model by means of a plaster build-up. This is done by pouring plaster over the posterior surface above the circumscribed mid-patellar-level line until the addition is 1-in. thick. The plaster is spread with a wet spatula, and the flare is formed with wet fingers and thumb. The back flare is not grooved for the hamstring tendons. Instead, a broad surface is provided against which the tendons can rest when the amputee is seated. The build-up for the posterior flare should be trimmed to about 3/4 in. with a flat rasp. <a></a> - <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>VARIATION USED AT NUPRC.</b> Another slightly different procedure sometimes used at the Northwestern University Prosthetics Research Center incorporates a patellar-tendon pad and a popliteal pad into the wrap during suspension casting. The pads used were developed at the Veterans Administration Prosthetics Center in conjunction with a pneumatic casting svstem. These pads define the patellar-tendon bar and the popliteal depression, and their use results in a positive stump model with an anteroposterior dimension that is within 1/16 in. of the measured anteroposterior dimension of the stump. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>VARIATION USED AT NUPRC.</b> Two wraps of standard plaster bandage are applied to the proximal aspect of the stump, covering the patellar-tendon area. The protuberance of the pad is positioned over the patellar tendon and covered with two additional wraps of bandage applied with firm tension to hold the pad in place.</p> <p>The popliteal area is then covered with two wraps of plaster bandage, and the pad is placed so that its top edge is approximately 1/2 in. above the top of the proximal border of the head of the fibula. The lateral edge of the pad should be placed 1/2 in. medial to the medial border of the head of the fibula. The pad is covered with two additional wraps of plaster bandage, and firm tension is applied during the wrapping. The wrap is then spiraled down to include the rest of the stump, and the plaster is worked by hand to emphasize bony areas.</p> <p>If the resulting stump model has a depression in the popliteal area, some plaster is removed from the medial and lateral border of the depression so as to prese nt a flatter posterior surface. A slight screening is usually all that is necessary to finish the patellar-tendon bar. The medial template should be used when modifying the cast to arrive at a true contour of the medial flare of the tibial condyle.</p> <h3>Suspension Casting of the Above-Knee Stump</h3> <p>Suspension casting of above-knee stumps may be used in conjunction with a UCB casting stand and brims. The technique permits the firming of stump tissues that are not in contact with the brim. It is also a means of controlling bulges at the distal end of the brim and the adduction angle of the femur. The technique results in a smooth interior to the negative cast of the stump. <b>Fig. 19</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE ABOVE-KNEE STUMP</b>. The major equipment required is a UCB stand, a set of brims, and a roll of 4-in. tubular gauze.</p> <p>Initially, the stump is correctly fitted into the brim, in accordance with the instructions contained in <i>Adjustable-Brim Fitting of the Total-Contact Socket</i>. <a></a> The brim is set in the stand horizontally. When all the necessary conditions-such as, the correct anteroposterior and mediolateral dimensions and the circumference of the brim-are satisfied, a piece of tubular gauze approximately 1-yd. long is applied to the brim. The tubular gauze is held to the outside of the brim with adhesive tape and is then draped down through the brim. A stump sock is then applied to the amputee's stump. The distal end of the stump sock is pulled down through the tubular gauze, and the stump sock is removed entirely while pulling the stump into the brim.</p> <p>Pulling the stump into the brim in this manner results in a bulging of the stump around the distal edge of the brim. To alleviate this situation, the amputee is instructed to flex his trunk over the brim as far as possible, thereby easing the gluteal muscles proximally. As the amputee straightens up in the brim, the tissues should be gently eased proximally in the anterior area of the brim. When the amputee bears weight on the brim, some of the bulging will have been eliminated. <b>Fig. 20</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE ABOVE-KNEE STUMP.</b> The tubular gauze distal to the brim is grasped and pulled downward, causing the tubular gauze to stretch longitudinally and reduce circumferentially, thereby compressing the stump tissues. With one hand, the prosthetist maintains tension on the distal end of the gauze as he grasps the gauze at the distal end of the stump with his other hand. The amputee is instructed to remove some weight-bearing from the brim, and the gauze is tied with string at the distal end of the stump. Weight-bearing should be reapplied to equal approximately one-half of the amputee's weight. A piece of 1-in. elastic webbing is tied to the distal end of the gauze and passed under the arch of the amputee's foot, usually from the lateral to the medial side. Sufficient force is applied to the elastic to maintain the correct adduction attitude of the femur. <b>Fig. 21</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE ABOVE-KNEE STUMP.</b> A firm, even wrap of standard plaster bandage is applied, enclosing the stump completely. While the plaster is still wet, the prosthetist palpates the stump to locate the distal end of the femur. He then applies gentle pressure approximately 1 in. above the end of the femur until the plaster sets.</p> <p>Before the plaster is poured to form the positive model of the stump, the tubular gauze is removed from the brim area down to its contact with the plaster wrap.</p> <h3>Suspension Casting for the Syme's Amputation</h3> <p>The suspension casting technique provides a means of wrapping a Syme's stump with plaster bandages under weight-bearing conditions. It is an excellent means of holding an unstable heel flap or supporting redundant tissue in the correct position during the casting procedure. It firms tissues, resulting in a smooth interior to the wrap cast, and it provides a means for checking the size of the medial opening prior to laminating the socket. <b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE SYME'S STUMP.</b> The equipment used is the same as that used for casting below-knee stumps; namely, an adjustable vertical stand, a ring, a gasket, a hose clamp, a cast sock, and a scale.</p> <p>A light-weight cast sock is used because it has more stretch than a heavy cast sock and can conform intimately to the contours of the stump. The sock should contact the thigh approximately 3 in. above the patella, with one-half of the amputee's weight borne by the sock.</p> <p>With the amputee supported in a level position, blocks are placed under the stump to contact its distal surface. Areas requiring relief are located by palpation and outlined. An outline of the medial opening is planned and drawn on the suspension sock, as described in <i>VAPC Technique for Fabricating a Plastic Syme Prosthesis with Medial Opening</i>. <a></a></p> <p>The largest circumference at the bulbous end of the stump is measured, and a horizontal line is drawn just proximal to this. The stump is then measured proxi-mally until the same circumference is obtained, and another horizontal line is drawn at this level. A line is drawn along the crest of the tibia. Just 3/4 in. medially from the tibial line another line is drawn parallel so as to intersect the two horizontal lines. The width of the cut-out is usually equal to 1/4 of the circumference measured. This remaining vertical line is drawn following the posterior contour of the stump to complete the medial opening. Relief patches 1/8-in<i>. </i>thick are prepared and applied to the areas previously outlined on the suspension sock. <b>Fig. 23</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE SYME'S STUMP.</b> The blocks are slid from under the stump, and the amputee retains weight-bearing on the sock. Plaster bandages are contoured to the distal end of the stump, and the bulbous end is wrapped up to the distal horizontal line of the medial panel. The plaster bandage is applied vertically to cover the stump to the anteromedial and posteromedial vertical outlines of the panel, and horizontally to include the top edge of the patella down to the top line for the medial opening. After wetting his hands, the prosthetist works the plaster to ensure an intimate contact of the wrap, especially in the area just proximal to the bulbous end. If necessary, one wrap of plaster bandage can be applied in this area to prevent possible bridging.</p> <p>The wooden blocks are then slid back under the plaster wrap of the distal stump. Slight contact pressure is all that is required to provide a flattened surface to the distal end of the cast. If too much weight is borne on the blocks, the amputee should be raised slightly by vertical adjustment of the casting stand. <b>Fig. 24</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE SYME'S STUMP.</b> The plaster is worked along the stump and around the proximal aspect of the wrap. The prosthetist locates and defines the patellar tendon and flattens the wrap cast posteriorly just below the midpatellar-tendon level. After the plaster has set, the remaining area to be covered is evident. Vaseline is applied to the uncovered portion of the sock and 1 in. to 1 1/2 in. along the plaster cast bordering the area. A splint of plaster bandages is made, large enough to cover the opening but not so large as to extend beyond the lubricated areas of the wrap cast. The splint is applied to cover the medial opening and worked well by hand to obtain an intimate mating along all the edges. <b>Fig. 25</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE SYME'S STUMP.</b> After the panel covering the opening has set, alignment lines are drawn on the cast to be used later for bench alignment. The amputee is oriented so that his pelvis is level, with half of his weight borne on the amputated side. Using a plumb bob, the prosthetist draws a vertical line on the anterior aspect of the wrap cast to determine the adduction angle of the socket and another vertical line on the lateral aspect of the cast to determine the flexion angle of the socket. Before removing the panel, the prosthetist draws two horizontal lines on the panel extending onto the body of the cast for positioning purposes.</p> <p>The clamp on the casting stand is loosened to permit the amputee to be seated. The clamp and ring holding the cast sock are removed. The prosthetist slides a knife under the edges of the medial panel and exercises care to avoid distortion during removal. The exposed cast sock is cut, and the stump is withdrawn from the cast.</p> <p>The cast sock and relief patches are removed from the interior of the wrap cast, and the medial panel is replaced and held in position with additional strips of plaster bandage.</p> <p>The positive stump model is then poured into the wrap cast, with the wrap cast held so that the alignment lines are vertical. The holding pipe is inserted vertically and should be invested into the plaster to within 1/2 in. of the end of the cast.</p> <p><b>References:</b></p> <ol> <li>Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1963.</li> <li>Foort, J., and D. A. Hobson, A pylon prosthesis system for shank (BK) amputees, Prosthetics and Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, Winnipeg, November 1965.</li> <li>Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</li> <li>Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, April 1965.</li> <li>Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Foort, J., and D. A. Hobson, A pylon prosthesis system for shank (BK) amputees, Prosthetics and Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, Winnipeg, November 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Technical Director, Prosthetics-Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, 800 Sherbrook St., Winnipeg 2, Man.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Manager, J. E. Hanger, Inc., of Florida, 938 South Orange Ave., Orlando, Fla. 32806.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Assistant Project Director, Northwestern University Prosthetics Research Center, 401 East Ohio St., Chicago, Ill. 60611. The work of the Center is supported by U. S. Veterans Administration Research Contract V1005M-1079.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Suspension Casting for Below-Knee, Above-Knee, and Syme's Amputations Creator An entity primarily responsible for making the resource Fred Hampton, C.P. * https://staging.drfop.org/files/original/502cd24e05dc13685ce6c563d104b2cb.pdf c70c27a74e2e66b798440e7ec879a61c https://staging.drfop.org/files/original/3035cab4876d5e39dab2d7edc8f4280b.jpg 951d63ffb5182b95b09608292e446731 https://staging.drfop.org/files/original/317321434223dd65228f625d548145c2.jpg 33aef1d70d11bb5ffc3b46cab9f52066 https://staging.drfop.org/files/original/0d927e9043f66bd3e3af11041dbd3773.jpg a042157b9df13bf8aaf8981539c337b1 https://staging.drfop.org/files/original/0aec22109bbbab540a2b674c0f7b5c6d.jpg 69bbd64c5529d66b42bce4a5ccfd1632 https://staging.drfop.org/files/original/c4eabe665ad4dd8ea652e3ce8c3d13c2.jpg 4beac600d40f940220fb8267dc991693 https://staging.drfop.org/files/original/ecbbc4f77a47d1d78ba3db33d9c2c0bd.jpg e7c5d8fea44a345fc700a7ae696bd459 https://staging.drfop.org/files/original/a0c06126276a088136acdb56cfd72933.jpg 6eed0cb3b76b3a15c24cc44ef909fc88 https://staging.drfop.org/files/original/9b71e91d2b0275c07dda585373e86535.jpg 7777d3cc087d37eafb6b05901bd25113 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_02_019.pdf Text Any textual data included in the document <h2>Swedish Attempts in Using CAD/CAM Principles for Prosthetics and Orthotics</h2> <h5>Kurt E.T. Oberg, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>This paper was presented for the American Academy of Orthotists and Prosthetists Annual Meeting and Scientific Seminar, San Francisco, January 30-February 1, 1985.</i></p> <h3>Swedish Cat/Cam History</h3> <p>In the mid-70s, James Foort and some of his colleagues began to investigate the use of CAD/CAM principles in prosthetics and orthotics. Others had also started to work in biostereo-metrics. Some colleagues of mine in Sweden and I had initiated investigations in order to find modern technology which could be used in prosthetics and orthotics. Reports on this subject had already been published and showed promising possibilities for new techniques to be used.</p> <p>Interest in CAD/CAM, however, was very low in Sweden at this time. Prosthetists and orthotists were very skeptical of the value of this kind of technology as applied to the improvement of prosthetic and orthotic technique. Therefore, further attempts in developing CAD/CAM technology for prosthetics and orthotics in Sweden were dropped. This skepticism was understandable because at that time the new technique could not possibly give us as good quality results as was already possible with the traditional techniques.</p> <h3>The Ispo World Congress In London</h3> <p>During the 1983 ISPO World Congress in London, it became clear to Swedish prosthetists and orthotists who attended the congress that CAD/CAM techniques really had something to contribute to the field. The exhibition showed hardware such as measuring equipment and a milling machine which gave an example of the automated socket fabrication technique. As a result of the London Congress, the interest in CAD/CAM for prosthetics and orthotics became quite high in Sweden.</p> <h3>Swedish Attempts</h3> <p>There is now a definite interest in Sweden and Scandinavia to implement CAD/CAM techniques into the prosthetic and orthotic field. The large company, LIC, which provides over 60 percent of the prosthetic and orthotic service in Sweden, and which also has started service in other countries, has a clear intent to adapt CAD/CAM techniques to their work. The first area to be involved will be the orthopaedic shoe service.</p> <p>Another large prosthetic and orthotic service company, Een-Holmgren Orthopaedic Inc., is also following the work that is going on around the world in this field.</p> <p>There are some counties in Sweden that run prosthetic and orthotic services themselves and they, too, are very interested in following and adapting CAD/CAM techniques. They have decided to seek co-operation with the work that is done by the College of Health and Care in Munksjöskolan, Jönköping, Sweden. My intention is now to present the research and development activities in Jönköping.</p> <p><b><a href="/files/original/3035cab4876d5e39dab2d7edc8f4280b.jpg">Fig. 1</a>: College of Health and Care Jönköping, Sweden</b></p> <p><b><a href="/files/original/317321434223dd65228f625d548145c2.jpg">Fig. 2</a>: Relevant Laboratory Resources for CAD/CAM<br /><br /></b><b><a href="/files/original/0d927e9043f66bd3e3af11041dbd3773.jpg">Fig. 3</a>: Criteria on CAD/CAM in Prosthetics and Orthotics<br /></b></p> <h3>Competence And Educational Considerations</h3> <p>The college runs the prosthetic and orthotic education programs for Sweden, Denmark, and Iceland. There are regular programs for orthopaedic engineers (2 1/2 years), prosthetic and orthotic technicians (two years), and orthopaedic shoe technicians (two years). Various types and lengths of special courses are also offered at the school. The educational program is connected to research and development activities and divided into three laboratories. One laboratory is called the Unit for Applied Orthotics and is testing and evaluating orthotic appliances for the Swedish Handicapped Institute. Another laboratory is the Orthotics Laboratory, which has been involved in the development of prosthetic and orthotic devices for more than 14 years. The newest laboratory is the Biomechanics Laboratory, which I started two years ago.</p> <p>There will be considerable consequences for a prosthetic and orthotic educational program when a technique like CAD/CAM is introduced into the orthotic and prosthetic field. The question for us is whether we should be passive and follow the development of techniques in different laboratories around the world, or whether we should be active in developing these techniques ourselves. The decision has been made that with regard to the resources and the competence we have in laboratories connected to the school, we should be active in development.</p> <p>There already are some relevant resources available at the laboratories. At the Biomechanics Laboratory there is equipment such as computers, digitizers, image processing equipment, and lasers. There is also experience with digital measuring technique, computer programming and prosthetic and orthotic biomechanics. The Orthotic Laboratory has a machine shop and design office experienced in prosthetic and orthotic development and the development of various instruments.</p> <h3>Cad/Cam Philosophy Of The Biomechanics Laboratory</h3> <p>The philosophy of CAD/CAM in prosthetics and orthotics at the college and at the Biomechanics Laboratory can be expressed by the following criteria:</p> <strong><a href="/files/original/0aec22109bbbab540a2b674c0f7b5c6d.jpg">Fig. 4:</a> The Principal Parts of the CAPOD System</strong><br /><br /><strong><a href="/files/original/c4eabe665ad4dd8ea652e3ce8c3d13c2.jpg">Fig. 5:</a> Specification of the Measuring Equipment</strong><br /><br /><strong><a href="/files/original/ecbbc4f77a47d1d78ba3db33d9c2c0bd.jpg">Fig 6:</a> Computer</strong><br /> <ol> <li> <p><i>The complete system should be available for each prosthetic and orthotic service shop.</i></p> <p>The alternative is a centralized organization where central units are put in place for the fabrication of the prosthesis from data and measurements taken at the clinics and sent to the central workshop. With this kind of centralized organization, the whole advantage of the CAD/CAM technique cannot be fully utilized. Patients change for various reasons and it is important to use the CAD/CAM system when there are changes or when modifications are necessary. This can increase the effectiveness of the service quite a lot. It also enables the prosthetist and orthotist to have a better control of the whole process when making a device.</p> </li> <li> <p><i>The system should require moderate investment.</i></p> <p>This criterion is only a consequence of the first criterion.</p> </li> <li> <p><i>Equipment of a very high specification (able to work to extremely close tolerances) should be avoided.</i></p> <p>Very high specification is generally not needed, but if it does not increase costs, it usually does no harm. However, machines or computer programs which are too generalized (that works to too coarse tolerances) can increase the cost of the system tremendously and consequently should be avoided.</p> </li> <li> <p><i>Individual 3-D shape sensing should be the basis for control of the numerically controlled (NC) milling machine.</i></p> <p>This is necessary in order to allow for individual variations that might occur, instead of working from more standard shapes, which is a simple but less effective way to work.</p> </li> </ol> <h3>Objectives Of The Capod System</h3> <p>There are potential possibilities for the use of CAD/CAM techniques in the whole prosthetic and orthotic field and the development that has been initiated at the Biomechanics Laboratory in Jönköping therefore uses the name CAPOD as an acronym of Computer Aided Prosthetic and Orthotic Design. The objective of this project is to develop a CAD/CAM system which fulfills the criteria mentioned above. The objectives of the CAPOD system are as follows:</p> <ul> <li> <p>To develop a CAD/CAM-system for prosthetics and orthotics as one complete unit based on a micro computer.</p> </li> <li> <p>The cost of the system should remain within the range of US$30-40,000.</p> </li> <li> <p>To allow commercially available video image processing equipment to be adapted for 3-D shape sensing.</p> </li> <li> <p>To encourage the development of a specially designed NC milling machine, costing less than US$12,000.</p> </li> </ul> <p><b><a href="/files/original/a0c06126276a088136acdb56cfd72933.jpg">Fig. 7:</a> NC-Milling machine for CAPOD System<br /><br /></b><b><a href="/files/original/9b71e91d2b0275c07dda585373e86535.jpg">Fig. 8:</a> Principal Parts and Cost of the NC Milling Machine</b></p> <h3>Technical Specifications And Project Status</h3> <p>The principal parts of the CAPOD system will be a micro computer that controls both the measuring of the limb shape and also the NC milling machine by means of a measuring program, a CAD program, and a control program. Almost all these computer programs must be custom written. The fabrication cost of the whole system is estimated to be about $35,000.</p> <p>The principle of the shape sensing scheme is generally the same as that developed at the West Park Hospital in Toronto. The plan is to take a video recording of a laser illuminated contour of the limb at increments of one one-hundredth of a turn. The videogram will then be transferred to the computer via the MicroSight image processing system. The software in the computer then takes care of data reduction and will define the surface of a limb as a set of digital coordinates. The custom made CAD program will then modify the shape as specified by the practitioner in a manner that corresponds to the plaster cast rectification process that he does today. At present, a Victor micro computer from Victor Technologies, Inc. is being used. This computer is equipped with an Intel 8088 processor and has an internal memory of 256 Kb, which can be expanded to 896 Kb. It has 2 x 1, 2 Mb Floppy Disk, but a Hard Disk of 10,6 Mb is more likely to be used in the future. The monitor is 12" and has a graphic resolution of 800 x 400 pixels.</p> <p>It has been found that commercially available numerically controlled milling machines are not suitable in this application. They are too over-specified for our purpose and the objectives of the CAPOD system cannot be fulfilled with such machines. Early on it became quite clear that for our purposes, a specially designed milling machine had to be developed. After some investigations, a design proposal, as illustrated by the schematic drawing, has been developed. The cutting is controlled by the same type of coordinates as were used during the measuring procedure, i.e., the model will rotate in steps of one one hundredth of a turn. The X and Y coordinates of the cutter are then controlled by coordinates corresponding to the X and Y coordinates of the measured and modified contour. The travel of this stroke is such that models of torsos and whole legs can be made. An important feature of the machine is the high speed which has been achieved through the use of stationary motors. By using stationary motors and transmissions to power the cutter, the moving parts have quite low mass, which gives a low inertia and allows high speed. It would be possible to cut a model of about 30cm in length in two minutes. It is estimated that the fabricating cost of such a machine would be $10,000-11,000. Fifty percent of that cost is commercial parts—for instance, the control electronics for the stepper motors and the complicated transmissions. There are a few custom made parts, the whole chassis and assembling of the machine, which make up the other half of the cost.</p> <p>The specification of the system has been worked out in co-operation with the orthopaedic technical departments in Gothenburg and Boras. They are also deeply involved in the educational program. The development work has come into a practical and detailed phase, and the whole team is very enthusiastic and anxious to fulfill the objectives and make the CAPOD system a successful system.</p> <em><b>*Kurt E.T. Oberg, M.D. </b> Dr. Oberg is Director of the Biomechanics Laboratory Jönköping City Council, Munksjöskolan, Box 1030-S-551, Jönköping, Sweden.<br /><br /><br /></em> Page Number(s) 19 - 23 Year 1985 Volume 9 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-8.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Swedish Attempts in Using CAD/CAM Principles for Prosthetics and Orthotics Creator An entity primarily responsible for making the resource Kurt E.T. Oberg, M.D. * https://staging.drfop.org/files/original/caebe3f12ffbae3736dc0772ee55ae46.pdf 2c2ad2a01e8a4dc8c3905be963fdf48c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_001.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Syme's Amputation</h2> <h5>Walter Mercer <a style="text-decoration:none;">*</a><br /></h5> <p>This issue of Artificial Limbs is, and always will be, a classical contribution to everything pertaining to Syme's amputation, including, as it does, the most detailed and accurate description extant of the proper method of doing the amputation.</p> <p>It has to be remembered that Syme was the greatest of the pre-Listerian surgeons and, indeed, his operation was developed to combat the disastrous septic complications that so often beset the surgeon who dealt with compound fractures, especially where the bone was divided, in contrast to cases that were disarticulated. The fear of sepsis was no longer a real one after Lister's discovery, but that there were other and great advantages in this operation is proved by the fact that Syme's operation is still recognised by competent surgeons as a method of choice in the suitable case. But there have been criticisms of the operation. Harris has stated the reasons for this difference of opinion. He believes that these lie in the method of the operation and in the after-treatment. Various imperfections of the end-results and the methods of their avoidance are described. Most of these can be avoided by a careful technique, and if this were generally practised there would be fewer complications about this excellent operation.</p> <p>Harris reminds us of an important feature of anatomy not generally recognised. This is the specialised form of elastic adipose tissue developed between the calcaneum and the plantar aponeurosis which is resistant to pressure. There are here pockets of fat enclosed by dense septa of fibrous tissue. These fibrous tissue strands are in the form of the letter "U," with the open end of the "U" pointing towards the calcaneum. If this concept is true, it is obvious why the dissection of the heel flap should be close to the calcaneum, because if these little loculi are opened, as will happen if the dissection is through the subcutaneous layer, the fat content is extruded and an important weight-bearing mechanism rendered useless.</p> <p>All modifications, apart from Syme's own one, have detracted from the good qualities of the Syme stump and, indeed, have often ruined its weight-bearing qualities and brought the modified Syme's operation into disrepute. Kelham and Perkins, of the British Ministry of Pensions, are often quoted for their strong objection to this operation, and they concluded their article by expressing the hope that the modified operations would soon be as dead as the original Syme. But their remarks were not based on the original Syme, and so it is not remarkable that they hoped that their modified operation would become obsolete.</p> <p>Modifications like that of Elmslie only lead to failure by reducing the weight-bearing area and making the positioning and fixation of the heel flap more difficult. The plane of transection of the tibia should be so placed that the minimum of bone is removed and the largest possible cross-section of the tibia remains, and that, of course, should be parallel to the ground.</p> <p>It is good to know that the opinions of the British Ministry of Pensions at Roehampton are now very different. The Chief Medical Officer there believes that a Syme amputation is the operation of choice and he adds that "nobody would persuade me to have a below-knee amputation if I could have a Syme."</p> <p>Opinion on durability, too, seems to have changed. Many of the cases seen at Roehampton have had little or no trouble over 30 and 40 years. Shellswell quotes a case who had no trouble in 74 years of limbwearing and in his investigation of 305 Syme's amputations with an average follow-up of 29.6 years he found that 66 percent had satisfactory stumps.</p> <p>Harris points out that an imperfection that is commonly overlooked is the misplaced heel flap. So often after the operation the patient is sent out of the theatre to have the bandaging and the dressing completed. A little too much pull inwards or outwards produces-and permanently-a flap which is not exactly beneath the centre of the cut lower end of the tibia. Harris secured this correct position by strips of adhesive plaster. A plaster-of-Paris support has also been suggested, and a very secure method is to fix the stump by a nail or pin driven up through the lower end of the tibia.</p> <p>Gordon Dale, who has had an immense experience when in charge of all amputations for the Canadian Department of Veterans Affairs, discusses the use of the Syme amputation in peripheral vascular disease. This is an interesting review of the subject with a detailed description of typical cases. The first Syme amputation for thromboangiitis obliterans was done as far back as 1925, and since then it has been used in such cases whenever it seemed warranted. By 1940 this amputation had been used successfully for a wide variety of conditions, including perforating ulcers, in unrecovered sciatic lesions, cauda-equina lesions, frostbite, arterial occlusion, and gangrene from peripheral arterial disease. Dale showed by demonstration of actual cases the great value and durability of these amputations in active life, and in so doing was able to refute the views on durability expressed by the British Ministry of Pensions.</p> <p>The biomechanics of the Syme prosthesis are reviewed by Radcliffe and particularly the locomotion pattern and the manner of weight-bearing for a Syme amputee. In an analysis of the process of human locomotion, the walking cycle is divided into two phases-the stance phase and the swing phase-and these are reviewed. The energy curves are most interesting and give some insight into the complexity of knee-ankle interaction in normal human locomotion. Because of the inherent limitations in available space in the Syme prosthesis, attempts to introduce ankle action have been for the most part unsuccessful. Because in this limited space the Syme amputee cannot achieve the same degree of function as the above-knee or below-knee amputee wearing a SACH foot, the function will in general represent an improvement over the result to be had with the usual articulated joint. This is perhaps an understatement, for when the knee joint on the prosthetic side assumes a greater proportion of the shock-absorption function as evidenced by increased knee flexion under load just after heel contact there is much less deviation from the normal gait.</p> <p>The actual prosthesis is described in a further article. In a review of the history it is apparent that there has been a gradual improvement since the beginning of the century, though even in 1940 the device was bulky, uncomfortable, and generally subject to mechanical failure. With the introduction of plastic laminates into the practise of prosthetics, research workers have been able to alleviate to a great extent the shortcomings of the designs then currently in use, and now excellent and enduring results have been obtained in a large number of Syme amputations observed in Canada. There seems to be little doubt but that the results in Canada, superior apparently to those in Great Britain, have been due chiefly to adherence to the classical procedure of Syme. In this connection, it is said that "Syme was seldom if ever meticulous as to detail," which is hardly consistent with the views of a famous assistant of Syme's, Joseph Bell, in expressing the special character of Syme's method of operating, nor indeed with his reputation in Edinburgh.</p> <p>The present prosthesis is the result of research undertaken by the National Research Council of Canada, an activity initiated by Dr. Harris in 1944, though it was not till ten years later that the device had sufficient merit to warrant its general adoption. This is known as the "Canadian-Type Syme Prosthesis," or more simply, in Canada, as the "Plastic Syme." Among the essential features is a socket made of laminations of Fiberglas applied to a plastic mould of the stump and bonded with a rigid epoxy resin. It is lined with foam rubber, and the stump is inserted posteriorly. There is no ankle joint, and the foot is of the SACH type. This prosthesis is stronger, lighter, and much neater than anything produced before and is now in general use, and we have in the last two articles the considered opinion on it from Canada and America. It is stated in the first of these that its chief advantages lie in its improved appearance with reduced weight, its improved durability by virtue of a stronger structure, its freedom from mechanical troubles, and its reduced cost.</p> <p>This issue of Artificial Limbs leads one to the conclusion that the Syme's amputation is a very good one when properly carried out and properly cared for afterwards. The limb, too, that is in common use as described is a vast improvement on the older types and permits a gait that is not much short of normal.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Walter Mercer </b></td></tr><tr><td class="clsTextSmall">'Bidston,' 7 Easter Belmont Road, Edinburgh 12, Scotland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Syme's Amputation Creator An entity primarily responsible for making the resource Walter Mercer * https://staging.drfop.org/files/original/35801aa99143213c24197cf394e4d956.pdf 5639c70b68cbd0e4326be89301a23af7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_044.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 44 - 51 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_044.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Syme's Amputation for Gangrene from Peripheral Vascular Disease</h2> <h5>Gordon M. Dale, M.B. <a style="text-decoration:none;">*</a><br /></h5> <p>Peripheral vascular disease as a cause of amputation was first forcefully brought out in Canada by the many cases of acute thromboangiitis obliterans occurring in young men after World War I. In the early days of the 20's, amputation for this disorder was carried out at knee level (Gritti-Stokes), an operation itself considered a daring innovation at the time, the site of election in such cases then being viewed as the junction of the upper and middle thirds of the thigh. In the present series, the first Syme amputation for gangrene of the foot was performed in 1925 in a case of thromboangiitis obliterans. Since that time, the Syme amputation has been used in Canada in such cases whenever it seemed warranted.</p> <p>By 1940, Syme's amputation had been used successfully for many and varied conditions, including infected and perforating ulcers in unrecovered sciatic-nerve and cauda-equina lesions, septic and tuberculous arthritis of the ankle joint, frostbite, arterial occlusion, and gangrene owing to peripheral arterial disease. When, after the beginning of World War II, the question of amputations once again became prominent, we were able to refute the views expressed by the British Ministry of Pensions in regard to Syme's and other end-bearing amputations generally.<a style="text-decoration:none;">*</a> We showed, by demonstration of actual cases, the great value and durability of these amputations in active life. We were fortunate in having an excellent prosthetic service started during World War I and concentrated in February 1919 at the Dominion Orthopaedic Hospital (later Christie Street Hospital). It had constantly been improving our prostheses, and to that group we owe much of our success.</p> <p>During the period 1920-1956, many new factors modified our views and methods of treatment. In 1930, lumbar ganglionectomy was adopted in vascular disease, and it is thought that doing so saved or postponed many major amputations. Embolectomy and anticoagulants saved some limbs. Sulfa drugs, penicillin, and later antibiotics bolstered our courage. Although the incidence of infection was no lower after than before the use of such agents, there were operated upon during World War II cases that in World War I would not even have been considered for surgery. Now arterial grafting promises well in selected cases. Advances in anesthesia and in medicine generally have of course helped a great deal. Of the problems facing the Department of Veterans Affairs today, one is senile gangrene owing to the advancing age of veterans.</p> <h3>CASE HISTORIES</h3> <p>The case histories that follow represent most of the Syme amputations performed for gangrene owing to thromboangiitis obliterans, diabetic gangrene where there was also peripheral vascular disease, and senile gangrene from arteriosclerosis <i>per se. </i>Omitted are those cases whose files were destroyed after death, but all failures are recorded. Included are 23 Syme amputations and one mid-tarsal amputation, all for vascular disease and all with gangrene. Six have undergone reamputation.</p> <p>Cases 3, 6, and 7, listed under thromboangiitis obliterans, each underwent reamputation within six months and must therefore be classified as failures. Two cases (17 and 22) listed under arteriosclerotic gangrene are doubtful operative failures. The first underwent reamputation after his stump had healed and he had walked quite well. The reason for reamputation apparently was not breakdown of the stump. The stump of the second healed <i>per primam. </i>Fitted at an early date, the patient bore his weight chiefly on the stump for 18 months. Case 9, discussed under diabetic and arteriosclerotic gangrene, is considered a success. Not only did he wear his limb for nine years but his stump breakdown was occasioned by neglect and later circulatory failure from myocardial infarction. Cases 16 and 19 (arteriosclerotic gangrene) had well-healed stumps and were fitted but never wore their limbs to any useful extent. They are therefore recorded as failures.</p> <p>There are thus seven failures in 23 cases (roughly 30%). So marked is the prevalence of myocardial infarction in thromboangiitis obliterans at all ages that an electrocardiogram and cardiovascular examination are now part of our routine examination.</p> <h4>CASES OF THROMBOANGIITIS OBLITERANS</h4> <p>CASE 1. (W. E.)</p> <blockquote><p>Male, born 1891. Served in the Imperial Army, 1914-19. Wounded and had trench feet in service. On discharge, complained of painful feet and occasional cramp in right calf. Had two attacks of phlebitis. Was doing heavy work.</p> <p>Admitted to Christie Street Hospital 1924 with localized gangrene, dorsum of right foot, arising from infection between second and third toes. Severe pain. No pulse below the femoral on the right side, weak pulsation in dorsalis pedis and posterior tibial arteries on the left.</p> <p>Right Syme amputation 1925, healed <i>per primam. </i>Case followed until 1947, when patient returned to England. No trouble with stump. Increasing disability in left leg had forced change to light work. Arterial pulsation below the femoral had disappeared. Left radial pulse absent. Patient had not smoked since 1924.</p> <p>Patient failed to communicate further as promised.</p> </blockquote> <p>CASE 2. (R. G.)</p> <blockquote><p>Male, born 1900. Served in Army, 1915-19. V.D.S. on service. Subsequently worked as teamster in the bush. Had frequent mild attacks of frostbite. Patient's feet were cold in winter, scalded in summer. Had claudication of left leg 1934. In the winter of 1934-35, left foot was frozen, and gangrene of the left great toe developed. Amputation of toe was performed at local hospital. Wound did not heal for nine months.</p> <p>In February 1936, right foot was frozen, right fifth toe amputated. Wound failed to heal and gangrene extended. Patient was referred to a city hospital, where thromboangiitis obliterans was diagnosed and a right lumbar ganglionectomy was done in March 1937. In May and November, same year, toes were amputated. Gangrene extended slightly.</p> <p>In November 1937, patient was admitted to Christie Street Hospital with gangrene involving the distal third of the right foot. Marked equinus deformity. No palpable pulsation in arteries below the femoral on either side. Vein filling on the right, two minutes. Patient had suffered great pain and was practically a morphine addict.</p> <p>Right Syme amputation in December 1937. Slight necrosis at center of wound, but stump healed well. Patient fitted and walking in March 1938.</p> <p>Patient readmitted in April 1939 for disabling claudication of left leg. Findings as before, except that vein filling was 90 seconds. Left lumbar ganglionectomy done with excellent result. Patient seen February 1940, March 1943, April 1945, December 1946, and January 1947, all for minor infections, left foot, due to lack of cleanliness, a carbolic-acid burn, and an artefact. Left Syme amputation, performed July 1947, healed <i>per primam.</i></p> <p>Review in June 1948 showed excellent stumps. Patient walking well and working at woodcutting. Doing well 1953, when photograph of stumps (<b>Fig. 1.</b>) was taken. Death for coronary thrombosis in 1954.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Case 2 (R. G.). Anterior view of bilateral Syme stumps. Right (viewer's left), 16 years after amputation; left (viewer's right), six years. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 3. (T. A.)</p> <blockquote><p>Male, born 1886. Served in Army 1914-19. V.D.S. on service. Alcoholic. Onset vague pains in feet 1915. Nothing definite noted on discharge. Subsequent attacks of phlebitis, diagnosed as thromboangiitis obliterans 1928. Patient then had absence of pulsation both arteries right foot and in the left dorsalis pedis. Erythromelia was marked. Vein filling, 30 seconds. Admitted to Christie Street Hospital 1936. Right lumbar ganglionectomy in November 1936. Much improved. Admitted Christie Street in February 1937. Sudden onset gangrene right foot and leg. Right Gritti-Stokes amputation performed in March 1937. Healed well. Fitted with limb and walking, June 1937.</p> <p>Admitted Christie Street Hospital in February 1938. Gangrene of toes, left foot. No pulse below femoral. Left lumbar ganglionectomy, performed in March 1938, produced some improvement, but patient complained greatly of pain. Left Syme amputation, May 1939. Heel flap did not slough, but wound healed slowly. Well healed in November. Patient refused to bear weight on Syme stump and complained so bitterly of pain that a left Gritti-Stokes was carried out.</p> <p>Patient thereafter made no attempt at walking. Remained an invalid until death from coronary thrombosis.</p> </blockquote> <p>CASE 4. (R. E. C.)</p> <blockquote><p>Male, born 1909. In 1947, patient was admitted to a city hospital for a nonhealing infection, right great toe nail. Thromboangiitis obliterans diagnosed and bilateral lumbar ganglionectomy performed. Right great toe was later amputated, and wound healed slowly. In 1949 and 1950, two other toes, right foot, were amputated. Right below-knee amputation, done later in 1950, healed fairly rapidly with some sloughing of the flaps. Four months after amputation, patient was fitted with a prosthesis and walked well. Shortly thereafter stump broke down.</p> <p>Admitted to Sunnybrook Hospital, March 1951, with complete breakdown of end of below-knee stump. No pulsation below the femoral on either side. Left foot blanched sharply on elevation. Vein filling, 25 seconds.</p> <p>Right Gritti-Stokes amputation in May 1951. Healed <i>per primam. </i>Fitted with prosthesis August 1951, and walked well. Readmitted in 1952 with minor infection of left foot requiring only few days to heal.</p> <p>Working steadily as engineer, March 15, 1953. Sudden, severe pain in left foot, which rapidly changed color. Admitted to Sunnybrook Hospital. Purple discoloration, distal half of left foot, which did not change on application of pressure or on elevation. Discolored area insensitive. Vein filling, 25 seconds. Weak femoral pulse. Pain very severe in left leg and foot.</p> <p>Treated by rest, heat, dry dressing, Buerger's exercise, whiskey, and papaverine. Pain not controlled and gangrene extended. Left Syme amputation in April 1953. Healed well with slight necrosis in small area around scar. Patient fitted in June 1953. In September 1953, developed stump abscess, which was opened widely and packed open. Secondary suture, done one month later, healed well.</p> <p>Patient was walking well in June 1954. Returned to full-time work. Died suddenly in October 1954 from acute coronary thrombosis.</p> </blockquote> <p>CASE 5. (W. S.)</p> <blockquote><p>Male, born 1914. While in Army, developed phlebitis in right foot, and claudication ensued. Symptoms increased, and thromboangiitis obliterans was diagnosed. Right lumbar ganglionectomy done and patient discharged.</p> <p>Admitted to Christie Street Hospital in September 1947 with gangrene of left great toe and whole right foot extending to the leg. Condition grave. Had had steadily increasing doses of morphine but obtained little relief. No pulsation below the femoral, either side. Right guillotine amputation at level of tibial tuberosity, October 1947. Patient's condition improved rapidly and pain was largely relieved.</p> <p>Left lumbar ganglionectomy six days later with good result. Disarticulation of the left great toe in November, flaps left open. Right Gritti-Stokes and left Syme December 1. Gritti-Stokes healed <i>per primam, </i>Syme showed slight necrosis at suture line but was well healed in seven weeks.</p> <p>Patient was walking well in August 1948 (<b>Fig. 2.</b>). Has worked as limbfitter ever since. No trouble, either stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Case 5 (W. S.). Anterior and lateral views of left Syme stump 11 years after amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 6. (H. T. O.)</p> <blockquote><p>Male, born 1910. Sprained right ankle while in Army, pain and phlebitis in right leg subsequently. Thromboangiitis obliterans diagnosed and right lumbar ganglionectomy performed in 1943. Twice admitted to Sunnybrook Hospital in 1946, first with gangrene of fourth toe (amputated and healed), second with gangrene of great toe (amputated but did not heal). Right Syme amputation in January 1947. Heel flap did not slough, but wound did not heal. Right Gritti-Stokes, May 1947, healed promptly.</p> <p>In 1951, patient underwent left lumbar ganglionectomy and amputation of a gangrenous great toe, then passed into other hands. Subsequent history includes left mid-tarsal amputation, 1952; left Syme, 1953; left below-knee, 1954; left Gritti-Stokes, 1956.</p> </blockquote> <p>CASE 7. (W. P.)</p> <blockquote><p>Male, born 1899. Discharged from Army in 1919 with history of painful feet. In September 1939, developed phlebitis of right leg with rapidly increasing claudication. Three weeks after onset, patient could walk only a dozen yards.</p> <p>Admitted to Christie Street Hospital in November 1939 with ulceration and gangrene of fourth and fifth toes, right foot. Acute phlebitis at calf and at dorsum of foot. No pulsation in arteries below femoral, either side. On elevation of limb, color faded in two minutes. Vein filling, one minute.</p> <p>Old thrombosed veins on dorsum of left foot and in left calf. On elevation of limb, purplish color remained for three minutes. Vein filling, 30 seconds. Right lumbar ganglionectomy November 17, 1939. Right Gritti-Stokes December 19, 1939. Left lumbar ganglionectomy April 5, 1940.</p> <p>After the last operation, patient returned to work as repair man. No trouble until October 1949, when he had acute onset of pain in left foot and leg. Able to walk only a few steps. Left great toe was gangrenous, left foot livid, cold, and insensitive. Left Syme amputation performed April 1, 1950, at patient's request and against professional advice. Flap remained viable but never regained natural color; wound did not heal completely. Left Gritti-Stokes, performed June 1, 1950, healed <i>per primam.</i></p> <p>Walking on two Gritti-Stokes prostheses, patient was discharged in December 1950. Died August 1957, acute coronary thrombosis.</p> </blockquote> <p>CASE 8. (B. P. H.)</p> <blockquote><p>Male, born 1923. While in Army in 1944, sustained superficial wound of left leg. Healed, but scar frequently broke down. Patient was in Christie Street Hospital on another service in 1948 because of phlebitis and breaking down of wound scar. X-rays showed no retained foreign bodies. Femoral vein was ligated.</p> <p>In a 1949 diagnostic, examination was negative except for erythromelia. Diagnosis of thromboangiitis obliterans was indefinite but patient was advised to stop smoking.</p> <p>Admitted to Sunnybrook Hospital 1952. Two months previously had infection of the left great toe nail. Claudication appeared shortly thereafter. No pulse below femoral on left side. On elevation of limb, color faded slowly. Vein filling, 40 seconds. Marked erythromelia. All pulses palpable on right side. Vein filling, 15 seconds. Left lumbar ganglionectomy done with good result. Three weeks later guillotine amputation of the great toe was effected, and a month after that the stump of the great toe was disarticulated and flaps sutured. Wound healed in three weeks, and patient returned to work.</p> <p>Sudden onset of pain in right leg in December 1953 following infection and gangrene of right great, second, and third toes. Admitted to Medical Service and put on anticoagulants, Priscoline, and heavy doses of morphine. Medication discontinued upon transfer to Orthopaedic Services and papaverine and whiskey substituted. When blood coagulation was again normal, right lumbar ganglionectomy was performed. Eight days later, guillotine amputation of the distal half of foot was done. Right Syme amputation, three weeks after that. Good healing. Patient was walking well on prosthesis in May 1954. Has worked steadily since and has had no trouble.</p> </blockquote> <h4>CASES OF DIABETIC GANGRENE WITH ARTERIOSCLEROSIS</h4> <p>CASE 9. (R. G.)</p> <blockquote><p>Male, born 1901. When patient enlisted in 1940, it was noted that the left third toe had been amputated. Subsequently, it was found that he had had diabetes prior to enlistment. Lues evident. Admitted to Christie Street Hospital in October 1940 with osteomyelitis of the tarsus and gangrene of toes. Many sinuses. Dorsalis pedis pulse absent. Weak posterior tibial. Marked neurotrophic changes. Patient emotionally unstable.</p> <p>Left Syme amputation, 1941, healed well. Patient, fitted with prosthesis and able to walk well, neglected diabetic treatment and was readmitted in 1950 with ulceration in the amputation scar. Ulcer excised, stump healed. While still in hospital, patient had severe myocardial infarct and wound broke down. Gritti-Stokes was carried out.</p> <p>Patient never was active, although he walked fairly well. Died in August 1954 from acute coronary thrombosis. Autopsy showed marked aortic degeneration with mural thrombus. Peripheral vascular endarteritis.</p> </blockquote> <p>CASE 10. (A. E.)</p> <blockquote><p>Male, born 1893. Truck driver. Diabetes discovered in 1948 and patient put on diet. While in local hospital for fractured right tibia, was put on insulin. Admitted to local hospital in 1952 with ulcer on sole of right foot. With incomplete healing, patient returned to Iwork. Perforating ulcer developed, and patient was admitted to Sunnybrook Hospital in January 1955.</p> <p>Examination showed extensive soft-tissue infection about a perforating ulcer. No dorsalis pedis pulse. Weak posterior tibial. X-rays showed extensive osteomyelitis (neurotrophic foot). Marked calcification of vessels. Culture showed organisms resistant to all antibiotics except terramycin.</p> <p>Right Syme amputation January 31, 1955. Healed <i>per primam. </i>Fitted and walked well. Returned to work in November 1955. No trouble since.</p> </blockquote> <p>CASE 11. (W. W.)</p> <blockquote><p>Male, born 1900. Diabetes recognized in 1932. In 1949, following lapse in diet, developed gangrene and osteomyelitis of right foot. Much neurotrophic change. Pulses in feet weak. Right Syme 1949. Wound healed well. Patient worked as caretaker until December 1951, when he developed infection in a callus on the left foot. Ten days later was admitted moribund to Sunnybrook Hospital. Discharging sinuses on sole of left foot, lymphagitis, and femoral adenitis. No sensation in foot. Abscess in sole drained. Patient put on antibiotics, and carbohydrate metabolism improved.</p> <p>Guillotine amputation of left foot January 10, 1952, followed by marked improvement. Left Syme January 22, 1952. Some wound infection, but healed well in six weeks.</p> <p>Patient is still walking on two prostheses. Is not now working, but can walk to bathroom on stumps alone (<b>Fig. 3.</b>). Sectioned arteries in both stumps show marked endarteritis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 11 (W. W.). Front and side views of bilateral Syme stumps. Right stump (viewer's left), after nine years; left stump (viewer's right), after six yeais. Corresponding x-rays show bony proliferation from subperiosteal dissection of the flaps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 12. (W. C.)</p> <blockquote><p>Male, born 1886. Diabetes diagnosed in 1948. Admitted to Sunnybrook Hospital in 1951 on Medical Service. Diagnosis: "Arteriosclerotic heart disease; peripheral vascular disease; diabetes with peripheral neuritis; lues; gangrene of right foot." No arterial pulsations below the femorals. Gangrene in distal half of foot. Right Syme done and well healed. Fitted with artificial limb on which patient walked well.</p> <p>Admitted 1953 with congestive heart failure and ulcer of left foot. Healed with bed rest.</p> <p>In 1954, dyspnoea, swelling of limbs, nephritis, ulceration (hot-water-bottle burn) on dorsum of foot.</p> <p>Admitted February 10, 1956. Died. Autopsy showed marked peripheral vascular disease, arteriosclerotic heart disease, and myocardial infarction.</p> </blockquote> <p>CASE 13. (A. J.)</p> <blockquote><p>Male, born 1886. Admitted to Sunnybrook Hospital in September 1949. One month previously had developed ulcer in bunion on left foot. Two weeks later great toe "became black." Patient was found to have severe diabetes, had recently lost much weight. Femoral pulse present, no pulse below. X-ray showed osteomyelitis of first and second metatarsals.</p> <p>Treated by bed rest, antibiotics, and dry heat. Fever continued, and pain increased. Great toe disarticulated October 5, 1949, and wound left open. Temperature normal 10 days later, patient much better.</p> <p>Left Syme amputation April 18. 1950. Arteries sectioned showed marked endarteritis obliterans. Stump healed well. Patient fitted in June 1950, discharged in September walking well.</p> <p>Patient admitted February 1951 with uncontrolled diabetes and jaundice. Had discontinued his insulin three months previously. Died June 10, 1951</p> </blockquote> <p>CASE 14. (W. R.)</p> <blockquote><p>Male, born 1872. Medical graduate. Diabetes diagnosed 1941, symptoms of polyuria and foot drop. Patient was put on diet and insulin. Did not follow diet strictly and stopped insulin in 1944.</p> <p>In September 1954, patient pared corn on right great toe. Infection spread over foot. Treated self. Healed in nine months.</p> <p>Infection, right great toe, December 1955. Hospitalized. Healed January 1956.</p> <p>Admitted to Sunnybrook Hospital February 26, 1956, with gangrene of great and second toes, right. Systolic blood pressure, 210; diastolic, 90. No pulsations other than femorals in right and left lower extremities. Treated by rest and antibiotics.</p> <p>Right lumbar ganglionectomy April 13, 1956. Right Syme May 3, 1956. Healed <i>per primam. </i>Fitted in August 1956. Patient gets about well on limb and states he is still (December 1958) fairly active.</p> </blockquote> <p>CASE 15. (R. C.)</p> <blockquote><p>Male, born 1896. Discharged from Army 1919. Diabetes diagnosed 1927. Did well on diet alone for three years. Then noticed numbness and coldness of feet. Health was poor. In 1941, patient developed septic arthritis of left knee and, later same year, of right ankle. Drained at local hospital.</p> <p>Admitted to Christie Street Hospital in February 1942, very ill. Sedimentation rate, 147 mm. X-rays showed destruction of outer condyle of left tibia and erosion of lower end of right tibia and upper margin of right astragalus. Ankle joint drained and knee drainage improved. <i>Staph, aureus </i>cultured from both.</p> <p>Condition improved, and carbohydrate metabolism was balanced in July 1942. Right Syme then performed, but destruction of lower end of tibia required section somewhat higher than usual. Stump healed in three weeks.</p> <p>In September 1942, left knee was excised. Patient fitted with prosthesis and walking well by January 1944. Continued to wear leg until sudden death in 1947, cause unknown.</p> </blockquote> <h4>CASES OF ARTERIOSCLEROTIC GANGRENE</h4> <p>CASE 16. (J. E. N.)</p> <blockquote><p>Male, born 1896. Was in good health until 1945, when intermittent claudication in left calf was noted on walking half a block. In June 1950, patient was put on Priscoline. In July, developed gangrene of fourth and fifth toes. Admitted to local hospital in August 1950 for left lumbar ganglionectomy. Fifth toe amputated, but wound failed to heal. In January 1951, patient underwent transmetatarsal amputation.</p> <p>Admitted to Sunnybrook Hospital September 20, 1951, in poor condition and in great pain. Stump foul with protruding bones. No arterial pulsations below femoral. Patient given choice of gamble with a Syme or almost certainty with a Gritti-Stokes. Left Syme performed September 24, 1951. Stump healed slowly but well. Patient discharged November 5, 1951, returned for fitting. Died of coronary thrombosis before limb could be issued.</p> </blockquote> <p>CASE 17. (L. G.)</p> <blockquote><p>Male, born 1880. Admitted to Sunnybrook Hospital in May 1954. Two years earlier had noticed claudication of left leg. Left inguinal herniotomy performed at local hospital in January 1954. Six weeks later, patient developed infection and gangrene of left third toe. Upon amputation of toe, gangrene spread rapidly involving distal third of foot.</p> <p>Weak femoral pulses. No pulsation in arteries, either foot. Left lumbar ganglionectomy May 12, 1954. Left Syme amputation May 26, 1954. Stump healed slowly but with little necrosis. Patient developed moderate flexion deformity at knee despite all efforts but was walking quite well in March 1955. Patient refused Veterans' care but did not wish to be discharged. Finally discharged walking well, September 1955.</p> <p>Patient returned to home town, where for reasons unknown leg was amputated at mid-thigh level. Syme stump had not broken down. Referred back to Sunnybrook in March 1956, patient had a 45-deg. flexion deformity of the hip and could not be fitted.</p> </blockquote> <p>CASE 18. (F. E.)</p> <blockquote><p>Male, born 1885. Worked as stableman. In summer of 1949, patient noticed fissure in skin on medial side of first tarsometatarsal joint, right. Consulted physicians and chiropodists, but an ulcer formed and increased until, when patient was admitted to a city hospital, it measured 1 in. x 1 1/2 in.. Given bed rest and antiluetic treatment, patient did not improve. Right lumbar ganglionectomy was performed with poor result.</p> <p>Admitted to Sunnybrook Hospital February 3, 1950. No pulsation below the femorals. Ulcer was inflamed and had become larger. Very severe pain. After treatment of a flexion deformity of the knee, a right Syme amputation was done in March 1950. Healing was complete by May. Slight marginal skin necrosis along suture line.</p> <p>Discharged September 1950 walking well on a prosthesis, patient has had no further trouble.</p> </blockquote> <p>CASE 19. (R. E.)</p> <blockquote><p>Male, born 1887. In 1939, had claudication in right leg. Right lumbar ganglionectomy done at a city hospital in 1940. Considerable improvement. In 1950, a left lumbar ganglionectomy was done for similar symptoms on the left side. In January 1951, left great toe nail became infected and was removed. Toe became red and swollen. Redness spread over whole foot, and toe became black. Large doses of morphine gave no relief for the severe pain.</p> <p>Admitted to Sunnybrook Hospital in March 1951 with gangrene affecting toes and distal third of foot. No pulsation below femoral, either limb. Left Syme amputation April 3, 1951. Completely healed May 13. Patient returned for fitting November 1951, died 1952 of coronary thrombosis.</p> </blockquote> <p>CASE 20. (G. E. O.)</p> <blockquote><p>Male, born 1881. Admitted to General Surgical Service, Sunnybrook Hospital, November 1950, intoxicated. Shotgun wounds both feet-superficial on left side, marked bony destruction on right. X-ray showed bony defect in right os calcis, numerous lead pellets in region of right heel. Wound debrided and plaster cast applied. Despite antibiotics, wound became infected and foot gangrenous.</p> <p>When, in February 1951, patient came under care of Orthopaedic Services, distal portion of right foot was gangrenous, and marked edema and cellulitis extended to ankle. No pulsation below femoral artery. Patient very ill. Abscess drained February 19, 1951. Eusol dressings. Right Syme February 28, 1951. Standard operation, except that no section was made of lower end of tibia or of malleoli. Wound left open. Pathological report on sectioned vessels: endarteritis obliterans. Patient improved rapidly.</p> <p>Right Syme completed March 14, 1951. Malleoli removed, but tibia not sectioned. Healing good, although a small sinus persisted until May 1951. Fitted in June, patient walked well.</p> <p>Hospitalized June 4, 1953, for infection about residual shot pellet. Discharged. Readmitted November 30, 1955, for bronchopneumonia and empyema. Discharged. No further trouble with stump, though health is poor.</p> </blockquote> <p>CASE 21. (J. A. S. J.)</p> <blockquote><p>Male, born 1876. A blind vagrant who had slept in an open boxcar while intoxicated, patient was admitted to Sunnybrook Hospital December 27, 1951, in moderate state of shock. Toes of right foot mottled but fairly warm. Distal third of left foot purple and showing no color change on application of pressure or on elevation of the limb. Left toes livid. No sensation in distal third of left foot. Edema in left leg up to knee. No arterial pulsation below the femorals.</p> <p>X-ray showed marked arterial calcification. Patient treated expectantly by antibiotics, rest and dry heat. Well-marked line of demarcation, left foot, by February 16, 1952. No loss of tissue of note, right foot. Left mid-tarsal amputation proximal to line of demarcation, March 4, 1952. Wound healed well. Stump was good, but patient walked poorly. Died February 1954.</p> </blockquote> <p>CASE 22. (W. R.)</p> <blockquote><p>Male, born 1890. Complained in 1953 of coldness and pain in feet, left being most affected. Admitted to a city hospital, where left lumbar ganglionectomy was performed. In 1954, following myocardial infarction. developed gangrene in the second and third toes on the left.</p> <p>Patient admitted to Sunnybrook Hospital in April 1955 on the Medical Service. Weak pulsation in arteries, right foot. Posterior tibial absent; weak dorsalis pedis, left foot. Gangrene extended and caused great pain.</p> <p>Left Syme amputation, March 1, 1956, healed <i>per primam. </i>Fitted with a prosthesis, patient had no trouble with stump. Right foot broke down, and weight was borne mainly on the amputation stump. By October 1957, patient walked with crutches and took weight on the stump only.</p> <p>By January 1958, stump showed bluish discoloration and was cold. Deep fluctuation appeared and was aspirated. Two c.c. of serosanguinous fluid were obtained. Skin was intact. Disarticulation at the left knee was carried out January 29, 1958. Wound healed <i>per primam, </i>but patient has not walked since.</p> </blockquote> <h3>SUMMARY</h3> <p>Between October 1920 and May 1956, I personally conducted or else supervised all Syme amputations performed in the DVA Hospitals at Christie Street and Sunnybrook. Uniformly satisfactory, they resulted in durable and stable stumps. In the cases owing to vascular disease with gangrene, the amputations were equally satisfactory. Six cases (2, 6, 7, 9, 17, and 22) required reamputation. Only two were subjected to amputation for failure of healing. One (Case 9) is considered a success. Two cases (16 and 19), while healed and fitted, died before use of their prostheses and are considered failures. Stumps were in active use for periods of 22, 17, 7, 12, 4, 9, 10, 7, 5, and 5 years, others for shorter periods.</p> <p>From my experience, I would venture to suggest:</p> <ol> <li>Lumbar ganglionectomy at an early date in all cases of thromboangiitis obliterans and, should gangrene develop, Syme's amputation.</li><li>In diabetic gangrene where carbohydrate balance can be maintained and where minor amputations have failed, Syme's amputation.</li><li>In selected arteriosclerotic (senile) gangrene where ganglionectomy and arterial resection and graft have failed to arrest gangrene, Syme's amputation. These patients should understand the great risk of failure.</li><li>In all cases of gangrene with infection, and in diabetics with infection where carbohydrate-metabolism disturbance is not yielding to treatment, a preliminary guillotine amputation.</li><li>Success in the Syme, or other type of tarsal amputation, gives a degree of activity otherwise impossible. Such cases may expect trouble in the other limb.</li><li>Amputation between the knee and ankle (below-knee) is not advisable in cases of severe vascular disease.</li><li>Amputations through the knee (Gritti-Stokes) are almost always successful in healing and give good walking comfort where the patient's condition warrants. Such patients frequently have severe cardiac and cardiovascular lesions, and activity may result in sudden death.</li></ol> <p>-G. M. D.</p> <p><b>References:</b></p> <ol> <li><i>Artificial Limbs and Their Relation to Amputations, </i>British Ministry of Pensions, His Majesty's Stationery Office. London. 1939.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Artificial Limbs and Their Relation to Amputations,British Ministry of Pensions, His Majestys Stationery Office. London. 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gordon M. Dale, M.B. </b></td></tr><tr><td class="clsTextSmall">Present address: 84 Woodlawn Ave., E, Toronto, Ontario, Canada. Until his retirement in May 1956 as Chief of the Orthopaedic Service at Sunnybrook Hospital, Toronto, Dr. Dale had for more than 35 years (since October 1920) been in charge of all amputations for the Canadian Department of Veterans Affairs at Christie Street Hospital and at Sunnybrook. His patients have been drawn not only from World Wars I and II, the Korean War, the Boer War, and the Northwest Rebellion but also from many lesser campaigns in many parts of the world, from the Canadian Mounted Police, from the Canadian Department of Indian Affairs, and, until recently, from Canada's active Army. The cases here reported upon are of interest for at least two reasons-first because a goodly number were followed for periods ranging from five to 22 years (or until death from other causes), second because Dr. Dale either has performed the operation himself or else has served as the supervisor.-Ed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Syme's Amputation for Gangrene from Peripheral Vascular Disease Creator An entity primarily responsible for making the resource Gordon M. Dale, M.B. * https://staging.drfop.org/files/original/e1690cf1890c573375cb787032399988.pdf 87ee8a5abed800c76c98156dc2200899 https://staging.drfop.org/files/original/eabe930fc32847ec7e0d92434e7bc45f.jpeg b3f9edfdc10e1b362dba27c588c54d35 https://staging.drfop.org/files/original/4c55a6f8fb1adae4dd686d30f0e72e98.jpg 7ea898f965eb05a136608fe7f0fa85db https://staging.drfop.org/files/original/972fd80c1ddfa050d6812e2062ddeca8.jpg 3019cc6d45434da220cde813c997c009 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_010.pdf Text Any textual data included in the document <h2>Technical Note: A Cervical Orthosis Modification</h2> <h5>Paul Trautman, CPO&nbsp;<a style="text-decoration: none;">*</a><br />George Varghese, MD&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Recommending or prescribing the best possible cervical orthosis for a patient whose cervical vertebrae require support is a difficult task for an orthotist or physician.</p> <p>In recent years the plastazote® (Philadelphia) cervical orthosis has become a highly prescribed device for several reasons (<a href="/files/original/eabe930fc32847ec7e0d92434e7bc45f.jpeg"><b>Fig. 1</b></a>). Most importantly, the orthosis limits flexion and extension of the cervical spine as well as rotation between C-3 and C-7 and patients find it reasonably comfortable and accept wearing it. This is due, to some extent, to the fact that the low temperature, and easily moldable plastazote® conforms in time to the patient's contours. The better distribution of pressure and comfort for the patient may provide more relaxation of the para-cervical spinal <br /><br />Secondly, the Philadelphia cervical orthosis is relatively inexpensive compared to more rigid appliances. Thus, it is less costly to replace when it becomes contaminated or spoiled beyond cleansing.</p> <p>A third important feature is the ease of selecting and donning the device. Only two measurements, the length of the neck and the circumference of the neck are required. The orthotist is able to provide the item to the patient readily, and it is not necessary to maintain a large, costly inventory.</p> <p>In the Neurosurgery Intensive Care Unit of the University of Kansas' Bell Memorial Hospital, this cervical orthosis has become the orthosis of choice for treating head trauma patients. The posterior half of the collar can be slipped behind the patient's supported head and neck with a minimal amount of need to move the patient. The anterior half is easily put into place to complete the fitting.</p> <p>Since a number of ICU patients have required a tracheotomy it became necessary to modify the Philadelphia cervical orthosis. The design modification created by staff orthotist Wallace Whitney, CO is seen in <a href="/files/original/4c55a6f8fb1adae4dd686d30f0e72e98.jpg"><b>Fig. 2</b></a> and <b><a href="/files/original/972fd80c1ddfa050d6812e2062ddeca8.jpg">Fig. 3</a>.</b></p> <p>Since we do this modification fairly regularily we have made a plaster cast to preform the low temperature plastic (K-splint® or Orthoplast®) reinforcement piece. The original anterior strap is cut in the center, folded over and riveted to the plastic reinforcement piece and the collar. A hole (1 1/4 inch) for the tracheotomy tube is cut through the collar. A side effect is that the collar is made slightly more rigid which is often desirable for those patients.<br /><br /><em><b>*George Varghese, MD </b>Associate Professor, Department of Rehabilitation Medicine University of Kansas College of Health Sciences and Hospital Kansas City, Kansas</em></p> <p><em><b>*Paul Trautman, CPO </b>Director of Orthotics/Prosthetics University of Kansas College of Health Sciences and Hospital Kansas City, Kansas</em></p> <p><em>&nbsp;</em></p> <div style="width: 400px;"></div> Page Number(s) 10 - 11 Year 1983 Volume 7 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: A Cervical Orthosis Modification Creator An entity primarily responsible for making the resource Paul Trautman, CPO * George Varghese, MD * https://staging.drfop.org/files/original/666cfa2a8d900d4b2efb1a009252fa73.pdf f59717a74400ff0ab5095ddffea74b4f https://staging.drfop.org/files/original/17e8a00f37ae987d6c843c8412d4b0e2.jpg b63ddbe760c50ee253d76f42eca4d956 https://staging.drfop.org/files/original/46d862f73b2e9fc9ec844c2b951ca24e.jpg 748745d3b330d67f707679ee011a6836 https://staging.drfop.org/files/original/4242f12d317f1a7ab6d8045a8876497b.jpg 5402ccb72158719c003f664b4fd179c5 https://staging.drfop.org/files/original/8ee7cd25050f94773cb45ef98356241f.jpg 126d19241c60416ec37fa343f5b67a70 https://staging.drfop.org/files/original/bd0b9a100a09d924db2ddcfafb0bce26.jpg d56eb7f7a83a1e97e40b5c0d1717d804 https://staging.drfop.org/files/original/380a58ec4d8724fa7bfcaedf4a69050a.jpg 2c05e9d4f88546fe77cdbf7e84fd5833 https://staging.drfop.org/files/original/65a023e3490a43a115438d29c1640630.jpg 3b5b83d904e8f0092b48ac81539603f6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_123.pdf Text Any textual data included in the document <h2>Technical Note: Cosmesis and the Knee Disarticulation Prosthesis</h2> <h5>Robert Gilley, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>One central problem confronts the prosthetist when fabricating a knee disarticulation prosthesis with side joints, regardless of the socket style (laminated, molded, leather, or flexible frame) used. As the knee flexes, the space anterioraly between the thigh section and the inner edge of the shin increases in width (<b>Fig. 1</b>). The result is cosmetically unacceptable. The gap develops because the radial distance from the knee joint center to the periphery of the socket gradually decreases from anterior to posterior (<b>Fig. 2</b>). Resolution of the problem may be achieved by building up the distal end of the socket so as to maintain a constant spherical shape through the full range of motion (<b>Fig. 3</b>). Observation over the years has led me to conclude that many younger prosthetists are not as familiar with the process as perhaps they should be. Therefore, these few notes are offered in hopes of redressing the situation.</p> <strong><a href="/files/original/17e8a00f37ae987d6c843c8412d4b0e2.jpg" target="_blank" rel="noopener">Figure 1.</a> As the knee flexes, the gap anterioraly increases.</strong><br /><br /><strong><a href="/files/original/46d862f73b2e9fc9ec844c2b951ca24e.jpg" target="_blank" rel="noopener">Figure 2.</a> This problem results from the fact that the radial distance from the knee joint center to the periphery of the thigh decreases from anterior to posterior.</strong><br /><br /><strong><a href="/files/original/4242f12d317f1a7ab6d8045a8876497b.jpg" target="_blank" rel="noopener">Figure 3</a>. The distal end of the thigh has been built up so that the space between the thigh and shin is constant throughout the range of motion.</strong><br /> <p>Fabrication of the prosthesis begins by mounting the proximal portion of both joints to the thigh, and similarly, mounting the distal portions in a suitably sized block of wood. Obviously, every effort should be made to maintain the narrowest possible medial-lateral diameter at the knee joint center and to keep the joints square. Wood is removed from between the distal joint sections to permit proper mating of the shin block to the thigh and full range of motion. The interior inner edge of the shin block should fit closely to the thigh in the fully extended position while allowing sufficient space distal to the edge for the material to be added to the thigh during finishing.</p> <p>The distal end of the thigh is then built-up with rigid urethane foam. The convex shape of the anterior socket from medial to lateral, and at the level of the proximal anterior edge of the shin block, is repeated radially about the knee joint axis from anterior to posterior. This can be accomplished, rather laboriously, by first removing enough extra material from the thigh to permit it to be assembled with the shin block in the fully extended position. Then, as the knee is gradually flexed through the full range of motion, the anterior edge of the shin is used as a guide to judge how much material to remove at each successive position of flexion. Sufficient material is removed to permit full range of flexion. Care must be taken to maintain a smooth, even surface from medial to lateral and to not remove too much material. Nonetheless, it will doubtlessly be necessary to add material.</p> <p>The posterior surface of the distal thigh is finished off flat from medial to lateral, so as to fill most of the posterior knee opening. It should not rise above the anterior rim of the shin in the fully flexed position, and at the same time, should not protrude too far posteriorly when in the fully extended position.</p> <p>The process can be greatly expedited if the following simple apparatus is used. Two aluminum plates are modified so that a piece of stiff paper or cardboard can be clamped between them (<b>Fig. 4</b> and <b>Fig. 5</b>). The plates are cut away on one edge so as to span the largest socket. At the leading edge of the cut away side, two threaded rods with tapered points are mounted on a common axis (<b>Fig. 6</b>). These two rods permit the device to be mounted on the proximal knee joints and swung around the distal end of the thigh section (<b>Fig. 7</b>). The stiff paper clamped between the two plates of the device is cut to match the shape of the anterior surface of the thigh at the requisite level. The resulting template is then used to duplicate the shape through the full range of motion. (Some prosthetists will of course identify the device as a simple adaptation of the templates that were formerly used when shaping the ball of the knee of a handmade knee-shin set-up for an above-knee prosthesis.) The device described has been in use by us now for over a year. It greatly speeds up the process of finishing a knee disarticulation prosthesis.</p> <strong><a href="/files/original/8ee7cd25050f94773cb45ef98356241f.jpg" target="_blank" rel="noopener">Figure 4</a>. Knee spanning template holder. Six inch rule included in photograph to give a sense of scale.</strong><br /><br /><strong><a href="/files/original/bd0b9a100a09d924db2ddcfafb0bce26.jpg" target="_blank" rel="noopener">Figure 5</a>. Template holder with stiff cardboard template clamped between the two plates of the holder.</strong><br /> <p><strong><a href="/files/original/380a58ec4d8724fa7bfcaedf4a69050a.jpg" target="_blank" rel="noopener">Figure 6.</a> Exploded parts view of template holder and template.</strong></p> <p><strong><a href="/files/original/65a023e3490a43a115438d29c1640630.jpg" target="_blank" rel="noopener">Figure 7</a>. Template holder in place mounted on the knee bolt of a conventional above-knee prosthesis (for illustrative purposes only, a knee disarticulation prosthesis was not available at the time this article was prepared).</strong></p> <p>In conclusion, it is hoped that these comments on the matter will aid a prosthetist confronted for the first time with the task of finishing a knee disarticulation prosthesis-a task that is rather infrequently confronted in the United States and not always addressed by the schools.</p> <p><em><b>*Robert Gilley, CP. </b> Robert Gilley, CP., is with Durr-Fillauer Medical, Inc., 2710 Amnicola Highway, Chattanooga, Tennessee 37406.<br /><br /><br /></em></p> Page Number(s) 123 - 127 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Cosmesis and the Knee Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Robert Gilley, CP. * https://staging.drfop.org/files/original/d30d90150edc24e748bab158375cb723.pdf aa70fbf64b2b0a120d496af8fc3055be https://staging.drfop.org/files/original/225dc1b21aefe0852c68ef5b2e996348.jpg 8ab20befafe25dde5db91d3b298002e9 https://staging.drfop.org/files/original/0b2de6b395b114394842205a02afef18.jpg a63b96cb4a0c54917747fb79a032b485 https://staging.drfop.org/files/original/64306830b9afd89a7374bd95f3a753b8.jpg 9158f03044f9ae6c9d51e47bd761513d https://staging.drfop.org/files/original/3a0c484f58ba18c2b9bf3063e1455320.jpg affb00b0c04bff688f65f72440927ee4 https://staging.drfop.org/files/original/0b4a9ac4b93a10eaf842a3baf263266b.jpg d882b9048a91bfd682ad26c6e302954f Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_041.pdf Text Any textual data included in the document <h2>Technical Note: Fabrication of the Syme Prosthesis</h2> <h5>Robert Gilley, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>I first became familiar with this method of fabricating a Syme prosthesis in 1981, when I was transferred to Snell's of Memphis from Nashville. The technique had been in widespread use there and in the Memphis area for sometime, with every evidence of satisfactory service. I am describing the procedure here for it has proven to be not only durable, but a most practical and simple method of fabrication.</p> <p>A Syme socket is set in a foot block (Kingsley catalog, #K1910) slightly behind the anterior-posterior centerpoint (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-1.jpg"><b>Fig. 1</b></a>). Care should be taken to set it in the proper angle of flexion and adduction.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-1.jpg"><strong>Figure 1. Socket set in block.</strong></a><br /> <p>An ordinary Kingsley Syme SACH foot (Catalog #K07) is taken and sectioned horizontally below the level of the proximal surface of the keel (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-2.jpg"><b>Fig. 2</b></a>). This leaves the distal portion with a flat proximal surface.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-2.jpg"><strong>Figure 2. Cross sectional diagram of Syme SACH foot, showing cut line.</strong></a><br /> <p>The foot and socket are then positioned together in the proper bench alignment. The height is checked and corrected by removing material from the socket block. Bench alignment is reestablished and the position of the bolt hole is marked on the distal surface of the socket block. The bolt hole is drilled and a recess for the adapter nut is counterbored in the distal end of the socket. This is done with an improvised counterbore made from a 3/8"-16 bolt and adapter nut. The adapter nut is set in place, and thickened resin is used to secure it there and smooth the surface. The foot and socket are assembled and excess material is removed from the socket block (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-3.jpg"><b>Fig. 3</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-4.jpg"><b>Fig. 4</b></a>), leaving some to allow for any adjustments in toe-out. The foot bolt should be cut to length.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-3.jpg"><strong>Figure 3. Foot and socket unassembled.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-4.jpg"><strong>Figure 4. Foot and socket assembled.</strong></a><br /> <p>Following completion of dynamic alignment, the prosthesis is laminated and finished in a manner identical with that employed to finish the shin of any below-knee or above-knee prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-5.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-5.jpg"><strong>Figure 5. The finished prosthesis.</strong></a><br /> <p>To recapitulate, the technique offers the prosthetist an efficient and expeditious method of fabricating a Syme prosthesis with good cosmetic results. It has the added advantage that foot replacement, should it become necessary, is facilitated.</p> <em><b>*Robert Gilley, CP. </b> Robert Gilley, C.P.O., is Supervisor of Prosthetics Central Fabrication Services for Durr-Fillauer Medical, Inc., Orthopedic Division, 2710 Amnicola Highway, Chattanooga, Tennessee 37406.<br /><br /><br /></em> Page Number(s) 41 - 43 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Fabrication of the Syme Prosthesis Creator An entity primarily responsible for making the resource Robert Gilley, CP. * https://staging.drfop.org/files/original/1bc3249b9871bf77d6deaebeec0f9573.pdf 062b6087654766cc1458acca6e7a8016 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/cpo/pdf/1984_04_028.pdf Text Any textual data included in the document <h2>Technical Note: Rigid A.F.O. - Another Choice</h2> <h5>Robert E. Doran, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>When an orthotic prescription calls for an ankle/foot orthosis to provide rigid ankle/foot stabilization, the two basic choices have been (1) a double bar metal orthosis or (2) a thick and/or reinforced thermoplastic orthosis. We are all familiar with the advantages and disadvantages each has to offer.</p> <p>It was this author's goal to design a rigid A.F.O. that would combine the advantages of both. The features of such an orthosis should include light-weight construction; provide rigid ankle stabilization; provide adjustable plantar and dorsiflexion in order to dynamically align the orthosis; fit inside the shoe; be cosmetically acceptable; be easily donned; and maintain alignment while changing heel heights.</p> <p>With the above in mind, the following orthosis was designed. The orthosis consists of "pre-preg" (the resin is impregnated in the matrix in an uncatalyzed form prior to lay-up, generally at the factory. Once the desired lay-up is achieved, the structure is exposed to a catalyzing agent so that it hardens), carbon-fiber and fiberglass fabric. Epoxy and polyester resin have been used as bonding agents and the orthosis is formed over a plaster model of the patient's leg. Such pressure applying agents as vacuum bags and pressure wraps have been used. The carbon fiber and fiberglass fabric are properly oriented to resist the stresses imposed upon the orthosis and comprise a structure that provides a high strength to weight ratio.</p> <p>The orthosis has a foot section which begins on the plantar aspect of the foot and extends proximally on the medial and lateral sides of the leg. The "uprights" are connected by adjustable velcro-closing calf straps. Plantar and dorsiflexion adjustments are independently achieved by adjusting the anterior and posterior velcro-closing calf straps.</p> <p>In some cases, donning is simplified by removing the posterior strap, thus allowing for a posterior entry of the foot and leg into the orthosis and shoe.</p> <p>Over the past eighteen months, nine patients with diagnoses that include low level paraplegic, C.V.A., and neuromuscular disease have been fitted with the graphite composite A.F.O. as a successful alternative to "traditional" orthoses.</p> <p>Orthotists now have another choice when designing a rigid ankle foot orthosis for their patients. The graphite composite A.F.O. combines some of the advantages of the standard metal and thermoplastic constructed A.F.O.</p> <b>Robert E. Doran, C.P.O. </b> Thousand Oaks Prosthetic Orthotics, 253 Lombard Street, Suite C, Thousand Oaks, California 91360.<br /><br /><br /> <div style="width: 400px;"></div> Page Number(s) 28 - 28 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Rigid A.F.O. - Another Choice Creator An entity primarily responsible for making the resource Robert E. Doran, C.P.O. * https://staging.drfop.org/files/original/275fab2ea3b3d6677f16b2fc3c4f84d4.pdf c2bbef75d554db7e69924d9f9f9c3be5 https://staging.drfop.org/files/original/945444737a803091f2f7bb1f33166de1.jpg a44bea2f00eb9d7426d0babc659224e9 https://staging.drfop.org/files/original/805377d1e0c88a555e639acf4505f9d9.jpg a43839ca800ea32a700efaf4bfa8c04c https://staging.drfop.org/files/original/765458c0a65fb32f59bc3f28a9e0a770.jpg aa8eff94b32c7b7db5b52dffb56eec36 https://staging.drfop.org/files/original/d780ea0687580fe5cebc29a049984303.jpg 5a3a3e48efd9f9539ee371ddb261a7a2 https://staging.drfop.org/files/original/d7de2d0bc53c05faa2e263ccba47e3c2.jpg 0245c6a4e08793989816f7455b5379d8 https://staging.drfop.org/files/original/c83d9d8de2014f43049249a501eaf7ac.jpg 8e116daad4f180da07481663e4931c0f Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_119.pdf Text Any textual data included in the document <h2>Technical Note: RMB Reinforcement</h2> <h5>Robert O. Gooch, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Because of the humid climate, the Department of Prosthetics and Orthotics at Duke University Medical Center receives many prescriptions for hard socket below-knee prostheses. The great majority are supracondylar wedge suspension, utilizing the Removable Medial Brim (RMB) concept. For the past several years, we have designed and fitted approximately 150 such prostheses annually.</p> <p>Based on this experience, we have developed a method to reinforce the RMB structure and prevent gradual loss of alignment under the constant pressure of the femoral condyles. We now use this technique routinely, and find it greatly enhances the stability of the removable brim.</p> <h3>Method</h3> <p>Fabricate the socket in the conventional manner, following the instructions supplied by the hardware manufacturer.<a></a> Rather than packing the mechanism with clay, we prefer to substitute Johnson's Stik-Wax,<a></a> which is easier to work with and lubricates the assembly, allowing easier removal. Once the lamination is fully cured, break out the positive model.</p> <p>At this point, the medial brim is cut away from the socket. Although a variety of tools can be used for this operation, we prefer a simple modification of an ordinary hacksaw blade.</p> <p>Grind the fine-tooth hacksaw blade into the contour shown in (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-1.jpg"><b>Fig. 1</b></a>). This is preferable to a commercial sabre saw blade, because its wide, thin shape creates a smoother, less irregular cut.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-1.jpg">Figure 1.</a> Fine-toothed hacksaw blade, modified to fit sabre saw.</strong><br /> <p>Using the sabre saw, cut the anterior and posterior portion of the brim free, being careful not to nick the metal upright. Cut the area adjacent to and over the metal upright with a cast saw or sharp knife. Carefully pry the medial brim free with a thin-bladed screwdriver.</p> <p>Grind the distal end of the upright an amount equal to the saw kerf, to insure the wedge will seat fully (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-2.jpg"><b>Fig. 2</b></a>). Place the brim back onto the socket to be certain it fits properly, with minimal gapping along the cut edge.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-2.jpg">Figure 2.</a> Grind distal upright to insure the wedge fits without gapping.<br /></strong><br /> <h3>Reinforcement</h3> <p>Remove the brim and apply PVC tape<a></a> to the lateral surface and distal trimline. This serves as a parting agent, and prevents the resin used in subsequent steps from bonding the wedge back onto the socket.</p> <p>Roughen the socket immediately beneath the cut-line, to insure good adhesion for the reinforcement lip (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-3.jpg"><b>Fig. 3</b></a>). Lubricate the cut edge with petroleum jelly and reapply the wedge carefully to avoid gapping.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-3.jpg">Figure 3.</a> Tape wedge and roughen socket prior to lamination of lip.</strong><br /> <p>Cut three 1 1/2" wide strips of Xynole-polyester<a></a> fabric long enough to cover the saw cut. This material saturates readily when used with polyester resin and forms a thin, strong, and rigid reinforcement.</p> <p>Promote a small amount of pigmented polyester 4110 (rigid) resin. Paint the roughened area of the socket with resin, and apply one layer of Xynole reinforcement extending at least 1/2" onto the wedge (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-4.jpg"><b>Fig. 4</b></a>). Brush additional resin onto the Xynole until it is fully saturated, and apply the second layer. Fully saturate this layer and apply the final layer. Saturate this in a similar manner.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-4.jpg">Figure 4.</a> Saturate Xynole layers individually with the polyester resin.</strong><br /> <p>When the resin has gelled, but not fully set, remove the wedge. This insures that the wedge will insert smoothly, without binding, in the finished prosthesis.</p> <p>Once fully cured, trim the reinforcement to form a 3/16" lip (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-5.jpg"><b>Fig. 5</b></a>). Using a felt arbor, bevel the inside edge of the lip and the outside edge of the wedge (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-6.jpg"><b>Fig. 6</b></a>). This unobtrusive lip will significantly reinforce the wedge, particularly against malrotation.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-5.jpg">Figure 5.</a> Trim lip to 3/16" above socket edge.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-6.jpg">Figure 6.</a> Posterior view of lip with wedge in place. Note bevel on inner edge of lip and outer edge of wedge.<br /></strong><br /> <h3>Finishing</h3> <p>Once dynamic alignment and transferring are completed, the prosthesis is ready for the finish lamination. We typically set the wedge aside and relaminate the prosthesis without the proximal brim in place.</p> <p>An old RMB upright can be inserted into the channel and clamped in a vise. This prevents resin from filling the channel and provides a mandrel to secure the prosthesis during the lamination procedure. Lubricate the upright with Stik-Wax<a></a> to fully seal the channel.</p> <h3>Summary</h3> <p>Fabrication of a Xynole reinforcing lip significantly improves the stability of the supracondylar wedge when using the Removable Medial Brim procedure. Based on the Duke experience with hundreds of RMB prostheses, we recommend this be done routinely.</p> <p><b>References:</b></p> <ol> <li>Durr-Fillauer Medical, Inc.&nbsp;<br />P.O. Box 5189&nbsp;<br />Chattanooga, TN 37406&nbsp;<br />RMB Hardware Kit&nbsp;<br />Catalog #127019 (Heavy Duty)&nbsp;<br />Catalog #127001 (Standard Duty)</li> <li>S.C. Johnson &amp; Sons, Inc.&nbsp;<br />Racine, WI 53403&nbsp;<br />#140 Stik-Wax-15 oz. container</li> <li>Otto Bock Industries&nbsp;<br />4130 Highway 55&nbsp;<br />Minneapolis, MN 55422&nbsp;<br />Coroplast PVC tape&nbsp;<br />Catalog #616F8</li> <li>Durr-Fillauer Medical, Inc.&nbsp;<br />P.O. Box 5189&nbsp;<br />Chattanooga, TN 37406&nbsp;<br />Xynole-Polyester cloth&nbsp;<br />Catalog #211094</li> </ol> <em><b>*Robert O. Gooch, CP. </b> Robert O. Gooch, CP., is with the Department of Prosthetics and Orthotics at the Duke University Medical Center.</em> <div style="width: 400px;"><br /><br /></div> Page Number(s) 119 - 121 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: RMB Reinforcement Creator An entity primarily responsible for making the resource Robert O. Gooch, CP. * https://staging.drfop.org/files/original/7726a0b6d065fcfc2a69ee0f0fbdd82a.pdf aaecbd42a917de5b36eeb049f73ef608 https://staging.drfop.org/files/original/907b3b60ab891d2c062f4ceb5bb2af8d.jpg 31530cab1a56fffba73f07af39b2d077 https://staging.drfop.org/files/original/3a4e9c51a778e57578a9fabe571b7158.jpg c30f2899c6c3b59f9ad0d33d8b10c9bf Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_090.pdf Text Any textual data included in the document <h2>Technical Note: The Soft Socket</h2> <h5>Arthur Forman, B.S., M.A.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> <p>Oftentimes we are presented with an above-knee amputee who poses difficult problems for a successful prosthetic fitting. Some of these problems include advanced age, atrophy, trigger points, bony prominences, surgical implants, cardiopulmonary problems, short residual limbs, and other complications. Any one of these conditions might make for a difficult fitting, but any combination of these could contribute to an unsuccessful fitting, or a situation which precludes ambulation.</p> <p>It is my contention that given the current generally accepted practices and when presented with an involved patient as indicated above, we are doomed to failure, in terms of comfort and ambulation. Further, it is my contention that very often, although these patients may be confined to a wheelchair even after prosthetic fitting, it is of paramount importance that they be fitted as comfortably as possible. Although they have lost a limb, they may be just as motivated as any other patient and can suffer psychological stigma.</p> <p>Therefore, it is our duty as prosthetists to provide a prosthesis that will allow these patients to ambulate as much as possible, resulting in both psychological and physical benefits.</p> <h3>Soft Socket Rationale</h3> <p>As we all know, the quadrilateral above-knee socket was originally designed and fitted for World War II traumatic amputees. They were fairly young, usually with no other complications, good musculature, and in many cases of long length. Today we are faced with a high geriatric amputee population with conditions quite different than the World War II veteran. The quadrilateral above-knee socket design impinges directly on the neurovascular bundle in the area of the Scarpa's triangle. The posterior seat area bears directly on an anatomical area which is usually atrophied to the point of being uncomfortable. These features alone call into question the viability of the quadrilateral design when considering an involved patient as described previously. The soft socket design as described, owes its inception to the CATCAM design.</p> <p>The soft socket is almost an exact anatomical negative duplication of the residual limb without extreme scarpas impingement and without concentrated ischial weight bearing. It is lined with 1/2" thick Plastizote, or similar forgiving material that enhances soft tissue bearing, hence "soft socket." It is compatible with all existing above-knee components, far more cosmetic, aligned using current practices, and is fabricated only in a slightly different fashion. Also, it will allow the amputee to ambulate in a comfortable non-restrictive manner.</p> <h3>Case Study</h3> <p>A seventy-six year old man was presented for prosthetic fitting. He was a traumatic amputee who had lost his leg during the Korean War and was left with a four inch length femur. He had been wearing an exoskeletal system with an hydraulically controlled knee, conventional quadrilateral socket, hip joint, and pelvic belt. The prosthesis weighed approximately 13 pounds. The lateral wall of the socket was modified at mid-femoral length to impinge on the femoral shaft. The patient had recently undergone surgery to repair a fractured femoral head on the amputated side due to a fall. He had also recently developed emphysema and had lost a significant amount of weight. During weight bearing on the sound leg, he exhibited extreme fatigue and loss of breath. Despite these contraindications to prosthetic fitting, he expressed great motivation.</p> <p>I proceeded with the standard impression technique using the Berkeley brim. The patient experienced discomfort while suspended in the Berkeley brim. He indicated specific areas of discomfort including the ischial/gluteal area and the lateral femoral area. This continued despite angular adjustments to the brim. An impression was taken. Upon examination of the impression and after discussion with colleagues, it was decided that a conventional fitting would not work. After mulling over the situation, it was decided to hand wrap a new impression, while the patient laid on his sound side. This was done in a very particular way, encompassing the gluteals, and hand forming the medial and posterior wall. A very anatomic impression was obtained. Modification was minimal and consisted mainly of smoothing up and adding a layer of 1/2" Plastizote (<a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-1.jpg"><b>Fig. 1</b></a>) after lamination. The prosthesis weighed 7 1/2 pounds. This included a modular safety knee, extension assist, hip joint, pelvic belt, foam cover, foot, and shoe (<a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.jpg"><b>Fig. 2</b></a>). The patient has been wearing this prosthesis and is quite satisfied.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-1.jpg">Figure 1.</a> The Berkeley brim above the AK prosthesis with hip joint and pelvic band. Note presence of Plastazote pad in the ischial seat area.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.jpg">Figure 2.</a> The completed prosthesis.</strong><br /> <h3><br />Conclusion</h3> <p>It is my belief that we, as prosthetists, should approach our patients as individuals and if necessary, modify or completely discard commonly accepted techniques in order to successfully fit the uncommon patient. We should continue to examine our techniques in order to upgrade our profession and better serve the community.</p> <h3>Acknowledgments</h3> <p>Kevin S. Garrison, CP., Mahnke's Prosthetics-Orthotics, Inc., Fort Lauderale, Florida; Joseph Leal, C.P., Custom Prosthetics of Tucson, Arizona; John Sabolich, C.P.O., Sabolich, Inc., Oklahoma City; Thomas Guth, C.P., R.G.P. Orthopedic Appliance Co., Inc., San Diego, California; Ivan Long, C.P., Polycadence, Inc., Arvada, Colorado; Timothy B. Staats, C.P., Director of Prosthetics, education training programs, UCLA.</p> <b>*Arthur Forman, B.S., M.A. </b> Arthur Forman, B.S., M.A., is a prosthetist formerly with Mahnkes Prosthetics and Orthotics, Inc., 1915 N.E. 45th Street, Fort Lauderdale, Florida 33308. Page Number(s) 90 - 92 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: The Soft Socket Creator An entity primarily responsible for making the resource Arthur Forman, B.S., M.A. * https://staging.drfop.org/files/original/cafa9b743d894ef8ac329dd049105439.pdf c5c3c6f8570f5611fb7f6c5a42f9907f https://staging.drfop.org/files/original/da8d8abfb620ef2e663567dd50bcc654.jpeg 1a03a7488c0c4c3a9df9bdbc0366fc44 https://staging.drfop.org/files/original/3f58c60474774ff9e63168d5ae29a02e.jpg 815138367afbe230364d1322051cddfe https://staging.drfop.org/files/original/3144aa6cc1e6fdbd0b6a2114007d029c.jpg 5b636b99ef116d0e221fdb299ac85bb1 https://staging.drfop.org/files/original/5d13bc560af79f59d4201f44574589b8.jpg c266285611b6774216497b8f21a83e26 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_008.pdf Text Any textual data included in the document <h2>Technical Note: Wrist Flexion Unit Modification</h2> <h5>Peter A. Ockenfels, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Several years back we learned that a wrist flexion unit, be it the Homser FM 500, 300, 200, or the Pope Easy Flexion Wrist PW 4-6, has little value for bilateral above elbow or bilateral shoulder disarticulation amputees. The patient involved, a right true shoulder disarticulation and left humeral neck amputee, had been successfully fitted with bilateral prostheses. The term "successful" can only be used in terms that the patient felt comfortable, was able to flex his elbows to 90 degrees and 135 degrees, and able to open the terminal device with extended elbow 100 percent of full opening elbow flexion of 90 degrees, 80 percent, and at elbow flexion of 135 degrees, 50 percent. Both prostheses were harnessed with leg loops and the usual elbow lock controls. Wrist units were prescribed and incorporated into both forearms, but proved to be quite useless due to the fact that the patient was unable to activate the wrist units.</p> <p>To rectify the situation, the following modification was constructed. The trigger bar that activates the wrist flexion units is located medially on either wrist unit; therefore, an activating lever was designed and incorporated into the forearm (<a href="/files/original/da8d8abfb620ef2e663567dd50bcc654.jpeg"><b>Fig. 1</b></a>), so that the patient can trigger wrist flexion by pushing against a chair, his leg, or any other object (<a href="/files/original/3f58c60474774ff9e63168d5ae29a02e.jpg"><b>Fig. 2</b></a>). Extension of the wrist unit is achieved using the legs (<a href="/files/original/3144aa6cc1e6fdbd0b6a2114007d029c.jpg"><b>Fig. 3</b></a>). The trigger lever (<a href="/files/original/5d13bc560af79f59d4201f44574589b8.jpg"><b>Fig. 4</b></a>) is made of 1/8" aluminum and pivots on a 3/16 half-threaded rod, mounted in the sides (ant. and post.) of the forearm wall. The patient no longer uses his right SD prosthesis and has been converted to a special chest harness. The wrist flexion trigger mechanism has proven to be very successful, and the patient would not be able to accomplish many tasks of daily care without it.</p> <em><b><b>*Peter A. Ockenfels, CPO </b></b>American Orthotic &amp; Prosthetic Laboratory, Inc. Columbus, Ohio</em><b><b><br /><br /></b></b> Page Number(s) 8 - 8 Year 1983 Volume 7 Issue 3 Figure 2 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Wrist Flexion Unit Modification Creator An entity primarily responsible for making the resource Peter A. Ockenfels, CPO * https://staging.drfop.org/files/original/1bda4488b7bcaad58f689c611e408747.pdf 3dbe8feffcd1fb52115ac4f72537fb35 https://staging.drfop.org/files/original/2b5c10bb36baba4b040aee904e471d71.jpg 58a95731305645b10b6f85d8f67c0245 https://staging.drfop.org/files/original/7eafccb497b126ccef5122f33650546e.jpg 95f4117b856b786b71073155002d428d https://staging.drfop.org/files/original/fb0a7e94a169ec63ff7cf95527d469db.jpg bfcf718cf5f1dbeb7d91194c1cd973f3 https://staging.drfop.org/files/original/2afccc1e2421258e552469eb88bf971e.jpg 9b7fc5a4e7b85110d68fd68f2807d779 https://staging.drfop.org/files/original/38d490d55a00c077b1478f5a0103487b.jpg 45ffc4432052bb51531a1472db207f25 https://staging.drfop.org/files/original/fbd0d897aea6ec8ffb409a610bdb0565.jpg 1391815c9cc113e718f2a49af9320dd0 https://staging.drfop.org/files/original/e74beaad9794f0c38e5b4a2167e3ad53.jpg 0b0a047d912ac402d46d3935c3b9c31e https://staging.drfop.org/files/original/300d567518504315a715a10eb776fea3.jpg 65e2651387f382c71b4515df75547aeb https://staging.drfop.org/files/original/bd66530125b2eec809b4a982578e7298.jpg a604f5d8d25c448cebce95a930d473b4 https://staging.drfop.org/files/original/8c57d9a3ad45c3dddd9363974ba16cbf.jpg c00ad4fa54bb32068faf2b1ce4351adf https://staging.drfop.org/files/original/5ef1b1af6313f0e9535a397f23f3dc8e.jpg 9f2caa21c1bd051f677d1a98f1525b34 https://staging.drfop.org/files/original/3b4dfae891f5fe8d20b4805a2c42caad.jpg f62e04fc490408ac07010086995967df https://staging.drfop.org/files/original/f101f2f8cfe7c638bd4fe254d6a41eeb.jpg ddecbf2853ea7cf90f4c5ea0d633cba4 https://staging.drfop.org/files/original/e2fd7092fcbfa3cff3fcdb2b8d67522f.jpg d7cdaf9276e991c1515ed26738370b8b https://staging.drfop.org/files/original/7c9b09638c60a8e08f198d66a29c3e89.jpg eeec08eb556f5a122fd20be791683be6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_015.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 15 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Technique for Forming Sockets Directly on Above-Elbow Stumps</h2> <h5>F. L. Hampton, C.P. <a style="text-decoration:none;">*</a><br />J. N. Billock, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The ability to make a socket by applying a thermoplastic material such as Poly-sar X-414 (Polymer Corp. Ltd. TM) directly to an amputee's stump offers many advantages to the prosthetist, as pointed out by Wilson. <a></a> Direct forming obviously eliminates the casting procedures necessary to produce a good modified replica of the stump and eliminates the laminating procedures necessary to produce the socket. The thermoplastic properties of Polysar X-414 allows quick postforming of the socket in areas which may require relief, and the material lends itself well to the attachment of components during assembly. These time-saving advantages enable the prosthetist to fit amputees with a temporary prosthesis much earlier than the time normally required for a definitive fitting. This hastens the amputee's rehabilitation and helps to condition him <i>and </i>his stump for the definitive prosthesis. The prosthetist also has the advantage of noting any corrections which are applicable to the definitive prosthesis. These advantages are also helpful to the research prosthetist, for he can save valuable time in evaluating new control techniques and testing new components.</p> <p>A direct-forming technique related to those developed by Staros and Gardner <a></a> for below-knee PTB sockets and by Labate and Pirrello <a></a> for below-elbow sockets using Polysar X-414 has been developed for above-elbow sockets. If done properly, this technique will provide a well-fitting socket which has the above-mentioned advantages. A complete above-elbow prosthesis can be fabricated in approximately three hours.</p> <p>The technique was used at this center to construct Polysar sockets for four above-elbow amputees who participated in an evaluation study of externally powered upper-extremity prosthetic components. Each amputee (described briefly below) wore his prosthesis successfully for two hours a day, three days a week, during a two-month period without problems.</p> <p><i>D. H., </i>a 38-year-old male, with a right above-elbow amputation 11 in. distal to acromion, acquired in June 1964. He was fitted with a standard above-elbow prosthesis, which he has used actively as a laborer since.</p> <p><i>R. W., </i>a 35-year-old male congenital amputee, with a right 11-in. above-elbow stump from the acromion. He was fitted with his first standard above-elbow prosthesis in June 1954, and has been an active prosthesis wearer since that time. He is presently employed as a hotel clerk.</p> <p><i>J. H., </i>a 44-year-old male with a left above-elbow amputation 8% in. distal to the acromion, acquired in March 1964. He was fitted with a standard above-elbow prosthesis and has been an active prosthesis wearer since that time. He is presently employed as a quality-control inspector for a leather factory.</p> <p><i>R. R., </i>a 22-year-old male with a left above-elbow amputation 9 1/2 in. distal to the acromion, acquired in November 1968. He was fitted with a standard above-elbow prosthesis and has used it actively since. He is a student in college at the present time.</p> <h3>Materials and Equipment</h3> <p>A tube of the synthetic rubber 3 in. ID x 1/4 in. x 12 in. is adequate for the average above-elbow stump. The diameter can be reduced for smaller stumps by elongating the tube after it has been heated. Larger sizes of tubing should be used for larger stumps.</p> <p>The only special equipment needed is a deep, water-filled container, approximately 20 in. in height and 8 in. in diameter. The water should be preheated to a temperature of 160 degrees F to 180 degrees F.</p> <p>The following materials and equipment should be available within the prosthetic facility:</p> <ul> <li>Two 1 in. x 40 in. elastic webbings</li> <li>Four Yates clamps</li> <li>Tubegauz (TM), size #56 (tubular gauze)</li> <li>Heavy cast sock</li> <li>Braided Dacron (TM) line, approximately 130-lb-test</li> <li>Standard Hosmer elbow turntable</li> <li>Hose clamp, expandable to 11-in. circumference</li> <li>Hot plate</li> <li>Parallel bar</li> <li>Pressure-sensitive tape</li> </ul> <h3>Preparations for Casting</h3> <p>Cut a length of tubular gauze approximately 18 in. longer than the stump and slit it 6 in. from the proximal end. Apply the tubular gauze with the slit in the axilla, allowing the tubular gauze to encompass the shoulder proximal to the acromion process. Pass a piece of 1-in. elastic webbing under the axilla on the sound side and attach it to the anterior and posterior wings of the tubular gauze (<b>Fig. 1</b>). Cut the toe from a heavy cast sock and slit the proximal end in the same manner as the tubular gauze. Pull the cast sock on the distal third of the stump, with the slit under the axilla (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Tubular gauze suspended with elastic webbing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Heavy east sock applied to distal one-third of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Mark the proximal section of the synthetic rubber tube to be cut out for the axilla. The width of the section will depend on the stump size, and the depth must be sufficient to allow the synthetic rubber to pass over the acromion. The synthetic rubber stretches well; therefore, caution should be taken not to cut out too large a section. For average stumps, a section 3 in. x 3 in. is adequate.</p> <p>Completely immerse the synthetic rubber tube in the preheated water. The tube will rise to the surface when it has reached the appropriate temperature. Remove it from the water and cut out the axilla section (<b>Fig. 3</b>). Allow the tube to cool until the hand may be placed inside the tube without discomfort.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Cutting out axilla section after tube is heated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Application of Synthetic Rubber</h3> <p>Stretch the proximal end of the tube at the axilla level to aid in starting the tube on the stump (<b>Fig. 4</b>). Roll the axilla edge to provide a good flare for the axilla (<b>Fig. 5</b>). Insert the tubular gauze and cast sock through the tube and apply the tube to the distal third of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Synthetic rubber tube stretched at axilla level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Medial edge rolled to provide a good flare for axilla. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tubular gauze is anchored to a parallel bar so that the amputee can apply tension on the tubular gauze. The tension will compress the stump tissues and prevent tissue-bunching while the synthetic rubber tube is being applied. An adjustable webbing belt with an O ring is used as the anchoring point on the parallel bar (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Synthetic rubber tube applied to the distal end of the stump and tension applied to the tubular gauze. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stand the amputee away from the parallel bar with the stump in abduction and the shoulder in depression. This will assist in placing the tube well into the axilla. Pull the synthetic rubber tube onto the stump, using the cast sock to work it up the stump (<b>Fig. 7</b>). Make sure it is well into the axilla and over the acromion. Support the tube with a piece of elastic webbing in the same manner as the tubular gauze (<b>Fig. 8</b>). This will also aid in forming the proximal end of the socket. Eliminate any wrinkles in the cast sock by pulling on it at the distal end of the tube.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Synthetic rubber tube is pulled up the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The tube suspended with elastic webbing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Contouring the Socket</h3> <p>When contouring the socket for a left amputee, place the left hand firmly into the axilla, keeping the hand parallel to the sagittal plane. Have the amputee move back to the parallel bar, adduct his stump, and elevate his shoulder to the neutral position (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Left hand in the axilla and right hand contouring distal end of socket to accept elbow turntable </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Firm tension should be maintained on the tubular gauze without causing the amputee to strain. Only the shoulder muscles should be used to maintain the tension. The finished socket will be loose if the stump muscles are contracted during contouring of the socket.</p> <p>Reduce the diameter of the synthetic rubber distally to conform to the stump and to approximate the circumference of the turntable if necessary (<b>Fig. 9</b>). Mold the proximal section by placing the right hand so that the thumb and forefinger outline the anterior and posterior borders of the deltoid muscle group. The thumb is used to mold the anterior wing, and the remaining fingers to mold the posterior wing (<b>Fig. 10</b>). Hold the socket in this manner until the synthetic rubber cools enought to retain the contours.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Right hand contouring the proximal socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Mark the proximal trim line before removing the socket. Either the conventional trim line can be used or the open-shoulder described by McLaurin et al. <a></a> After the trim line is cut out, the edges can be finished with a felt cone, fine-sand cone, or toluene.</p> <h3>Attachment and Alignment of Turntable</h3> <p>Determine the proper distance for the elbow center from the acromion process and mark where the turntable will be located on the tube. Reheat the distal end of the tube approximately one-half inch above the mark by immersing it in water. Insert the turntable into the tube and work the synthetic rubber into the knurling and tie-off groove. Secure the synthetic rubber by wrapping 130-lb-test, braided Dacron (TM) line around the tube and pulling it into the tie-off groove (<b>Fig. 11</b>). Two passes of line are sufficient. Cut away the excess tubing and apply pressure-sensitive tape around the tube, making sure the synthetic rubber conforms to the turntable (<b>Fig. 12</b>). A hose clamp can be used for more strength if necessary (<b>Fig. 13</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Turntable tied in place and excess synthetic rubber trimmed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Socket compressed against turntable with pressure-sensitive tape. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Turntable attached with hose clamp. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attach the elbow unit and forearm section and check the alignment of the turntable. If it is not properly aligned, reheat the distal end in water and realign.</p> <p>The harness and cable system are attached in the conventional manner (<b>Fig. 14</b> and <b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. The completed prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. The completed prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Acknowledgments</h3> <p>The authors wish to thank Miss Carole Herhold and Dr. Dudley S. Childress for their help in the preparation of this report.</p> <p><b>References:</b></p> <ol> <li>Labate, Gennaro, and Thomas Pirrello, Direct forming of below-elbow sockets, Artif. Limbs, 14:1:65-72, Spring 1970.</li> <li>McLaurin, C. A., W. F. Sauter, C. M. E. Dolan, and G. R. Hartmann, Fabrication procedures for the open-shoulder above-elbow socket, Artif. Limbs, 13:2:46-54, Autumn 1969.</li> <li>Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Artif. Limbs, 14:1:57-64, Spring 1970.</li> <li>Wilson, A. Bennett, Jr., A material for direct forming of prosthetic sockets, Artif. Limbs, 14:1:53-56, Spring 1970.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, C. A., W. F. Sauter, C. M. E. Dolan, and G. R. Hartmann, Fabrication procedures for the open-shoulder above-elbow socket, Artif. Limbs, 13:2:46-54, Autumn 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Labate, Gennaro, and Thomas Pirrello, Direct forming of below-elbow sockets, Artif. Limbs, 14:1:65-72, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Artif. Limbs, 14:1:57-64, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., A material for direct forming of prosthetic sockets, Artif. Limbs, 14:1:53-56, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>J. N. Billock, C.P. </b></td></tr><tr><td class="clsTextSmall">Research Prosthetist, Northwestern University Prosthetic Research Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>F. L. Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Coordinator, Prosthetic Research and Education, Northwestern University Prosthetic-Orthotic Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-15.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technique for Forming Sockets Directly on Above-Elbow Stumps Creator An entity primarily responsible for making the resource F. L. Hampton, C.P. * J. N. Billock, C.P. *