15 20 371 https://staging.drfop.org/files/original/366a1b6eaf8bdac3bf9bcd5f96e1e444.pdf c15a1b90ec331cb4018325209aeb65ef https://staging.drfop.org/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg 8e66cf5f8e78aecdf2a5e3408530f798 https://staging.drfop.org/files/original/92afbcf437362864c05cee1d9fa423c2.jpg c0d649cd24f105d7e78a3eab0426d1cf https://staging.drfop.org/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg a90f1c11e95d0e45be2d704ef73f3783 https://staging.drfop.org/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg 5061311d76421aff2b48d025e41524ac https://staging.drfop.org/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg a90f1c11e95d0e45be2d704ef73f3783 https://staging.drfop.org/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg 6a18a10291eac44ee2e3b2f40d37a99c https://staging.drfop.org/files/original/104394cd613cd757fc34ae6b51dfc916.jpg 0cbd76a6321d43132c8d653b6a6537d5 https://staging.drfop.org/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg 5018452d2616ca984b0b8fbc9ddf3f8e https://staging.drfop.org/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg 79e8f6d9e08cb4a44e6e7bbdb9e3957a https://staging.drfop.org/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg 4c431528b25733c9af6035131de80b91 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/1984_02_004.pdf Text Any textual data included in the document <h2>The Technical Aspects of the Orthopaedic Treatment of the Knee after Sports Injuries</h2> <h5>Andre Bähler <a style="text-decoration: none;">*</a></h5> The last decades have shown a marked increase in the number of people, both young and old, participating in sporting activities. As a result of systematic education and schooling, it has become generally recognized that a certain amount of physical exercise is necessary for a healthy body. The mass media—radio, television, the press—as well as schools and private insurance companies, have systematically reported the advantages to be gained by participating in physical activities. Sports are no longer the prerogative of the young; there is no age limit for those engaged in sports in one form or another. Senior citizen keep-fit groups, jogging, and the like, have proven to many older people that age is not a justified reason to neglect physical fitness, and they have become aware that exercise is a means of showing the body the respect it deserves. However, this almost revolutionary attitude towards sports is not limited to amateurs, but has also brought changes into the world of top athletes. Today, the degree of involvement is greater than ever before, but so accordingly are the associated risks. Many forms of sports seem to have lost sight of the original ideal of sportsmanship. Enjoyment and leisure have been replaced by a deadly seriousness in attitude that only total dedication will bring the desired results. Not only in the competition itself, but in the long months and sometimes years of training prior to it, the body is stretched to its utmost. Success at any price is the motto of the day, and such an attitude consciously calculates and accepts casualties and losses as part of the "game." It has been proven that this type of approach to sports results in an increase in injuries, strain, and general wear, particularly in the joints of the lower limbs. Clearly, modern sports put the knee-joint under great pressure. Be it cycling, football, skiing or ice-hockey, the movement of the knee is of central importance, as changing techniques increase the pressure put on it. The large number of knee injuries are a cause of great concern to modern sports medicine. The top athletes in particular, are anxious to start training again as soon as possible after injury. Although the knee is capable of taking great strain, mobility is often restricted, either by external injuries, or because of wear within the joint itself. Immobilization of the joint after injury or surgery can damage the cartilage, hindering the assimilation of nutrients. The ligaments begin to lose their tensility, there is a loss of coordination between muscle groups, and muscles atrophy. Finally, immobilization of a limb also affects the whole organism, particularly circulation, respiration, and the digestive system, and last but not least, the psychological effect of immobilization should not be underestimated. Controlled movement of the knee-joint after ligament surgery has great advantages during rehabilitation: movement between 20-60 degrees does not strain the collateral or cruciate ligaments to any degree. The muscles are also activated within pre-controlled limits. In tests, Hettinger found that 20-30 percent of the maximum pressure was sufficient to retain normal muscle strength. However, in order to increase muscle strength, the pressure must be at least 40-50 percent, and this is not possible after surgery. Therefore, rehabilitation requires electro-stimulation. A pre-condition of functional treatment is the exact restoration of all the anatomical elements, (e.g. cruciate and collateral ligaments). <h3>Rehabilitation Phases</h3> Pre-operative Treatment When reconstructive surgery is required in the case of an old injury to the knee, the time before the operation should be used to improve and retain muscle strength, for coordination exercises, and to instruct and explain the postoperative treatment Post-operative Treatment Day 1: For the rest period, the leg should be held in a preoperative prepared plaster-splint with a flexion angle of 20-30 degrees. Day 5: A knee-orthosis with a 20-50 degree range of movement is fitted and a gentle swinging movement is allowed. The orthosis is also worn in the pool but the injured leg should not actually be used for swimming. Rehabilitation at this stage should also include controlled extension and flexion exercises between 20-60 degrees and isometric quadricep training. Fifth to sixth week: Flexion and extension exercises from 0-90 degrees should be practiced. For walking, the orthosis must be locked in extension with the swiss-lock. After eight weeks: The lock can be removed and the patient may be allowed to walk with free movement of the joint. The orthosis is usually worn for approximately one year. <h3>The Principles of Fixation and Correction with the Orthosis</h3> Both the upper and lower leg must be securely held all round. If necessary, support at the thigh is given on the same principle as a prosthetic support. If the upper and lower leg are kept straight, then it is best to use a physiological (polycentric, Ed.) knee-joint. However, if the securing bands of the orthosis are made of rubber or a similar material, then a simple single-axis knee-joint is sufficient. Besides the above mentioned points, the orthosis for post-operative rehabilitation after ligament reconstruction must also exhibit the following characteristics: <ol> <li> The program of correction or fixation must be exactly determined in advance. </li> <li> The upper and lower leg must be securely held in the orthosis. </li> <li> The construction of the joint must allow for varying ranges of mobility: <ol> <li> 20-50 degrees </li> <li> 0-90 degrees with the option of a locking device </li> <li> 0-120 degrees with free movement. </li> </ol> </li> </ol> <h3>Procedure to Relieve the Medial or Lateral Ligaments</h3> Principle: Triple-point correction (<a href="/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg">Fig. 1</a>) <a href="/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg">Figure 1</a>. Triple-point correction to relieve the medial or lateral ligaments.  The principle underlying the triple-point correction, forms the basis for efficient correction of genu varum or genu valgum. With young patients, it is possible to position the correcting pressure-pads exactly, but with older patients, because of the flaccid tissue, pressure must be applied over as large an area as possible, e.g., with splints which distribute the pressure equally. For technical as well as anatomical reasons, it is often not possible to apply pressure at the centre of the joint itself, therefore pressure must be applied above and below the joint, but as near to it as possible. If the splints do not fit securely, then the orthosis will twist inwards when bent and this results in a reduction of the correcting forces at extension. <h3>Procedure for Controlling the Posterior Drawer</h3> Principle: Posterior pressure on the proximal lower leg and anterior pressure on the distal upper leg (<a href="/files/original/92afbcf437362864c05cee1d9fa423c2.jpg">Fig. 2</a>) <a href="/files/original/92afbcf437362864c05cee1d9fa423c2.jpg">Figure 2</a>. Controlling the posterior drawer. There are two biomechanical procedures to choose from: <ol> <li> Fixation of the upper and lower leg with the orthosis on the basis of the triple-point method. With this method, the splints are fitted individually to the upper and lower leg and the correcting pressures are placed so that a posterior drawer is held firmly. </li> <li> Placing the correcting pressures in such a way that together with the knee-joint of the orthosis, they act as a lever. Here too, it is advantageous to distribute the pressure over as large a surface as possible (<a href="/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg">Fig. 3</a>). <a href="/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg">Figure 3.</a> An alternative approach</li> </ol> <h3>Procedure to Correct the Anterior Drawer</h3> Principle: Anterior pressure on the proximal lower leg and posterior pressure on the distal upper leg This involves, first, the fixation of the upper and lower leg with the orthosis on the basis of the triple-point principle (<a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg">Fig. 4</a>), and second, placing the correcting pressure so that together with the knee-joint of the orthosis, they act as a lever. The greater the distance between the knee and the external counter-pressure, the better the corrective effect (<a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg">Fig. 5</a>). <a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg">Figure 4</a>. Fixation of the upper and lower leg.  <a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg">Figure 5</a>. Increase the distance between the knee and the external counter-pressure <h3> Restricting Rotation</h3> The restriction of rotation depends on how well the orthosis fits the upper and lower leg. The efficiency of the orthosis in restricting rotation is determined less by the type of orthosis, than by the size and type of the surface area of support. In practice, the following points must be checked: <ol> <li> Any fixation of the knee-joint must conform to the principles of biomechanics. </li> <li> The orthosis and all bandages should cover the leg properly to ensure that the orthosis does not slip. </li> <li> The orthosis must fit so as not to hinder or limit muscle activity. </li> </ol> As we found that the orthotic devices available at present did not completely satisfy our needs, we devised a system of our own which we would now like to explain with the help of some photographs. <h3>Type I: Sport Orthosis for Old Injuries to the Knee, or for Instability of the Joint</h3> In order to keep the reduction in fitness to a minimum, the athlete aims to return to training as soon as possible. However, the knee is often not strong enough to cope with the high demands made upon it and needs some form of support, without however, limiting the range of movement. This orthosis guides the joint and eliminates the forward and backward drawer as well as movements to the side (<a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg">Fig. 6</a>, <a href="/files/original/104394cd613cd757fc34ae6b51dfc916.jpg">Fig. 7</a>, <a href="/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg">Fig. 8</a>). If necessary, it can also be fitted so as to restrict all extreme movements. The half-splints of the orthosis are made of the new Plexiglass XTO (natur) by the Röhm Company (Darmstadt 1). This material is much tougher than the well-known Plexidur. It is easy to form, and locks can be fitted to the joints without first having to be strengthened. In order to stop the splints from slipping, they are lined with a thin layer of foam-rubber. The best results are achieved when the orthosis is formed from a plaster model of the leg. <a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg">Figure 6.</a> The sport orthosis eliminates forward and backward drawer.  <a href="/files/original/104394cd613cd757fc34ae6b51dfc916.jpg">Figure 7.</a> The orthosis can be fit to eliminate all extreme movements.  <a href="/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg">Figure 8.</a> The half-splints are made of Plexiglass XTO. <h3>Type II: Orthosis for Operative Ligament Reconstruction, or Other Similar Serious Knee Injuries</h3> Basically the same orthosis is made as in Type I (<a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg">Fig. 4</a>, <a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg">Fig. 5</a>, <a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg">Fig. 6</a>) but with the difference that a lock and positioning-screw are fixed to the outside of the splint (<a href="/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg">Fig. 9</a>, <a href="/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg">Fig. 10</a>). As already mentioned, the positioning screw allows a movement between 20-60 degrees. After a while, this can be removed and the lock used to hold the leg in extension. <a href="/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg">Figure 9</a>. A lock and positioning screw are fixed to the outside of the splint. <a href="/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg">Figure 10</a>. The positioning screw allows movement between 20-60 degrees.  Depending on the injury, the half-splints are placed either at the front or at the back of the upper and lower leg. Securing straps and pressure-pads increase the corrective effect. *Andre Bähler Andre Bähler is an Orthotist/Prosthetist from Zurich, Switzerland. <div style="width: 400px;"></div> Page Number(s) 4 - 7 Year 1984 Volume 8 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-02.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-05.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/1984_02_004/1984_02_004-06.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-03.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-10.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 The Technical Aspects of the Orthopaedic Treatment of the Knee after Sports Injuries Creator An entity primarily responsible for making the resource Andre Bähler * https://staging.drfop.org/files/original/3736a23e738166381c6803e355cc30aa.pdf cb532dab7ed020184153028bdd91a2d2 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/1984_02_003.pdf Text Any textual data included in the document <h2>The Role of Orthoses in the Care of Knee Ligament Injuries</h2> <h5>Kenneth E. DeHaven, M.D. <a style="text-decoration: none;">*</a></h5> The role of braces in the management of knee ligament injuries, particularly in high risk athletics, continues to receive a great deal of attention. There are a multitude of braces currently being manufactured and marketed with various claims relating to the effectiveness, comfort, durability, and cost. Two key questions remain for most clinicians: (1) Should knee braces be used at all?, and (2) If so, what type of brace should be used and under what circumstances? At present there is a paucity of scientific data available to answer either of these questions with certainty, but there are encouraging signs that this essential information will be forthcoming from current and future research. Until an adequate scientific basis has been established it is necessary to develop a philosophy about bracing in athletics that is consistent with the data that is available and our clinical observations. <h3>Should braces be used at all?</h3> There is frequently an ego problem for both the athlete (who views a brace as a sign of weakness) and the physician (concern that a brace reflects less than optimal results) who delight in the statement "Doc, I don't need that brace—I can run and cut without it." Definitive treatment, whether rehabilitation or surgery followed by rehabilitation, must provide the functional stability, and it is rare in my experience that an unstable knee is made stable simply by applying a brace. However, no matter how good it might feel to the athlete, a knee that has previously sustained major ligament injury is not normal, and in fact has suffered ligament disruption at a time when it was normal. The role of bracing, therefore, is not to provide stability but to help prevent reinjury by keeping the knee from going into extreme positions when subjected to sudden stress. When presented in this light, the concept of protective bracing after major ligament injury to the knee is more reasonable and more acceptable to both the athlete and the physician. <h3>What type of brace should be used and under what circumstances?</h3> While not definitively established, it appears that the beneficial effects of knee orthoses are related not only to their mechanical strength but also to providing increased proprioceptive input from the knee area (which can explain how some patients feel more stable in braces that provide little or no mechanical support). Optimal support is provided by braces that protect against varus/valgus and hyperextension stresses and are utilized routinely in our Center following ligament repair or reconstruction of collateral and/or cruciate ligaments. The brace is initially worn for ambulation in the early postoperative period (two or four months) and later for agility, contact, or other types of "high risk" sports. Less sophisticated braces that provide just varus/valgus support usually are sufficient for athletes returning to similar sports in the same season following Grade II collateral ligament sprains. The practicality, efficacy, and cost effectiveness of prophylactic bracing to prevent injury in contact sports such as football is also a topic of great interest but remains unresolved at present. It is important to emphasize that this represents personal philosophy and recommendations based upon the information available at this time. It is recognized that while these concepts appear to be reasonable they are largely unproven, and there continues to be great need for more biomechanical and clinical research to firmly establish a scientific basis for knee bracing in athletics. *Kenneth E. DeHaven, M.D. Professor of Orthopaedics, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, New York 14642. <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1984 Volume 8 Issue 2 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 The Role of Orthoses in the Care of Knee Ligament Injuries Creator An entity primarily responsible for making the resource Kenneth E. DeHaven, M.D. * https://staging.drfop.org/files/original/5d0ee93720e3cc29afeb69569f942ec3.pdf ec7d305e66c4b1672edc65546d744f4a https://staging.drfop.org/files/original/7e69b86f4f3e01170fb59ef73e47cd16.jpg 153b782803915d8c141c800756b99b14 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/1984_02_001.pdf Text Any textual data included in the document <h2>Biomechanical Considerations in the Orthotic Management of the Knee</h2> <h5>Victor H. Frankel, M.D., Ph.D. <a style="text-decoration: none;">*</a></h5> The challenges facing the contemporary orthotist are akin to the interminable task of Sisyphus, the Greek mythic figure who was condemned to pushing a huge rock up an endless hill. Unlike Sisyphus, however, the orthotist has made and continues to make significant strides in the rational design and fabrication of prostheses and orthotic devices. Over the past decade major contributions to solving the anatomical and functional problems associated with joint replacement prostheses and orthoses have directly resulted from the growing interaction between orthopaedic surgery and biomechanics. The result of this increased interaction has been improved diagnosis and treatment of musculoskeletal disorders with prostheses and orthotic devices. The knee is certainly one of the joints that has greatly benefited from these biomechanical developments. Biomechanics enables the scientist to accurately describe and quantify surface joint motion of the knee and to analyze the complex forces imposed on the knee. Biomechanics also brings the motion of and the forces acting on the knee into sharp focus by analyzing the mechanical properties of the static and dynamic structures surrounding the knee: muscles, bones, ligaments, cartilage, and tendons. The biomechanical analysis of motion and force in the knee joint can be widely and successfully applied in orthotic management of the knee. The human knee is the largest and perhaps the most complex joint in the body. It is a two-joint structure composed of the tibiofemoral joint and the patellofemoral joint. Both joints sustain high forces and, located between the body's two longest lever arms, are particularly susceptible to injury. The knee transmits loads, participates in motion, aids in conservation of momentum, and provides a force couple for activities involving the leg. Although motion in the knee occurs simultaneously in three planes, the motion in one plane is so great that it accounts for most knee motion. Similarly, muscle forces on the knee are produced by several muscles, but a single muscle group (according to the activity) produces a force so large that it accounts for most of the muscle force acting on the knee. Thus, biomechanical analysis can be basically limited to motion in one plane and to the force produced by a single muscle group, and yet can still give an understanding of knee motion and an estimation of the magnitude of the main forces acting on the knee. To analyze motion in any joint, one must use kinematics, the branch of mechanics that deals with motion of a body without reference to force or mass. To analyze the forces imposed on a joint one must use both kinematic and kinetic data. Kinetics is the branch of mechanics which analyzes the motion of a body under the influence of given forces. <h3>Kinematics</h3> Kinematic data define the range of motion and describe the surface joint motion in three planes: frontal (coronal or longitudinal), sagittal, and transverse (horizontal). The range of motion can be measured in any joint and in any plane. Gross measurements can be made by goniometry, but more specific measurements must be made with more precise methods such as electrogoniometry, roentgenography, or photographic techniques using skeletal pins. <a></a> The range of knee joint motion needed for performing various physical activities can be determined from kinematic analysis. A full range of knee motion is needed for performing the more vigorous activities of daily life in a normal manner. Moreover, any restriction of knee motion will be compensated for by increased motion in other joints. The values obtained in several studies indicate that full extension and at least 117 degrees of flexion are necessary for carrying out the activities of daily life in a normal manner (Table I).<a></a> Table I. Range of Tibiofemoral Joint Motion in the Sagittal Plane During Common Activities <img src="/files/original/7e69b86f4f3e01170fb59ef73e47cd16.jpg" h3="" width="415" height="337" /> <h3>Surface Joint Motion</h3> Surface joint motion, the motion between the articulating surfaces of a joint, can also be described for any joint in the sagittal and frontal planes, but not the transverse plane. The method used is called the instant center technique. This technique allows a description of the relative uniplanar motion of two adjacent segments of a body and the direction of displacement of the contact points between these segments. The instant center for motion of a planar joint can be obtained by the method of Reuleaux (1876).<a></a> Clinically, a pathway of the instant center for a joint can be plotted by taking successive roentgenograms of the joint in different positions (usually ten degrees apart) throughout the range of motion in one plane, and applying the Reuleaux method for locating the instant center for each interval of motion. After the instant center pathway has been determined, the surface joint motion can be described. In a normal knee, the instant center pathway for the tibiofemoral joint is semicircular. Especially pertinent to orthotic management is data concerning knees with internal derangements. If the knee is extended and flexed about a displaced instant center, the tibiofemoral joint surfaces do not slide tangentially throughout the range of motion, but become either distracted or compressed. Such a knee is analogous to trying to close a door with a bent hinge. If the knee is continually forced to move about a displaced instant center, it will gradually adjust to this situation by either stretching the ligaments and supporting structures of the joint or by exerting abnormally high pressure on the articular surfaces. Such internal derangements of the tibiofemoral joint may interfere with the so-called screw-home mechanism, which is a combined motion of knee extension and external rotation of the tibia. The tibiofemoral joint is not a simple hinge joint, but has a spiral, or helicoid, motion. The spiral motion of the tibia about the femur during flexion and extension results from the anatomical configuration of the medial femoral condyle; in a normal knee this condyle is approximately 1.7cm longer than the lateral femoral condyle. As the tibia slides on the femur from the fully flexed to the fully extended position, it descends and then ascends the curves of the medial femoral condyle and simultaneously rotates externally. This motion is reversed as the tibia moves back into the fully flexed position. The screw-home mechanism gives more stability to the knee in any position than would be possible if the tibiofemoral joint were a simple hinge joint. The Helfet test, a simple clinical test, is used to determine if external rotation of the tibia occurs during knee extension, thus showing whether the screw-home mechanism is intact.<a></a> In a deranged knee it may happen that no external rotation of the tibia occurs during extension. Because of the altered surface motion, the tibiofemoral joint will be abnormally compressed if the knee is forced into extension, and the joint surfaces may be damaged. <h3>Kinetics</h3> Kinetic data, based on static and dynamic analysis, are used to analyze the forces acting on a joint. The medical scientist can use kinetic analysis to determine the size of the forces imposed on the knee by muscles, body weight, connective tissues, or external loads in either static or dynamic situations. In particular regard to orthotic management, however, situations and movements which produce excessively high forces can be identified. In static analysis, the three main coplanar forces acting on a body in equilibrium are identified as: (1) the ground reaction force (equal to body weight), (2) the tensile force exerted by the quadriceps muscle through the patellar tendon, and (3) the joint reaction force acting on the tibial plateau. Since most of our activities are dynamic, however, an analysis of the forces acting on the knee during motion-dynamic analysis-must be applied to given situations. In addition to the three coplanar forces of static analysis, the medical scientist must also take into account the acceleration of the body part (the amount of torque needed to accelerate a body, for which anthropometric data-tables are used).<a></a> An orthotist might use dynamic analysis, for example, to calculate the joint reaction, muscle, or ligament forces on the tibiofemoral joint at a particular instant in time during walking, or at a particular instant in time (with a stroboscopic film) while kicking a football. Other biomechanical considerations in the orthotic management of the knee involve the two important functions of the patella: (1) it aids knee extension by lengthening the lever arm on the quadriceps, and (2) it allows a better distribution of stresses on the femur by increasing the area of contact between the patellar tendon and the femur. In a patellectomized knee, for example, the quadriceps muscle, now with a shorter lever arm, must produce even more force than normal to achieve the required torque about the knee during the last 45 degrees of extension. Full, active extension of a patellectomized knee may require as much as 30 percent more quadriceps force than normally required.<a></a> During most dynamic activities, the greater the knee flexion, the higher all the muscle forces acting on the patellofemoral joint. Forces increase proportionately with knee flexion, for example, from walking to stair climbing to knee bends. Patients with patellofemoral joint derangements experience increased pain when performing activities requiring knee flexion, and orthotic management could be greatly aided by knowledge of such predictive biomechanical factors as knee flexion, and the muscle and joint reaction forces for specific situations. Biomechanical analysis can yield invaluable, practical data for the orthotic management of the knee. A continuing, close interaction among orthopaedic surgeons, bio-engineers, and orthotists will insure the applied efficacy of such data. References: <ol> <li><a href="http://www.oandplibrary.org/al/1964_01_044.asp">Drillis, R., Contini, R., and Blustein, M.: "Body segment parameters: A survey of measurement techniques," Artificial Limbs, 8:44, 1964.</a></li> <li>Frankel, V.H., and Nordin, M.: Basic Biomechanics of the Skeletal System. Philadelphia, Lea & Febiger, 1980.</li> <li>Helfet, A.J. : "Anatomy and mechanics of movement of the knee joint," Disorders of the Knee, edited by A. Helfet, Philadelphia, J.B. Lippincott, 1974.</li> <li>Kaufer, H. : "Mechanical function of the patella," Journal of Bone & Joint Surgery, 53A:1551, 1971.</li> <li>Kettelkamp, D.B., Johnson, R.J., Smidt, G.L., Chao, E.Y.S., and Walker, M.: "An electrogoniometric study of knee motion in normal gait, Journal of Bone & Joint Surgery, 52A:775, 1970.</li> <li>Laubenthal, K.N., Smidt, G.L., and Kettelkamp, D.B. : "A quantitative analysis of knee motion during activities of daily living," Physical Therapy, 52:34, 1972.</li> <li>Murray, M.P., Drought, A.B., and Kory, R.C.: "Walking patterns of normal men," Journal of Bone & Joint Surgery, 46A:335, 1964.</li> <li>Perry, J., Norwood, L., and House, K.: "Knee posture and biceps and semimembranosis muscle action in running and cutting (an EMG study), "Transactions of the 23rd Annual Meeting, Orthopaedic Research Society, 2:258, 1977.</li> <li>Reuleaux, F.: The Kinematics of Machinery: Outline of a Theory of Machines. London, Macmillan, 1976.</li> </ol> <div style="width: 400px;">*Victor H. Frankel, M.D., Ph.D. Director of Orthopaedic Surgery, Hospital for Joint Diseases Orthopaedic Institute, 301 East 17 Street, New York, New York 10003, and, Professor of Orthopaedic Surgery, Mt. Sinai School of Medicine, New York, N.Y. </div> <div style="width: 400px;"></div> Page Number(s) 1 - 3 Year 1984 Volume 8 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1984_02_001/1984_02_001-1.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 Biomechanical Considerations in the Orthotic Management of the Knee Creator An entity primarily responsible for making the resource Victor H. Frankel, M.D., Ph.D. * https://staging.drfop.org/files/original/55a3a7b173a4ea49841968b5b80df860.pdf 30ec3d14f98a7ba60ecf7428947253e5 https://staging.drfop.org/files/original/3fc21ceaa5b19ada556ba3270df45738.jpg 02bb4d6365ac241f87b6773edcb7e0c1 https://staging.drfop.org/files/original/8f618f54353873ee21984ffd68d8d05a.jpg c3e7d29a8e7b778ed3c74a7defb1e58b https://staging.drfop.org/files/original/44447ecd073a0cc7c351cea452163a32.jpg ee515bdf345c39774428067d5ecef159 https://staging.drfop.org/files/original/5b949cda2964dd9764e61908c066bc6f.jpg 760890658c08795998286568770b9a05 https://staging.drfop.org/files/original/12b48da7443410fc2c39aec2a208a4a8.jpg 517767050abb9972fcd7bb791f3c924c https://staging.drfop.org/files/original/c0bda2f49bcde7fbdb45d9aa932572f0.png da19301ad0fdfca7f5f640abb9c3b40b 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/1984_01_009.pdf Text Any textual data included in the document <h2>A Case History: Clinical Indication for Flexible Above-Knee Prosthetic Socket</h2> <h5>Howard Adelglass, M.D. <a style="text-decoration: none;">*</a> Don Sung Chu, M.D. <a style="text-decoration: none;">*</a> H.R. Lehneis, Ph.D., CPO <a style="text-decoration: none;">*</a></h5> R.W. is a 62 year old male with a 32 year history of insulin dependent diabetes mellitus. He was in a normal state of good health until August, 1982 when he developed gangrene of the first three toes of his left foot. A left femoral popliteal bypass was performed unsuccessfully. He then underwent a left below-knee amputation which also was unsuccessful and, in October, 1982, a left above-knee amputation was done. In December, 1982, he was admitted to the Institute of Rehabilitation Medicine, NYU Medical Center(IRM-NYU) for a prosthetics rehabilitation program. At that time, his stump became infected and dehisced, requiring stump revision. In July, 1983, he was readmitted to IRM-NYU and started on gait training with an AK prosthesis with a semi-suction socket, hip joint and pelvic belt, polycentric knee joint (Lang) and SACH foot (<a href="/files/original/3fc21ceaa5b19ada556ba3270df45738.jpg">Fig. 1</a>). During the course of his rehabilitation training, he began complaining of pain at the distal stump. The socket was adjusted numerous times by alternately relieving painful areas distally and placing padding above these areas, but with little success. Subsequently, x-rays taken of the stump revealed a small amount of soft tissue calcification distally with a small spur at the posterior lateral side of the femur (<a href="/files/original/8f618f54353873ee21984ffd68d8d05a.jpg">Fig. 2</a>). The patient was started on anti-inflammatory agents which provided a moderate amount of pain relief. However, he still had difficulty ambulating secondary to stump pain. A lateral pad above the distal end was inserted into the prosthesis which relieved some of the pain. However, within a few days, the patient developed a skin breakdown in the left peroneal area, and an erythematous area on the distal stump. The patient was not allowed to wear his prosthesis for 2 1/2 weeks. During this time, a repeat stump x-ray showed a large spur in the posterior lateral side of the distal stump and more soft tissue calcifications on the anterior surface of the stump (<a href="/files/original/44447ecd073a0cc7c351cea452163a32.jpg">Fig. 3</a>). Consequently, a new socket was designed to give relief over the distal anterior and posterior stump in order to decrease the pain and improve ambulation. This socket consisted of a vacuum-molded ionomer (Surlyn®) flexible socket contained in plastic laminated socket. There were fenestrations put into the anterior (<a href="/files/original/5b949cda2964dd9764e61908c066bc6f.jpg">Fig. 4</a>) and posterior walls (<a href="/files/original/12b48da7443410fc2c39aec2a208a4a8.jpg">Fig. 5</a>) of the rigid outer socket, which afforded relief to the area of spur formation and soft tissue calcification. The flexible inner socket was chosen for several reasons : <ol> <li> Flexibility of the socket results in a more comfortable fit and reduces pressure concentration. </li> <li> Its transparency allows direct visualization of the stump, if skin breakdown is a problem, and to monitor pressure areas. </li> <li> It permits quicker heat dissipation because of reduction in socket wall thickness. </li> <li> The socket allows improved sensory feedback, especially while sitting, due to flexibility in fenestrated areas. </li> </ol> The patient tolerated the prosthesis well, however, he still had pain over the anterior distal stump. Thus, new x-rays of the patient were taken while he was wearing the prosthesis to determine if the fenestrations were, in fact, over the spur and the soft tissue calcifications. Because of the design of this socket, it was easy to determine that the fenestrations needed correction. The anterior cut out was then enlarged to better accommodate the soft tissue calcification (<a href="/files/original/c0bda2f49bcde7fbdb45d9aa932572f0.png">Fig. 6</a>). This afforded the patient the relief needed. He is presently ambulating independently with a straight cane and the above-knee prosthesis without any pain. In summary, this flexible socket technique allows improved accuracy in fitting not only routine cases, but is especially suited for problem cases as illustrated here. *H.R. Lehneis, Ph.D., CPO Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). *Don Sung Chu, M.D. Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). *Howard Adelglass, M.D. Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). <div style="width: 400px;"></div> Page Number(s) 9 - 11 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-6.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-1.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-2.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-4.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/1984_01_009/1984_01_009-5.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-3.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 A Case History: Clinical Indication for Flexible Above-Knee Prosthetic Socket Creator An entity primarily responsible for making the resource Howard Adelglass, M.D. * Don Sung Chu, M.D. * H.R. Lehneis, Ph.D., CPO * https://staging.drfop.org/files/original/6f9164852f923d934924fa8fcf1f17fc.pdf 1b58d80ae3b0054e7a4e88d749254638 https://staging.drfop.org/files/original/e16607ccd46c9c7e42dd07751d977682.jpg 8eaff6854b224c7b799187bdded6988d https://staging.drfop.org/files/original/2166b64e7aaf0c784c32236c01c93747.jpg 410b2c45e6cf4b741c28fe03999558fd https://staging.drfop.org/files/original/331bf1cb4de93a9584b33553af58c3f7.jpg f1b22d42a14fec42d03dc4b116e3a685 https://staging.drfop.org/files/original/df476f11eb4ab1fd182da42ae9133165.jpg 18ded7ff78503d7a542bdbb93f7fa5fa https://staging.drfop.org/files/original/18d2e38e612b0c2cbc33f88021561703.jpg 3c1da62f89d9fe83a64335c1b8383f6a https://staging.drfop.org/files/original/c9afab133e1b7a0100fb05064a779272.png 2ba2e902e2ced64b216af2c281388060 https://staging.drfop.org/files/original/55b9142f83521a8a0e523c679963214e.png 6960cb5288eaf7123f81be484479e8d3 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/1984_01_006.pdf Text Any textual data included in the document <h2>Flexible Prosthetic Socket Techniques</h2> <h5>H.R. Lehneis, Ph.D., CPO <a style="text-decoration: none;">*</a> Don Sung Chu, M.D. <a style="text-decoration: none;">*</a> Howard Adelglass, M.D. <a style="text-decoration: none;">*</a></h5> The continuous development and availability of new materials of various kinds, e.g., elastomers, copolymer thermoplastics, and composite materials have brought a potentially revolutionary development in the design, configuration, and fitting principles of prosthetic sockets, especially for above-knee prostheses. All of this may result in greater patient comfort, physiological, and psychological advantages. Improvements in socket comfort with concomitant physiological and psychological benefits are not only due to the materials themselves, but rather, the inherent characteristics of the various materials used permit socket configurations heretofore not possible. For example, socket fenestrations over selected or entire stump surface areas are now possible. The desirability and principle of permitting greater flexibility over muscular areas than is possible in a rigid, laminated socket were appreciated more than 25 years<a></a> ago in the fitting and design of the "Flexi-cage" socket<a></a> which consisted of nylon cords strung between the proximal brim and the distal end of the socket. McCollough, et al.,<a></a> as early as 1968, attempted fenestrations over selected socket areas. These attempts, however, were not generally successful because of the potential and real problems with window edema and the properties of the material used. These problems now have been overcome through the availability of materials which can be used as elastic or semi-elastic inserts, preventing window edema, yet permitting removal of the outer rigid socket shell in selected areas.<a></a> Below are described several approaches allowing flexible or semi-flexible stump containment, while maintaining the essential biomechanical characteristics required for interface stability to transfer body weight through the prosthesis to the ground, and for dynamic and safe control of the prosthesis. Two systems are curently used at the Institute of Rehabilitation Medicine at NYU Medical Center (IRM-NYU) to provide the characteristics described above. The first system consists of an inner socket laminated of Perlon fiber and silicone elastomer contained in a rigid plastic laminated socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-1.jpg">Fig. 1</a>). The laminated silicone elastomer has nearly perfect memory and permits fenestrations of the rigid outer socket over the posterior area (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-2.jpg">Fig. 2</a>), rectus femoris (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-3.jpg">Fig. 3</a>) and the adductor group, without causing window edema. This design permits greater muscle expansion than the designs described below because of the elasticity of the silicone material. It also provides enhanced sensory feedback, particularly when sitting, i.e., the patient is able to feel the surface of the chair or seat. The soft liner is also a boon to improved comfort, particularly in geriatric amputees and those with a history of general socket discomfort. The second design utilized at IRM-NYU is a Surlyn® inner socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-4.jpg">Fig. 4</a>) which permits removal of even more of the hard outer laminated socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-5.jpg">Fig. 5</a>). The reason larger areas of the hard socket can be removed is the lesser flexibility of Surlyn®. Thus, more rigid material can be eliminated without compromising the integrity of known biomechanical principles (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-6.jpg">Fig. 6</a>). A more recent design developed in Iceland and further refined in Sweden and at New York University, known as the ISNY socket, consists of a medical rigid frame only, leaving the rest of the polyethylene socket semi-flexible. For below knee amputations, similar systems have been developed at IRM-NYU and in Belgium by Van Rolleghm of CEBELOR.<a></a> In the IRM-NYU system, a Surlyn® inner socket permits removal of material in the outer laminated socket over bony or pressure sensitive areas (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-7.jpg">Fig. 7</a>). This permits easy inspection of these areas and ease of adjustment by heating the inner socket to further relieve painful areas. The CEBELOR consists of a silicone laminated soft socket insert for the SP-SC below-knee prosthesis. Thus, it is self-suspending, provides improved comfort, and permits selected fenestration over pressure sensitive areas, e.g., head of the fibula, distal end of the tibia. To prevent slippage and rotation of the inner silicone socket, distal and posterior plugs are laminated as an integral part of the soft socket to fit into female counterparts in the plastic laminated socket. <h3>Summary</h3> While the various systems described above employ different materials and socket configurations, certain characteristics are common to all systems. These are: improved muscle physiology due to greater socket flexibility; enhanced sensory feedback; quicker heat dissipation due to thinness of the flexible stump containment material; and improved comfort, especially in the IRM-NYU and CEBELOR systems with the soft silicone liner. All these are important improvements which were made possible through the use of flexible or semi-flexible materials. Yet, the biomechanical principles of providing stump containment, weight transfer, and control of the prosthetic limb are not compromised. In the ISNY System, however, it is not clear how lateral and anterior/posterior stability of the femur is achieved, since there are no structural components in areas conventionally considered to provide such stability. This question, however, will be addressed in studies to be conducted in the near future. <h3>Acknowledgments</h3> The participation of Donald Fornuff, CP, and Roger Chin, CPO, in the development of the IRM-NYU systems is gratefully acknowledged. References: <ol> <li>Bach, Johann; Essen, Germany, personal communication, 1958.</li> <li>Fillauer, Carlton; Chattanooga, Tennessee, personal communication, 1983.</li> <li>McCollough, Newton, and Sinclair, William, "Some Considerations in Management of the Above-Knee Geriatric Amputee," Artificial Limbs, 12:2, 28-35, Autumn, 1968.</li> <li>Ockenfels, Peter; Columbus, Ohio, personal communication, 1983.</li> <li>Sabolich, John; Oklahoma City, Oklahoma, personal communication, 1983.</li> <li>Van Rolleghm, Jacques; Brussels, Belgium, personal communication, 1983.</li> </ol> <div style="width: 400px;">*Howard Adelglass, M.D. Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). *Don Sung Chu, M.D. Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). </div> <div style="width: 400px;">*H.R. Lehneis, Ph.D., CPO Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). </div> Page Number(s) 6 - 8 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-5.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/1984_01_006/1984_01_006-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-7.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 Flexible Prosthetic Socket Techniques Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., CPO * Don Sung Chu, M.D. * Howard Adelglass, M.D. * https://staging.drfop.org/files/original/a32e7ddca38ac3658b7debb50c742a7d.pdf 94386f89329ed90de7d4de19d32ee144 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/1984_01_004.pdf Text Any textual data included in the document <h2>From Research Lab to Consumer: The Manufacturers' Point of View</h2> <h5>Carlton Fillauer, CPO <a style="text-decoration: none;">*</a> Charles H. Pritham, CPO <a style="text-decoration: none;">*</a></h5> The matter of transferring new developments from the researcher to the consumer is one that has bedeviled the American prosthetic-orthotic establishment for years. The researcher, the agency that funds the research, the manufacturer, the clinician, and the patient are all, of course, interested in seeing new products brought to market, and all stand to benefit. Financially, the manufacturer is the one who stands to benefit the most from the successful introduction of a new product. Only by such means does a manufacturer expand his base and increase earnings. If the incentives are greatest for a manufacturer, the risks are also proportionately greater. In making a decision to produce a new product, the manufacturer must weigh the risks against the potential benefits and make a decision about committing his resources. It should be obvious that once resources of time, effort, and money are lost backing an unsuccessful product, they are lost forever. What is not so obvious is the fact that the loss is threefold. Potentially, at least, the resources expended for backing a losing product could have been invested in a successful one, turning a loss into a profit. Also, in making the decision to back a new product the manufacturer commits his prestige and credibility. A positive result resounds to his credit, attracting new attention to products currently being produced and assuring a positive reception for future products. A negative result has the opposite effect, tarnishing the image of other items in the manufacturer's product line and damaging his credibility. That the investment in a new product can be a high one should not be discounted, therefore. A small group of highly skilled and motivated individuals (or an inventor working alone) can, with a relatively low investment in machinery, produce complicated prototypes efficiently and with a low rejection rate. When the time comes to produce the same object in large numbers, the factors are fundamentally different. Production workers are seldom so skilled or motivated. Oftentimes, to overcome bottlenecks in production and to achieve consistent results, a product must be redesigned. The cost of this redesign must be borne by the manufacturer. To achieve productivity and consistent results, the manufacturer will develop tools, dies, and molds with which to produce a device. Resorting to such an alternative can enable relatively unskilled personnel using inexpensive materials to produce products of great appeal and excellent quality. While the material costs of such objects can be measured in the cents, the cost of the molds and dies can frequently run in the thousands of dollars each. If it is necessary to produce the device in a range of sizes and in right and left, the cost can be prohibitive. It should also be borne in mind that the researcher or inventor frequently has only partially tested the prototype and further testing and development must precede redesign for production. The direct expense of manufacturing an object, however, is only a portion of the cost. In order to sell a product it must be promoted and advertised. The total expense of attending a convention (often far from home), renting space to exhibit, and obtaining a suitable display is not cheap. Commissioning the art work and copy of an advertisement, and obtaining space for it in a journal are, similarly, of considerable expense. The organization that makes all this possible (research and development, production, and promotion) can frequently be quite large and demand a sizable indirect labor force to administer the resources and personnel involved. The total expense of all factors involved in developing a new product is a figure to be reckoned with and can be justified only if the product has the potential of selling in sufficient quantities to recoup the original investment and earn a favorable rate of return. It is in connection with this that the greatest stumbling block is encountered. Whatever the merits of a design may be, a manufacturer can not afford to devote the resources to its development if it will not sell in a large enough volume to enable him to sell it at a reasonable cost. Despite the optimistic expectations of a developer, the market for his new object is seldom as large as he hopes. All researchers and developers seeking federal research money are asked to project the number of individuals for whom their work will be applicable. As all involved will admit, it is a fundamental fact of the way that health care is funded in the United States and the way that health care statistics are gathered that the best of projections are crude estimates. What statistics are available point to the fact that the total market for any one product is small. This market is rendered smaller because not all members of that market are in the marketplace at one time, or even interested in the new product. A new product must compete for a share of the market with existing products that do the same thing. It should be kept in mind that few, if any, developments are so radically different as to have no potential competiton for market share. The price at which established products are sold limits the price for which a new product can be sold. For a new product to rapidly gain market share, it must be reasonably priced versus the competition, potentially much better than the competition, and current users must be very dissatisfied with the competing product. On a practical level, the people to whom a product must be marketed are not the ultimate consumer, but the prosthetist-orthotist who will render that product into a form suitable for a particular patient, and who must also frequently convince the physician to prescribe the device. At any one time, there are said to be about 2,000 practicing prosthetists-orthotists; that is hardly a mass market. Prosthetists-orthotists as a group are not the easiest group to introduce to a new product. Most of them have experience with one or more products that, despite the manufacturer's best efforts, were released before all the problems were worked out. Like the car buyer who chooses not to buy a car during its first model year, they prefer to wait and see. Others, while interested in trying a new product are "waiting for just the right patient." On the other hand, a disconcerting number are all too ready to rush in without thought. Battling for preeminence in every prosthetist-orthotist's lexicon of adages to live by are the two: <ol> <li> If all else fails, read the instructions. </li> <li> Don't force it, get a bigger hammer. </li> </ol> Every manufacturer can recount instances of practitioners who provided a device to a patient for whom it was specifically contraindicated, or who neglected one or more crucial precautions in fabricating the completed device. This can result in a wave of negative word of mouth publicity despite a manufacturer's best efforts to promote a new product and educate the profession about its proper use. The end result may be passive indifference, or active rejection whatever the positive merits of a new device are when it is properly prescribed and utilized. A developer of a new object has a vested interest in making it work successfully and will go to considerable pains to make it do so. It is a well recognized fact that a product, when transferred to even the best motivated and prepared practitioners, seldom works as well as it does for the developer. In summary, then, the following points can be made: <ol> <li> The following factors are sizable expenses: <ol> <li> Research and development of the original idea to a workable prototype </li> <li> Production design </li> <li> Tooling </li> <li> Manufacturing </li> <li> Quality control and testing </li> <li> Marketing </li> </ol> </li> <li> Considerable uncertainty surrounds the business of gauging market size and reception for a new product. </li> <li> However well an object sells, the field of prosthetics and orthotics can hardly be said to constitute a mass market of sizable proportions. </li> <li> Experience has repeatedly shown that it takes three years to achieve a profitable volume of sales once a new product is introduced. </li> </ol> The result of these facts is that the manufacturers of items for use in the prosthetic and orthotic market are confronted with the need to make sizable initial investments for a rather small market that is oftentimes slow to adopt new products of even the greatest merit. Considerable uncertainty surrounds the decision to make the investment and it can take many years for a return on the investment to be realized and the decision to be vindicated. Given these facts, it is understandable that manufacturers differ from developers and their backers about the utility and acceptability of many developments, and that they are slower to adopt new products than others might wish. *Charles H. Pritham, CPO Technical Coordinator, Durr-Fillauer Medical, Inc. *Carlton Fillauer, CPO Vice President, Durr-Fillauer Medical, Inc., Orthopedic Division, 2710 Amnicola Highway, Chattanooga, Tennessee 37406. <div style="width: 400px;"></div> Page Number(s) 4 - 6 Year 1984 Volume 8 Issue 1 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 From Research Lab to Consumer: The Manufacturers' Point of View Creator An entity primarily responsible for making the resource Carlton Fillauer, CPO * Charles H. Pritham, CPO * https://staging.drfop.org/files/original/12c366995fac640412262b97e21e05bc.pdf 5425bdb7fa0bf0a71fba5604a71cbe09 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/1984_01_003.pdf Text Any textual data included in the document <h2>Prosthetic-Orthotic Research - A New Thrust is Needed: A Clinician's Perspective</h2> <h5>Charles H. Epps, Jr., M.D. <a style="text-decoration: none;">*</a></h5> Since the prime supporter of research, the federal government, has sharply reduced some areas of funding, the efforts of many established investigators and programs have been curtailed. Hardest hit has been the young aspiring investigator without a track record, who has found it virtually impossible to acquire funding for initial research efforts. Basic research as well as clinical research has suffered. Prosthetic and orthotic research programs which have never had abundant or even adequate funding also have been adversely affected. In the area of upper extremity prosthetics, much research remains to be done. For the patient who wears a prosthesis, cosmesis is still a major concern. Cosmetic acceptability must be improved and sensory feedback must be developed; sockets must be made more comfortable and suspension must be improved. Myoelectric control systems and other methods of external power must be made more functional, more compact, and more economical. In the lower extremity, newer materials and techniques must be developed to make prostheses lighter in weight, especially for the geriatric wearer. Although there seems to be less enthusiasm today for skeletal attachment of prostheses, the concept remains a challenge. The mechanical integrity and durability of knee devices can be improved along with fitting and alignment techniques. Because of basic lack of knowledge about the effects of forces on bone, ligaments and tendons, the need for orthotic research is even greater than in prosthetics. More needs to be known about the magnitude and patterns of forces that are necessary and safe to orthotic applications. Workers in kinesiology and gait laboratories around the country are endeavoring to find more answers to diagnostic problems and to collect useful data for orthopaedic assessment and even surgical treatment. New materials offer the orthotist new versatility. The pneumatic orthosis, a new concept, is ready for full development. Electrical applications are at an embryonic stage in the stimulation of paralyzed muscles, inducing therapeutic exercises, and providing afferent or feedback systems. New interest has developed to improve powered mobility devices to replace the conventional electric wheelchair for the high level spinal cord injured patient. Specially adapted vans can be operated safely by paralyzed, limb deficient patients and other severely handicapped. In view of the potential offered by computer applications and rapidly improving robot technology, environment control devices are on the threshold of great advances. So much remains to be done in prosthetic-orthotic research that even the casual observer must be concerned. At the same time that public research dollars have decreased, private research dollars have not increased sufficiently to fill the void. Obviously, research needs offer a challenge to orthopaedic surgeons who must increase the amount of personal time and funds given for research. At least one encouraging sign of private sector philanthropy exists. Bristol-Meyers/Zimmer U.S.A. has donated 1.2 million dollars to the Orthopaedic Research and Education Foundation (OREF) for the 1983-1984 Campaign. To date, more than 150 orthopaedic surgeons have given $1,000 each to OREF for the current campaign. This is in sharp contrast to the previous years' total of $200,000 from all sources. Other members of the industrial community should duplicate and even surpass the example set by the Zimmer group. If this instance of giving by the orthopaedic surgeons and a prime industrial supplier is replicated by prosthetic-orthotic practitioners and members of the corresponding industrial manufacturing community, the funding for prosthetic-orthotic research can be adequately raised to support needed research programs. *Charles H. Epps, Jr., M.D. Division of Orthopaedic Surgery, Howard University Hospital, Washington, D.C. Page Number(s) 3 - 4 Year 1984 Volume 8 Issue 1 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 Prosthetic-Orthotic Research - A New Thrust is Needed: A Clinician's Perspective Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/a35cfabdeded6efeb701fabb13e0203a.pdf 1c6c0d675c28db96ad766418ff443a9b https://staging.drfop.org/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg 14d5744670f9a9f1540367bb959c02c2 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/1984_01_001.pdf Text Any textual data included in the document <h2>Transfer of Rehabilitation Research and Development Results into Clinical Practice</h2> <h5><a href="/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg">Margaret Giannini, M.D. *</a></h5> For more than thirty years, Dr. Margaret Giannini has been a pioneer in creating programs for the diagnosis, treatment, education, rights and affairs of the mentally retarded, developmentally disabled and the handicapped. In 1950, Dr. Giannini founded and directed the Mental Retardation Institute at New York College. In 1980, she accepted a Presidential appointment as the first Director of the National Institute of Handicapped Research, a branch of the U.S. Department of Education. In April, 1981, Dr. Giannini took over the position of Director for the VA Rehabilitation Research and Development Service (Rehab R&D). In addition to these positions, Dr. Giannini is past-president of the American Association on Mental Deficiency and past-president of the American Association of University Affiliate Progams, two of the most influential organizations concerned with the mentally and physically handicapped. Dr. Giannini is the recipient of many awards from varying organizations in recognition of her professional and humanitarian services and achievements. She also has authored and co-authored numerous publications; presented many lectures, papers, keynote addresses; and participated in panel discussions and workshops throughout the world. The Veterans Administration, Rehabilitation Research and Development Service (Rehab R&D) funds approximately 100 projects a year aimed at developing new methods or improving existing techniques for assisting disabled veterans. The program was created by a Congressional mandate, U.S.C. 38, Sec. 4101, (c)(1) and (2), which directs that the VA "carry out a program of medical research including prosthetics research. Prosthetics research should include research and testing in the field of prosthetic, orthotic and/or orthopedic appliances and sensory devices." A review of Rehab R&D scientific and engineering accomplishments provides insight into the VA/Rehab R&D technology-transfer programs. Some of the recent and ongoing research conducted under this sponsorship includes: maxillofacial restorations—to include use of biomaterials and their clinical applications; development and evaluation of robotic aids for the severely disabled; seat cushions for the paralyzed to prevent decubitus ulcers; functional electrical stimulation (FES) systems for upper extremity control; physiological effects of FES on paralyzed muscles; walking restored in a paralyzed man using FES; a motion-guiding load-bearing external frame for the knee; possible myoelectric controlled above-knee prosthesis; oprimum prosthetic foot characteristics for the dysvascular below-knee amputee. Image: Dr. Giannini In addition to sponsoring such research in the past, Rehab R&D has established a program concerned with the transfer of research into clinical practice. This program consists of the following six parts: <ol> <li> Establishing clinically relevant research priorities. </li> <li> Insuring that the significant research encompasses clinically relevant factors. </li> <li> Dissemination of research findings to the scientific community. </li> <li> Evaluation of research results for suitability for transfer to clinical settings. </li> <li> Support to private industry to make new devices and equipment commercially available. </li> <li> Dissemination of new methods to clinical practitioners. </li> </ol> Each of these is examined at length in the remainder of this paper. <h3>Establishing Clinically Relevant Research Priorities</h3> In the past, the VA had only general research priorities for award of Rehab R&D funds. Oftentimes researchers focused proposals on esoteric topics which were of little or no clinical significance while major clinical issues went unaddressed. To remedy this situation, a series of workshops were held with consumers and clinical leaders to develop priorities for research on clinically significant issues. Many of the workshops sponsored by RESNA and the VA have been published. Workshop topics have included sensory aids, functional electrical stimulation, and prosthetics/amputation. Rehab R&D also has participated in meetings of the International Standards Organization (ISO) which established specific priorities within the areas of prosthetics/amputation, spinal cord injury (including wheelchairs), and sensory aids. Rehab R&D now has a policy of soliciting and approving funding for only those proposals which fall within these priorities. <h3>Ensuring that Research Addresses Relevant Clinical Issues</h3> There is a vast distance between research and clinical application of methods and devices. Rehab R&D has the responsibility not only to fund research, but also to initiate and support the development of the clinical methods necessary for effective application. For example, the outstanding work done by Ernest Burgess, M.D., in Seattle, and others on immediate postoperative fitting requires new and complex clinical procedures. A necessary step in promoting clinical application of this method has been the development of a clinical procedures manual and the training of practitioners and patients. <h3>Dissemination of Research Findings</h3> The new VA Journal of Rehabilitation R&D replaces the earlier Bulletin of Prosthetics Research with a number of major changes. Aimed at the entire scientific community, and charged with following the highest standards of scientific quality, the Journal of Rehabilitation R&D is designed to offer an interdisciplinary vehicle for publication of technical materials which can most directly reach rehabilitation professionals. In addition to the Journal, the first edition of a new annual publication Rehabilitation R&D Progress Reports, is now in press. This publication is aimed at providing a comprehensive overview of research and development now in progress both in the United States and internationally. One of the publication's functions will be to serve as a guide to sources of information within the areas of Rehab R&D priorities. Rehab R&D, in the planning stage of developing, will work in coordination with professional organizations in the field to facilitate the translation of scientific results into technical clinical information of direct relevance to practicing clinicians. <h3>Evaluation of Research Results</h3> The Chief Medical Director of the VA has given approval to establish the Development and Evaluation Program (DEP) for the evaluation of research and development findings to determine their suitability for adoption into clinical practice. The program is designed to stimulate, evaluate, and acquire and disseminate information, including the development of educational guidelines and technical manuals. The educational guidelines will be coordinated between the Continuing Education Resources Service and the Prosthetics and Sensory Aids Service (PSAS). Thus, both the people who will prescribe and/or use these new devices, techniques, or concepts, will be trained. Rehab R&D will not actually provide the training, but it will provide the data and/or research scientists as instructors for the training program. This Rehab R&D program is currently limited to devices specifically developed in VA or other federally funded R&D projects. Rigorous evaluation will provide objective and comprehensive information to the key decision makers related to clinical adoption. Information will be provided to funding agencies—including the VA—which must formally approve reimbursement of the devices or use of procedures in clinical practice; to industry so they can decide whether to add the devices to their commercial lines; and to clinicians who must decide on how to apply the new methods or devices. VA responsibility for evaluation will be shared cooperatively between Rehab R&D on new research, and by the VA's Prosthetics and Sensory Aids Service on devices which are already commercially available, but have not been previously evaluated. <h3>Support to Private Industry to Make New Devices Commercially Available</h3> No matter how good research and engineering results are, they are of no value unless they become available to clinicians. Many useful devices which have resulted from research are not commercially available. To overcome this gap, discussions have been held with industrial leaders who have offered advice on the nature of the rehabilitation market, which is just one impediment. Based upon the input of these industrial leaders, commercial availability is being attacked on two fronts. First, an interagency agreement with the Department of Commerce has been developed to assist small minority business firms in tooling-up for offering new products as a part of their commercial lines. Specifically, the interagency agreement provides for the study of marketing and development methods to fully utilize the research and development of new devices for the disabled. The purpose of this interagency agreement is to utilize existing programs in the Minority Business Development Agency (MBDA) and stimulate marketing for devices that result from VA-sponsored R&D. The National Commission of Technology Transfer, of the Department of Commerce, is in the process of offering funding in order to: <ul> <li> plan for an international conference on making prosthetic and orthotic devices and sensory aids readily available to the handicapped population; </li> <li> identify and develop potential markets and financing for such devices; </li> <li> examine the use of microcomputers and other high technology areas; </li> <li> examine the impediments to obtaining funding for high-technology products; and, </li> <li> develop a process that leads to the commercialization of technology researched and developed by the VA, with emphasis on providing access to these markets for minority entrepreneurs. </li> </ul> Arrangements have been made to encourage private industry to adopt the results of individual research products which are judged to have particular merit. As a result of these efforts, the Johns Hopkins Manipulator will soon be commercially available. Other negotiations are continuing. To facilitate this process, VA Rehab R&D has assisted in the creation of a National Commission for Technology Transfer, which is concerned with making research results commercially available to handicapped people. <h3>New Directions</h3> Future plans by VA Rehab R&D to assist in the transfer of technology from research to clinical practice are as follows: <ul> <li> Continued publication of the Journal of Rehabilitation R&D and the R&D Progress Reports; </li> <li> Publication and distribution of papers on subjects potentially relevant to future clinical practice (e.g. training manual for use of robotic systems for the severely disabled); </li> <li> Design and implementation of a formal research program, based at the Office of Technology Transfer, to evaluate and improve the transfer of technology, including: <ol> <li> The collection of clinical practice data from VA facilities to give a chronological picture of the gap between state-of-the-art devices and actual clinical practice; </li> <li> A series of consumer surveys to determine their needs and to uncover problems or frustrations with existing rehabilitation procedures and equipment; and, </li> <li> A series of surveys among clinical practitioners to collect data on clinical needs, problems and priorities. </li> </ol> </li> <li> A periodical and/or a technical communication in existing periodicals for clinicians, designed in cooperation with PSAS, the Academy, AOPA, AAOS, Paralyzed Veterans of America, Disabled American Veterans, National Institute of Handicapped Research, and other organizations to further enrich the transfer of new research findings to clinicians in a format tailored to their practical needs. In the long run, a computerized reference system may be developed; </li> <li> Seminars on selected topics between recognized clinical leaders and senior researchers who have achieved scientific breakthroughs relevant to clinical practice; and, </li> <li> Access to national and international scientific and clinical literature. </li> </ul> These thrusts are ambitious and will take time, but they convey the depth of Rehab R&D commitment to technology transfer. *<a href="/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg">Margaret Giannini, M.D</a>. A native of New York, Dr. Giannini is married to Louis J. Salerno, M.D. and has raised four sons. Dr. Giannini is scheduled to speak at the Academy Annual Meeting in Orlando on January 26, 1984. <div style="width: 400px;"> </div> Page Number(s) 1 - 3 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_001/1984_01_001-1.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 Transfer of Rehabilitation Research and Development Results into Clinical Practice Creator An entity primarily responsible for making the resource Margaret Giannini, M.D. * https://staging.drfop.org/files/original/8c11b3cbe55906e1a1186e314abc12de.pdf 89e25364859efdc360a9591d8eafde92 https://staging.drfop.org/files/original/6cd45f3b1fecdd1934f70f5984f7f04e.jpg 17a303332067cd2cc381bb5fef3e72a9 https://staging.drfop.org/files/original/280c3bdf5f55120e4c0ff0ca8df2cef8.jpg 9a6fcac68852c85bdace0fecdbd25448 https://staging.drfop.org/files/original/e27129c49cee597181f097ae05458f31.jpg 70e3eb3d448acc0502e384554fc7add8 https://staging.drfop.org/files/original/09cab4907fea00930e6fcb6e8e4313e4.jpg 47629a5785f7d3b3038584a0bf02b2e2 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_04_171.pdf Text Any textual data included in the document <h2>Prostheses to Achieve Independent Ambulation for a Geriatric Quadruple Amputee</h2> <h5>Gustav Rubin, M.D., FACS <a style="text-decoration: none;">*</a> Fred Harris, B.S., CO. <a style="text-decoration: none;">*</a></h5> The elderly quadruple amputee presents a challenge to a prosthetic clinic team. Although this problem is occasionally noted in children with congenital amputations,<a></a> it is much less commonly encountered in adults. During the past fifteen years there has been only one other total quadruple amputee-a young adult who was treated at our center and did not wish to have his case published. Here we have the opportunity to present a report on the prosthetic fitting of a 64 year old veteran who was referred to our Special Clinic Team in 1981, from the VA Medical Center in Cleveland, Ohio, with a history of quadruple amputations secondary to frost bite. H.F. was found on January 8, 1981, on a cold winter day, lying outside his home. He was unresponsive and had a rectal temperature of 77°. After a period of conservative care, amputations on all four limbs were done on February 4, 1981, at the private hospital in Canton, Ohio, to which he had been initially taken. The surgery resulted in a right wrist disarticulation, a left distal forearm amputation just proximal to the carpus, and bilateral below-knee amputations. The residual limbs healed without complications and the patient was transferred, on March 11, 1981, to the V.A. Medical Center in Cleveland, Ohio, where he was started on a course of physical and corrective therapy, including daily strengthening exercises to all four extremities. He was considered highly motivated and an "excellent candidate" for prostheses. He was referred to our center, which was then the V.A. Prosthetics Center, and was examined by the Special Prosthetic Clinic Team on May 21, 1981. H.F. also had a background history of gastrointestinal surgery ten years earlier for a perforated peptic ulcer. The report of the physical examination at the hospital prior to referral for prosthetic prescription revealed a normal cardiovascular examination, a blood pressure of 110/70, but a liver enlarged three cm. below the costal margin. The popliteal pulses were good. The evaluation by the clinic team confirmed that H.F. was well-motivated. He was an intelligent, cooperative, slender individual, whose amputations were all well-healed. The right below-knee residual limb measured 4 inches to the bone end and the left below-knee limb measured 4 1/2 inches to the bone end. There were mild knee flexion contractures which were not considered fitting problems. On the right below-knee limb there was a palpable, slight, irregular, distal anterior tibial bone prominence, unattached to the overlying tissues. On the left side the below-knee limb was poorly padded by soft tissue. As the examiner attempted to mimic piston motion of the soft tissue sleeve by drawing the soft tissue proxi-mally, the distal skin, overlying a slight bone irregularity, blanched. X-rays of the left below-knee residual limb confirmed the clinical impression of bone irregularity and x-rays of the upper extremities confirmed the right true wrist disarticulation and the left amputation just proximal to the carpus at the level of the distal radius and ulna. The amputee had been through a great deal (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg">Fig. 1</a>) prior to referral to the Clinic Team and it was the consensus, at this time, that referral for a lower extremity revision would have adverse impact on his motivation. It was the aim of the staff to make the patient as independent as possible by adapting the prostheses to his donning and doffing capabilities. PTS prostheses were prescribed to be fabricated with loops on the soft socket inserts (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg">Fig. 2</a>) to aid donning. The prostheses for the upper extremities employed a Northwestern ring for the figure of eight harness, double wall sockets, friction wrists, and Dorrance Lyre hooks. <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg">Figure 1. H.F., a 64 year old veteran and quadruple amputee.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg">Figure 2. Below-knee prostheses were adapted with loops on the soft socket inserts to aid in donning.</a> In addition, he was prescribed for platform crutches, which were modified with distal rings for the hooks and forearm loops (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg">Fig. 3</a>). The forearm loops had to be pre-adjusted into a fixed position so that H.F. could slip the prostheses through the loops and avoid the need for repeatedly adjusting the Velcro® straps. <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg">Figure 3. Platform crutches were also modified with distal rings for the hooks and forearm loops.</a> On June 11, 1981, fabrication of the below-knee prostheses was completed and the amputee demonstrated that he could stand and take several steps in parallel bars with assistance on each side. An exercise and training program with the prostheses was outlined at the hospital. The instructions included careful monitoring of the stumps during this time. On June 18, 1981, the amputee was observed to be doing "extremely well," as indicated by the clinic team's notes. By this time he had also been fitted with his upper extremity prostheses and forearm crutches. He rapidly progressed to unassisted ambulation with crutches (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg">Figure 4. H.F. progressed to unassisted ambulation with crutches.</a> When seen by the clinic team on August 10, 1981, H.F. walked with the aid of a platform crutch. Because of irritation over the right ulnar styloid process, which was unresponsive to modification of the socket, a new socket was prescribed incorporating a soft liner and he had no further problems with this. On September 16, 1981, four months after his initial presentation to the team, H.F., who had been under continuous training by the Rehabilitation Service at the VAMC, NY, demonstrated that he was able to don and doff his own prostheses and even walk without crutches. He did, however, have more confidence when using one crutch. He was advised to continue using at least one crutch at all times. He reported the prostheses to be comfortable. Objectively, they appeared to fit satisfactorily and they were accepted. The amputee was returned to the VA Medical Center in Ohio. Subsequent attempted follow-up has been unsuccessful. References: <ol> <li><a href="http://www.acpoc.org/library/1977_11_001.asp">Sullivan, Richard A., and Celikyol, Felice, "Prosthetic Fitting of the Congenital Quadrilateral Amputee: A Rehabilitation-Team Approach to Care," Inter Clinic Information Bulletin, XVI:11-12, November-December, 1977, pp. 1-6.</a></li> <li><a href="http://www.acpoc.org/library/1972_11_013.asp">D'onofrio, F. and Cope, P.C., "Crutches for the Quadrimembral Amputee," Inter Clinic Information Bulletin, XI:11, August, 1972, pp. 13-15.</a></li> </ol> *Fred Harris, B.S., CO. Fred Harris, B.S., CO., is also with STAMP, NY. *Gustav Rubin, M.D., FACS Gustav Rubin, M.D., FACS, is Director of the Special Team for Amputations, Mobility, Prosthetics/Orthotics, New York (STAMP, NY), 252 Seventh Avenue, New York City, NY 10001. Page Number(s) 171 - 173 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.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 Prostheses to Achieve Independent Ambulation for a Geriatric Quadruple Amputee Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., FACS * Fred Harris, B.S., CO. * https://staging.drfop.org/files/original/3ec7888cee2f851b5ad939cfc35e9698.pdf fa3c522ca3dfd7e1953c8cf88f054613 https://staging.drfop.org/files/original/2616f512f3d92ac4e805d79a4a8c64e8.jpg 6cd68ef1007dbe4d5d6544411ccf6f4f https://staging.drfop.org/files/original/d371115128acfc7dc1bd1659a5ceb2f1.jpg 8deb734fb9677fc2cf23fb2b9da7508a https://staging.drfop.org/files/original/e917b8732cef50461c1b681f0c7ecf1b.jpg e7deb03a7c60d3420be551312817837d https://staging.drfop.org/files/original/e1cf8112df2a1bb2aaf97e8332e6283c.jpg 00d0af6d0e569c08eb99f6c8a0b9bfb9 https://staging.drfop.org/files/original/c47154226c8b4249202c0177d968f9e4.jpg 788be41c8c242497efb0357b9909d3bd https://staging.drfop.org/files/original/d2df4f38ae19ba6c1560527a9c637a97.jpg 789ef1b71b6b7f3880aa1cc1b897b13b https://staging.drfop.org/files/original/425550a68b616b6cce5a9eeb50c3fc1b.jpg 11e3639315fd4c06d8fd6f7599c446ed https://staging.drfop.org/files/original/c00b05fc2d9be2f9a1cbf792263fab16.jpg 468d623d117056703073eb6525cb72bd https://staging.drfop.org/files/original/f7ef05f73d6d3e5119b1b1a3ea3df648.jpg 0f90542403702a924a2c605a62d317aa https://staging.drfop.org/files/original/62f30434ecf0464e8a03a8e7566f1fee.jpg e87645ad72adee68b98015e48c906e9d 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_04_159.pdf Text Any textual data included in the document <h2>Commercial Options for Positioning the Client with Muscular Dystrophy</h2> <h5>Michael Silverman, CO. <a style="text-decoration: none;">*</a></h5> Before the advent of modern medicine, progressive weakening of the musculature was thought to be due to disorders of the nervous system. Early researchers thought the problem was with the nerves somehow being unable to activate the muscles, which in turn caused the muscles to atrophy. It wasn't until the late nineteenth century that researchers began to understand that these problems were due to the muscles only, without involvement of the nerves. In 1861, Guillaume-Benjamin-Amant Duchenne, a Bolognese sea captain's son, published the first description of the severe childhood form of muscular dystrophy now known by his name. Specifically, Duchenne noted that the disease ran in certain families, and he clearly defined pseudohypertrophy (false overdevelopment) of the calf muscles as one of the disease's symptoms. It was thirty years later that Wilhelm Erb described the underlying clinical features of the various forms of progressive muscular dystrophy and outlined four subvarieties. "Some of the observed features included symmetrical muscle wasting, progression, abnormal gait, a development of charcter-istic body deformities. Erb was the first to see that these symptoms were disorders of muscle tissue, not of nerves, and he hazarded to guess that they were due to a complex nutritional disturbance."<a></a> Over the last few decades, many categories of muscular dystrophies have been designated. Some, such as Myasthenia Gravis, are controllable with simple medication and do not require special devices other than lightweight orthoses. Others, such as Duchenne muscular dystrophy, are progressive and require increasing amounts of specialized equipment to make the disability as manageable as possible. In this paper, the development of specialized seating for clients with muscular dystrophy, as well as new systems on the market today, which can help to make these clients remain as functional as possible for as long as possible, will be reviewed. Below are listed some of the major types of muscular dystrophy whose treatment will often require specialized seating. <blockquote> Duchenne (Pseudohypertrophic) Rapid, ultimately involving all the voluntary muscles. Death usually occurs within 10-15 years of clinical onset. Werding-Hoffmann (Infantile Spinal muscular atrophy) The earlier the onset, the more rapid the course. Respiratory failure and/or infection usually cause death. Kugelberg-Welander (Juvenile spinal muscular atrophy) Variable, but usually very slow. Most patients live to old age. Amyotrophis Lateral Sclerosis Rapid, leading to death usually within three to five years.<a></a> </blockquote> There are no easy rules for seating the client with muscular dystrophy. The pattern and severity of weakness varies from client to client and is usually changing so that each client has to be looked at for his individual needs. With the early onset of Werdnig-Hoffmann, specialized seating can be used to help with the prevention of deformities. These children tend to be very floppy. The positioning system will make them easier to handle and put them in a position where they can use their arms and hands to explore the world around them. The pre-adolescent onset of Duchenne muscular dystrophy will often times lead to extreme curvatures of the spine unless the client is properly managed in a positioning system or orthosis. The advantage of using a positioning system in place of an orthosis is usually that of comfort. The positioning system should provide greater comfort to its user than the use of a wheelchair with a sling seat and back. The orthosis can be a source of discomfort to the user and, for this reason, is likely to be left in the closet. "This tendency for the brace to be uncomfortable is understandable because of deformity is a collapsing type of scoliosis and the patient lacks the muscle power to pull away from a painful pressure area."<a></a> With degenerative forms of muscular disease, the most important thing a positioning system can do for the client is to aid in increasing his function, allowing him to continue with normal activities of daily life for as long as possible. The client with Amyotrophis Lateral Sclerosis (ALS) presents a whole new set of problems for the clinician. Because of the age of onset and rapid progression of the disease, the clinician does not usually have to worry about the prevention of deformity. But these same problems make it nearly impossible to design a positioning system that will provide these clients with comfort and function for any reasonable length of time. Clients with ALS tend to prefer less contoured systems, and require adjustable reclining mechanisms for comfort. Once the decision has been made that a positioning device may be beneficial, certain questions must be considered and information about the clients' family and home environment must be obtained. Then methods of transportation must be looked into. What is the prognosis of the clients condition? Is the client out with the family occasionally or most of the time? Are the outside conditions rural or urban? What are the client's favorite activities? What are the families needs? Does the family have, or will they be getting, a van which would allow the client to be transported in his or her positioning system? How close is the roofline to the clients head while seated in their standard wheelchair? Is powered mobility needed now or in the future? An overall clinical evaluation should be made and the results of these tests should be available before any positioning decisions are made. A complete physical and functional evaluation of the client is necessary to determine the extent of the weakness and whether there are any contractures present. Orthopedic considerations add another dimension and may require the input of a surgeon to determine if releases are possible to aid in good long-term positioning. (A consideration with Duchenne muscular dystrophy is the question of a possible spinal fusion.) Any deformities which are present must be noted, as their severity will help further narrow the options for positioning the client. Slight flexion contractures of the hips or knees should not pose a problem for a successful positioning system. However, extension contractures of the hips or ankles could be more of a problem. Remember that a positioning system can serve a preventative role in reducing the formation of contractures and deformities, but the positioning system cannot be used to correct these situations. If correction is needed, it is best done on the operating table before the seating system is provided. The seating system should allow the client enhanced abilities when using the system. The extremities also need to be looked at in relation to function. Arms must be free if independent mobility is possible. Strength must be tested to determine if ultralight bases would be of benefit. The wheelchair is as much a part of the seating system as a headrest or foot support. There are many types of wheelchairs on the market today and the initial evaluation is critical in determining what type wheelchair would best serve the client. For the purposes of this paper, we will concentrate on positioning solutions only. When deciding on the best position in which to seat a client with muscular dystrophy, it is necessary to start with the pelvis and achieve a neutral position to provide a stable base of support. Standard sling seats provide an unstable surface for sitting, as the pelvis will not sit level and forces a lateral compensatory curve up the spine (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg">Fig. 1</a>). The pelvis should be in midline and should not be allowed to slide laterally by blocks built into the positioning system. A 90 degree position of hip flexion is desired, and in some cases, a back-to-seat angle of less than 90 degrees may be beneficial, especially when introducing increased lordosis into the spinal section. An anteriorly wedged seat will help to achieve a proper hip angle, while assisting to maintain the client in the seating system. The object is not to immobilize, but to stabilize the pelvis. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg">Figure 1.</a> A person with abnormal tone becomes more a asymmetrical when seated on a hammock type surface. (A. Bergen and C. Colangelo, "Positioning the Client with CNS Deficits," 1985, p. 7). To complete the base of support for the upper body, the clinician must properly position the lower extremities. An abductor (wedge) will help to position the legs slightly apart giving a wider base of support (be careful not to bring the legs any wider apart than the diameter of the hips.) When using an abductor, keep it away from the groin and make sure it is of the flip-down or removable variety if a urinal is being used. Sometimes the clinician may wish to use an abductor as a reminder of the proper placement of the client in the positioning system, especially when there may be multiple care givers. The knees and ankles should be at 90 degrees unless contractures are present. In many cases, the knees may have to be extended slightly in order to clear the front casters of the wheelchair. The feet should always be supported so as to complete the stable positioning of the pelvis. As you can see, a great improvement in seating can be made just by replacing the sling seat upholstery with simple plywood and foam componentry (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg">Figure 2.</a> A firm sitting surface provides a base for symmetrical sitting. (A. Berger and C. Colangelo, "Positioning the Client with CNS Deficits," 1985, p. 7) Now, the clinician is ready to work his way up the spine. The trunk must be held in midline, as close to natural shape as possible to allow better head control. In older clients, the natural shape of the spine includes forward curves at the neck and lumbar region of the spine. For the floppy client, as well as those with a scoliotic deformity, lateral trunk supports are usually required. Usually with scoliosis, the pads are placed under the apex of the curve on the convex side and under the axilla on the other side. The third point of the pressure system is the pelvis held in with good lateral positioners (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg">Fig. 3</a>).<a></a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg">Figure 3.</a> Transverse loading in seating the patient with scoliosis (rear view). With clients who have flexible spines, many different approaches to positioning are used. For the small child with spinal muscular atrophy, allowing the spine to shape into a gentle C-curve may promote the best head position. Increasing the lordosis with these clients may help to push them out of the chair and cause their heads to fall backward. In the case of adolescent clients with Duchenne muscular dystrophy, increasing their lumbar spinal extension may actually help with the prevention of lateral curvature, as well as promote good head positioning. To understand this idea, one must first understand the mechanism of the spinal collapse in the client with Duchenne muscular dystrophy. The first sign of spinal instability as demonstrated by roentgenograms (x-rays) is the appearance of a long thoracolumbar curve of less than 10 degrees sent in patients who are ambulating with the aid of long leg braces. During the early wheelchair bound stage, the curves lose their flexibility. They also involve fewer vertebral segments, primarily in the lumbar spine, without axial rotation in curves of less than 20 degrees of lateral curvature as measured by Cobb's method. Rotation in the upper segment of the curve, which generally extends over the bodies of T10 to L3, is followed with maximal rotation at L2 of an estimated 5 degrees. Vertebral rotation then increases at a faster rate than the lateral displacement. Once rotation reaches 15 degrees and the lateral curve 30 degrees, both parameters increase rapidly. Mr. Jan Koreska and his group at the Hospital for Sick Children in Toronto, Ontario have done many studies of the spine which suggest that if lateral displacement of the lumbar spine is not prevented, axial rotation follows, and by this time conservative bracing is unlikely to succeed since structural failure has already occurred.<a></a> They also found that the posterior facets and ligaments of the lumbar spine appear to be responsible for the linear alignment of the lumbar spine. The influence of the posterior facets on the upper lumbar spine appears to be less significant because their resistance to axial rotation is reduced. "Some 80 percent of the children develop a collapsing type of scoliosis." The observation of 62 spines of boys by the Hospital for Sick Children yielded consistent results. "A few patients' spines gradually became very stiff and somewhat hyperextended over a period of years. When this happens, the patient will be a good sitter for a long time. The more usual pathway involves moving gradually from a straight spine to a rapidly steady progression into a severe kyphoscoliotic."<a></a> The first seating system developed specifically for prophylactic use by clients with Duchenne muscular dystrophy was developed in the mid 1970's. This specially designed seat was effective in limiting the progression of spinal curves to less than one degree per month in 13 out of 16 patients. The thought was, if spinal deformity could be maintained until skeletal maturity was achieved, good spinal alignment could be maintained. Clients whose curves progressed to greater than 35 degrees would usually ultimately require surgery. The Toronto Spinal Support System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg">Fig. 4</a>) is made of a fiberglass shell, lined with custom carved ethafoam, upholstered with a modified urethane foam and a tricot double knit covering. Headrests, arm rests and leg supports are attached to the fiberglass shell. The unit is meant to be inclined backward a minimum of 15 degrees. The pelvis is snugly fitted and the thoracolumbar junction extended, while the back has lateral guides to promote midline sitting. "The snug fit gives the spinal column a stable base (the pelvis), and the extension of the thoracolumbar region reduces the mobility seen when the interarticular facet joints at this level are opened up in flexion. The 15 degree backward tilt reduces the load on the spine every time the patient leans back, while the foam lining makes it comfortable and acceptable to the patient."<a></a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg">Figure 4.</a> The Toronto Spinal Support System. Conclusions from the group in Toronto over the last few years show that, although spinal deformity is not absolutely prevented, development is slowed, prolonging the period of trouble free sitting. This slowing down of the development of the spinal deformity takes place at a time when spinal growth is rapid, making the introduction of the system at a young age before puberty of utmost importance. A 10 year follow-up to the development of the Spinal Support System (SSS) sponsored by the Muscular Dystrophy Association of Canada was completed in late 1983. Following are some of the more significant findings. <ol> <li> The Spinal Support System has made a significant contribution to the management of individuals with Duchenne muscular dystrophy across Canada. Improvement of user comfort is the attribute most consistently stated. The SSS development has been particularly well received by parents. </li> <li> The SSS in its originally conceived design does not arrest the progression of spinal deformity. However, reduction in the rate of progression of deformity (1/3 to 1/2) was reported by the participating clinics. </li> <li> From the clinical data available, it was not evident that any one single feature of the SSS is the key to the improvement of spinal management; but rather suggests that there is a combination of multiple interrelated factors involved. </li> <li> There is no clear evidence supporting the hypothesis that extension of the lumbar spine is the key contributor to the lateral stabilization of the spine. </li> <li> Lack of easy adjustment for growth or change of spinal alignment creates serious delays or the postponement of the necessary revisions. </li> <li> Although biomechanically advantageous, the 15 degree recline of the backrest necessitates that the child lean anteriorly and away from the posterior supporting surfaces when participating in functional activities or seeking head stability. Only rarely were children observed or reported as using the back and head rest as intended by the designers. </li> <li> The use of prefabricated modular components which results in relatively easy assembly is viewed as a very positive feature of the design concept. </li> </ol> The overall experience with the Spinal Support System was pretty well summed up in a follow-up study completed by a review committee in 1983. "Most of the principles obtained from the SSS study in Toronto have included the importance of the incorporation of a lumbar lordotic pad to maintain the lumbar and thoracic spine in a lordotic position. The concept is, if the spine is going to become fused or rigid spontaneously, it will adopt a stiff extended alignment rather than collapsing kyphoscoliosis. However, this is the exception rather than the rule. There is no orthotic or seating system in use today, including the Spinal Support System, that will prevent the majority of these children (approximately 90 percent) from developing a collapsing kyphoscoliosis. Even in the few cases (perhaps 10 percent) in which the result is a stiff extended spine, the contribution of the seating system towards that outcome is probably only minimal. Surgery is serious; it must be offered to the patients and parents with full knowledge of potential complications. The patient's pulmonary reserve must be sufficient to withstand the surgery and the disease. The rationale for surgical intervention may be difficult to accept by the parents when the effects of non-surgical intervention are not yet readily evident. If successful, the surgical intervention will stabilize the spine, making the seating problems easier for the management team. However, even when surgical stabilization is undertaken, appropriate seating systems are required since the patient still requires pelvic support, upper and lower limb alignment and support, head support and mobility. Generally, the Spinal Support System has addressed the problem of development of scoliosis in muscular dystrophy patients. It has decreased the rate of progression, as shown in several studies. However, this may be detrimental to the patients general health because of the progression of the decreased pulmonary reserves. That is, the management team may be lulled into a "wait and see mode," only to find out later that the reduced vital capacities have shifted the balance of risk towards non-surgical management, whereas early surgical intervention would have been the treatment of preference. The use of the modified Spinal Support System in conjunction with early surgical stabilization of the spine may be useful.<a></a> The Spinal Support System was a pioneering development at a time when there were virtually no commercially available seating systems or components. Today, the interest in specialized seating is booming, and commitment by manufacturers has led to a variety of systems and components. In this next section, some of the newer systems on the market and how they are used as tools for positioning different types of clients will be reviewed. Also, current methods of seating and their ability to correct a corresponding level of orthopedic deformity will be considered. In a case where there is no, or very little, orthopedic deformity, that does not present positioning problems; the standard wheelchair should still be modified with a rigid seat insert or off the shelf wheelchair cushion over a rigid base. The normal folding wheelchair with a sling seat and back does not provide a stable base of support for the pelvis. It is alright when used temporarily, but if it is to be used for any length of time, a firm seat insert is mandatory. Sitting on a sling seat causes the hips to internally rotate, which contributes to abduction and usually an oblique pelvis. This causes a compensatory spinal curve. The client with muscular dystrophy will have differential muscle weakening in the spinal musculature and will almost always assume this position in due time. Therefore, for anyone sitting in a wheelchair for more than just quick trips, the addition of a rigid seat is mandatory. Most wheelchairs can be ordered from the factory with a rigid seat of either the drop-hook variety or attached with a special folding mechanism. A firm seat can also be made as a separate piece meant to be placed on an existing wheelchair seat. Those wheelchairs with attached non-removable rigid seats tend to make the folded chair unruly and increase the weight. The separate variety is preferred, but because it is removable, it is often left behind. This problem is usually alievated with the drop-hook seat. After removing the seat upholstery, these cushions have special hooks which clip on to the seat rails with clamps. (The wheelchair then can not be used if the seat is left behind.) The base of the seat cushion is usually plywood, at least 3/8". On top of the wood, different foams can be used. Preferably, a high density urethane which will not bottom out over time. In Chicago, we make three or four-inch cushions of two different types of T-foam or Sun-Mate foam, which have special weight distribution properties. On the first layer, we use one to two inches of firm Sun-Mate for the base and two inches of medium-to-soft foam on top of that. The cushions are then upholstered with a thin flexible vinyl surface. The vinyl takes away some of the properties of the Sun-Mate foam but protects the open cell structure against water damage. Where problems with either boney prominences or an already oblique pelvis are envisioned, the Jay Cushion will provide a stable surface while accommodating these deformities. The Roho cushion provides excellent pressure relief but may not provide enough stability and encourage leaning. The Roho is best used where pressure relief is the main concern and stability is not a problem, as with paraplegics. This is why an overall clinical evaluation is important as well as an understanding of available products. There are many other commercially available seating cushions on the market, and they must be in stock and tried on the client to determine if one will better fit the clients needs than another. A good place to see all of what is commercially available in this field is at the National Home Health Care Expo in Atlanta.<a></a> The show is always in late fall or early winter and is free. For the moderately involved clients with muscular dystrophy, there are also many choices available. More likely, they are the type of clients seen. When not in bed, these clients spend almost all of their time in a wheelchair and are in the early to moderate stages of deformity or contracture. Moderate levels of deformity or contractures are measurable but not enough to create seating or functional problems. The most widely used method of manufacture for seating devices today is using plywood and foam technology. Here, there is a seat and back section, with body supports, pelvic supports, and leg supports bolted on. Many clinicians combine the linear plywood technology with custom carving of blocks of foam (usually ethafoam) to give a custom contoured look. The advantage of the contoured system is that they provide a larger area of contact between the seating system and the client. The Toronto Spinal Support System mentioned earlier is just an advanced version of this method, utilizing component parts such as a preshaped fiberglass shell instead of plywood. It was also one of the first systems to have head rests, arm rests and leg supports specially designed as part of the seating system. Today, it really makes little sense to make an entire seating system from scratch with so many commercially available components on the market. Many companies will actually make the entire seating system based on measurements of the individual client. For componentry and/or complete systems of the non-molded variety, some of the leading systems include those manufactured by Scott Therapeutics, Freedom Designs, Miller's, CRD, Gunnell, and CP seat by Pin Dot Products. Of the contoured modular systems, there is the Winnipeg system, the Otto Bock MOSS System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg">Fig. 5</a>) and the Pin Dot Modular Seating System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg">Figure 5.</a> The M.O.S.S. system from Otto Bock. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg">Figure 6.</a> Pin Dot Modular seating system. These systems are all designed for "moderately involved" clients who have minimal deformities only, with no rotational deformities. Rotational deformities become more and more evident as lateral deformities increase, and the linear systems (or those contoured with preformed cushions) becomes less and less effective. The next group with rotational as well as lateral deformities are designated the high moderates or low severe. Two new systems developed recently by the University of Tennessee Rehabilitation Engineering Program work well for this category. The Foam-in-Place seating system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg">Fig. 7</a>) uses a plastic module with an elastic bladder which fits into the chair, and liquid polyurethane foam is measured, mixed and injected into the empty bladder while the client is properly positioned on a pre-ischial strap. The foam rises and within minutes sets up and forms a customized seat or back cushion. Because the foam takes on the exact contours of the individual, it is possible to accommodate difficult rotational deformities. The difficulties with this system are that the client is forced to sit on a 2 inch wide strap, and be perfectly positioned in a chair while the foam is mixed, injected and set up (about 5 minutes). Even though the foam can shape to the most severely involved, only the high moderates can support themselves or be supported in the proper position under these conditions. Foam-in-Place may be better used for seat cushions only, as they are easier to form and more consistent in their results. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg">Figure 7.</a> Foam-In-Place seating system. It is important to remember that all of the systems described here should not be thought of as complete systems only, but also as various components. The best way to produce an individualized seating system is to use some of the various components of each system in the best way possible to give the desired result for the individual client. Adrienne Bergen, O.T.R., a pioneer in this field, has used the word "eclectic" to describe those devices made from a variety of components from various companies, and it allows her to best fill her clients needs in the most economical manner. The Bead Seat is another new development from Douglas Hobson's group at The University of Tennessee Rehabilitation Engineering Program, which uses essentially the same componentry of the Foam-in-Place seating system. The difference between the two systems is the filling or "stuffing" in the cushions. In the Foam-in-Place system, there is a liquid foam which sets up and forms while the person is suspended over the empty shell. The Bead Seat's "stuffing" is a mixture of a fast setting epoxy and polystyrene pellets (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg">Fig. 8</a>). The epoxy will set up two hours after the introduction of the catalyst, locking the lightweight pellets into the form desired. The form is made while the whole system is under vacuum using the dilation method. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg">Figure 8.</a> Side view of Bead Seat Technology. Dilation is a molding technique used for more than three decades and consists of an airtight bag filled with pellets and attached to a vacuum pump. When the vacuum is introduced into the system, the bag compresses against the pellets and holds whatever shape it has prior to the introduction of the vacuum. To change the shape, air is introduced into the bag, loosening the pellets' structure and allowing a change in shape. The Bead Seat system depends on the vacuum to hold the shape until the epoxy sets up, creating a mechanical bond between the styrene pellets. Once the epoxy has set, the vacuum can be removed and the positioning system completed. The advantage of the Bead Seat over Foam-in-Place is that there is more time available to mold and remold the system, while simulating the finished system, to attain the desired shape. The extra time available for shaping with the Bead Seat allows it to be used with more severely involved clients than Foam-in-Place. This advantage of extra time is also a disadvantage when compared to the Foam-in-Place system, since it takes longer to produce the finished product. Also, when finished, the Bead Seat has a harder surface compared to the flexible surface of the Foam-in-Place cushion. This harder surface may be an advantage with positioning, but a disadvantage when pressure relief is the objective. Bead Seat, as well as Foam-in-Place, will accommodate rotational deformities but may not be durable enough for the long-term needs of the larger clients because of the plastic framework. For lighter clients (under 100 pounds), the Bead Seat will easily accommodate the severely involved. Another limiting factor of both the Foam-in-Place and Bead Seat systems is that only a headrest system and a simple 90 degree legrest are available as options for customizing the systems, as they are designed to be used with the accessories in the existing wheelchair and this may not be enough for the most severely involved clients. When dealing with the severely involved, the traditional orthotic approach is the vacuum-formed plastic or Gillette style seating system. Using this system, a mold is taken of the individual by placing the client prone on a table with the hips flexed to 90 degrees. The mold is taken using either the dilation method or with plaster bandages. This method of taking an impression is a problem. The mold (or measurements) should always be taken while the client is simulating the final seating position. The effect of gravity on the client cannot be felt when the client is molded in a prone position, and the client's shape may be completely different when upright. It is easy to straighten a client's spine when prone on a table; the problem is that the client may not be able to tolerate this corrected position for long periods of time when upright. This applies especially to the client with muscular dystrophy, who may not have the muscle strength to pull away from a sore area. When one is dealing with a client in the severely involved category, the idea is to correct as much flexible deformity as possible, while making the positioning system as comfortable as possible so the client will be able to use the system for long periods of time during the day. Other difficulties with the traditional orthotic approach include the time needed to fabricate the finished system and the inability to adjust the system once it is finished. These problems are the same as those encountered when making a sophisticated seating system out of plywood and foam. With the traditional orthotic approach, the finished mold is filled, smoothed and corrected. Over the finished mold, a layer of foam is vacuum formed, then a layer of polypropylene is added. The plastic shell is then trimmed out, set in a box to form a base so it sits in the wheelchair at the desired angle, and upholstered. Time is valuable, and today most private facilities cannot profitably produce seating systems in this manner. Today, because of the large amount of commercially available componentry, systems do not have to be made this way. Is anybody still hand forging knee joints? Today seating is where orthotics was in the late 50's or early 60's, at the advent of commercially available componentry. Two newly developed systems work especially well for the severely involved clients: the Contour-U seating system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg">Fig. 9</a>) and the Matrix seating system. Contour-U utilizes the same dilation technology as the Bead Seat, but molds are taken on a specially designed molding frame with rubber seat and back bags filled with polyethylene pellets. Once a mold is taken of the individual in the proper position, plaster splints are worked into the mold to give a positive impression of the client. The molds are then turned into flexible upholstered cushions on a central fabrication basis, designed to eliminate the shop time needed for fabrication. The finished seat and back cushions snap into aluminum hardware, which also has the ability to be angularly positioned (both back-to-seat angle and recline orientation) and adjusted for length. This system accepts a wide variety of accessories designed to accommodate even the most severely involved client properly. The system is not labor intensive but can be expensive, especially when used with the many accessories available. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg">Figure 9.</a> Contour-U seating system. As clinicians, knowledge of patient priorities should be uppermost. Don't use Contour-U when a Bead Seat will do. Don't use a Bead Seat where a Jay cushion will do the job. Think eclectically for the patient. Contour-U cushions with plywood and simple componentry can be used to create an inexpensive, custom molded seating system. For another client, a Bead Seat molded back and a Foam-in-Place seat may be the best solution. Another advancement in seating developed in Vancouver and now manufactured in England is the Matrix system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg">Fig. 10</a>). The Matrix takes an altogether different approach by providing a flat sheet of locking ball joints which can be contoured to almost any shape and locked into that position by individually tightening the ball joints. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg">Figure 10.</a> Matrix seating system. Essentially, a sheet of material into which tucks can be taken and contours formed, Matrix can be fabricated to position somebody in any position desired. A nice feature of the Matrix is that it can be loosened and reshaped when necessary. Also, where growth is expected, the matrix can be extended by just adding a row or two of modules. The disadvantage of this system is in the time required to produce the finished product. Anywhere from 15 to 25 hours is necessary, which puts it into the same category as traditional orthotic seating systems. Fortunately, Matrix fabrication is also available on a central fabrication basis. Some may consider the Matrix unattractive, but its high tech design also makes it airy, lightweight, and waterproof. The Matrix fits in well with the eclectic approach, as pieces of the material may be used for a custom head rest or arm trough when needed, making a whole system out of material unnecessary, unless preferred for the client. These are brief descriptions of some of the newer systems on the market today. Information is available from the manufacturers to learn the benefits and weaknesses of all these systems (see suppliers list). The idea is to best provide the client with a product which, individually, does what is required for the most economical price. Having a variety of systems at our disposal, as well as the ability to custom fabricate components when necessary, will allow us to provide the best service to our clients and establish our facilities as specialists in this expanding field. In Chicago, we have done just this by establishing the Chicago Seating Institute. At the facility, we specialize in proper positioning of clients, while providing various styles of seating systems, wheelchairs, and environmental controls. In the future, we hope to expand our field of expertise to include communication devices as well. Over the last few years, the development of the specialized seating side of our business has increased our volume from 12-15 clients a year in 1981 to 150-200 clients a year today. In no other area of our business could we have expected to see a ten fold increase in the number of clients seen, even with the same commitment made as we've done for specialized seating. The field of specialized seating is up and coming, not only for the orthotist, but the prosthetist and other allied health professionals as well. Unfortunately, traditional education for specialized seating is not available. However, there are some programs and seminars offered, with increasing frequency in the past few years. Watch the upcoming issues of the American Orthotic and Prosthetic Association Almanac, or contact The Association for the Advancement of Rehabilitation Technology (RESNA) at Suite 700, 1101 Connecticut Avenue, Washington, D.C. 20036; (302)857-1199. Historically, as with orthotics and prosthetics, the best and only real way to learn is to learn by doing. See your clients, and learn from making systems for them. This hands-on method is the best teacher for seating because you can watch the clients expression to know if they are comfortable. The "cookbook" approach with easy rules just doesn't work here since people do not demonstrate this reflex or that reflex, this deformity or that deformity, but a hodgepodge of various reflexes, deformities and contractures. Add to this differing age groups, backgrounds, living conditions, and mental abilities, and the cookbook method becomes impossible. Have a variety of solutions at your disposal. Think of the client as an individual. This education will help you understand your clients discomforts and needs. With the help of a therapist, decide on realistic attainable goals. With this in mind, there are many ways to achieve the desired results of functional (where possible) and comfortable (always possible) seating for clients. <h3>Suppliers</h3> BEAD SEAT Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. (Developed by The University of Tennessee Rehabilitation Engineering Program.) CP SEAT Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. (Second generation of the MPI seating system developed by The University of Tennessee Rehabilitation Engineering Program.) CONTOUR-U SEATING SYSTEM Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. CRE Creative Rehabilitation Equipment, 513 NE Schuyler, Portland Oregon, 97212. FOAM-IN-PLACE SEATING SYSTEM Carapace, Inc., P.O. Box 45040, Tulsa, Oklahoma 74147. FREEDOM DESIGNS Freedom Designs, Inc. 18165 Napa #8, Northridge, California 91324. GILLETTE SEATING SYSTEM Gillette Childrens Hospital, Orthotic Department, Minneapolis, Minnesota. GUNNELL Gunnell Manufacturing, 221 North Water Street, Vassar, Michigan 48768. JAY CUSHION Jay Medical Ltd., 805 Walnut, Boulder, Colorado 80302. MATRIX SEATING SYSTEM Pin Dot Products, 2215, West Belmont, Chicago, Illinois 60618. (Developed by Clinical Engineering Designs, Kingston upon Thames, England.) MILLER'S Miller's Rentals and Sales, 284 East Market Street, Akron, Ohio 44308. MOSS (Modular Orthotic Seating System) Otto Bock Industries, 4130 Highway 55, Minneapolis, Minnesota 35422. PIN DOT MODULAR SEATING SYSTEM Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. ROHO CUSHION Roho, Inc. P.O. Box 658, Belleville, Illinois 62222. SCOTTIE SEATING SYSTEM Scott Therapeutic Designs, 430 Robertson Lane, San Jose, California 95112. TORONTO SPINAL SUPPORT SYSTEM The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario. References: <ol> <li>Ogg, Elizabeth, "Milestones in Muscle Disease Research," Published by the Muscular Dystrophy Associations of America, Inc., 1971.</li> <li>Muscular Dystrophy Associations of America, Inc., "Chart of Differential Diagnostic Characteristics of the Primary Diseases Affecting the Neuromuscular Unit."</li> <li>Gisbon, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," Orthopedic Clinics of North America, Vol. 9, No. 2, April, 1978, pp. 437-450.</li> <li>Letts, M. and Rang, M., "Seating the Disabled," Atlas of Orthotics, American Association of Orthopedic Surgeons, p. 468.</li> <li>Koreska, J. and Robertson, D., "Biomechanics of the Lumbar Spine and its Clinical Significance," Orthopedic Clinics of North America, Vol. 8, No. 1, January, 1977, pp. 121-133.</li> <li>Gibson, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," Orthopedic Clinics of North America, Vol. 9, No. 2, April, 1978, p. 439.</li> <li>Gibson, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," Orthopedic Clinics of North America, Vol. 9, No. 2, April, 1978, p. 440.</li> <li>Hobson, D., Desrosier, F., Beauchamp, R., and Martel, G., "The Spinal Support System and Other Approaches to Specialized Seating for Duchenne Muscular Dystrophy Patients-A Review Report," The Muscular Dystrophy Association of Canada, November, 1983.</li> <li>National Home Health Care Expo, Atlanta, Georgia. Call (305)773-2222 for details.</li> </ol> *Michael Silverman, CO. Michael Silverman, CO., is with Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. <div style="width: 400px;"></div> Page Number(s) 159 - 170 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.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_04_159/1986_04_159-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.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 Commercial Options for Positioning the Client with Muscular Dystrophy Creator An entity primarily responsible for making the resource Michael Silverman, CO. * https://staging.drfop.org/files/original/956af9917cfd9fb73b6117b9755a239b.pdf 28056c529a6ea46e1a814ecafe5a80c1 https://staging.drfop.org/files/original/1f49c6a6104459f23e9dfa8d412ffc20.jpg f3c1be296810afcc436d77a028f4096f https://staging.drfop.org/files/original/18c0fff3747573c51ca352089bae7d61.jpg 7e809e33d97818d7336120ed42eeea61 https://staging.drfop.org/files/original/85ee0c8d37dc935163afb0a9962cc2f9.jpg 6e15d3342841553335fed7733d7d17e5 https://staging.drfop.org/files/original/0cd11f516d0a8d898a1c077d7f69c1d6.jpg 76b674ec1dfcf7f7d9228fccbd189ac4 https://staging.drfop.org/files/original/0ad3855daa5c64e669f6370bf4205d4e.jpg abc0396ea518e5bbd060585896a1670c https://staging.drfop.org/files/original/7b1e0d9f3acae3755f18794c4f13b5a9.jpg 1d1373c5a7ecaa142510b3fd7af23352 https://staging.drfop.org/files/original/a3f371e62d05f358ab3cf22baa7a04e3.jpg fa7512603a3985b6d5dc6cd28e082c65 https://staging.drfop.org/files/original/2024c472036ebd49cd351ae5072ccc7b.jpg e9485f2fdf3d4b688a644d35ab9208ff https://staging.drfop.org/files/original/2dc0c7d069912311dcc03cf6a6e4edd0.jpg 44805da8539f659e38ba2b6923ae23a7 https://staging.drfop.org/files/original/a0111079818b806d3cab00d12fdcf44a.jpg 6bd9f29bc5719a3f614184f504eb757b https://staging.drfop.org/files/original/a5d1d87db952fade6693daab80374e3b.jpg d1a98712df54e4fad870a24509d8c845 https://staging.drfop.org/files/original/4514ab332afd9e2ed6ada5ddf5e492cf.jpg 614b532eff922c51d19dc05e84a0d77a https://staging.drfop.org/files/original/578d772bde6a5c2a41ca7d6c6d6a708f.jpg 81b48b5acfcce6adf954134ba1632329 https://staging.drfop.org/files/original/92434ac02ce39b964cf841a8c3029e32.jpg 8879f138a8690b98a030f427a690ee51 https://staging.drfop.org/files/original/7634a137bdb42ac7bc88e89c969baff2.jpg d6970f01166c5e4483c4d09c3e192bd2 https://staging.drfop.org/files/original/a4e96c00f56e7528a88f795778034019.jpg 26e361bd945b842e6234dab07062df02 https://staging.drfop.org/files/original/45866a1de62c43372d858339cb0da3b8.jpg 1d658e11e001f0feab567d69a8014abc https://staging.drfop.org/files/original/4c657635e36b1cefe1d39c19f4113f5d.jpg b2010734777bcb3871335633a345e369 https://staging.drfop.org/files/original/6a4f8fcc12e7f2468458df8c09de853b.jpg fa79703822387436f620508ee389b651 https://staging.drfop.org/files/original/fc32068d54284cb07ea26577879848fd.jpg 5c12ecf92371977a3d8ccbf60619c57d https://staging.drfop.org/files/original/4da1345a2d271e4dc861aec691c18790.jpg 10464557b1f2336fa5c8692e44f39e8d https://staging.drfop.org/files/original/678a25ec51a9a74d262f5b192ac6d455.jpg aa0e051b42977683bbe6fba20c999bad https://staging.drfop.org/files/original/3f7acdef049a4e860068b0ba70107199.jpg 813f193ce34ce2551d80fbb2de03bcf6 https://staging.drfop.org/files/original/884e577ac31b028021608f33fc19035d.jpg c4c3d97f45d64348ce25dd32021b9cd9 https://staging.drfop.org/files/original/c89a9b0bf901d5ead0d311f1d6594647.jpg deb348ac5024036fe39b11b71df865fd https://staging.drfop.org/files/original/7c089cb36dae52e33064e3aee182771d.jpg 30568fcf56955d1579ddeb52a586e9a4 https://staging.drfop.org/files/original/f096896c807afb36a307a0e411d0ed1d.jpg e5e6eb8ca8a16d7ad060234d4586a822 https://staging.drfop.org/files/original/df2bb6c8e62291390610da54233f07b4.jpg e2086606367ea634b8d76f839fd3a890 https://staging.drfop.org/files/original/e6f39ff4932c931b96962c20f53dd136.jpg 297c2bdf7a7130af48d737f98ee56be6 https://staging.drfop.org/files/original/16991f31b18a6af294f160286d006f48.jpg f77c226f1afd1a87eb1d2875c41402e0 https://staging.drfop.org/files/original/88c86eef7c137e26d99b1fa83179eb6b.jpg 940fcd55d76b5030bbafa3d11828a7cc https://staging.drfop.org/files/original/558a4264f026c229641591b232b8f5f3.jpg c20d1278438bae7072788e8ef808411a https://staging.drfop.org/files/original/69e28afdd6ed6bb9aa3a4cc7ff8d4bcc.jpg 946d63a2bd3e82c2d758a2b0e6dd4c10 https://staging.drfop.org/files/original/22cd6c0d4dea3a9cd00ed4a56ca6c7fc.jpg ae78f10177a3eada809893f54e6a493c https://staging.drfop.org/files/original/8c88c00f9a9da16d60b1f734dc8bafc5.jpg fb81e4666dab0b4f292a620106dad32f https://staging.drfop.org/files/original/923a5481243d688972cf556770c36a57.jpg 24ed8bc0e0820831ecb614f36196709b https://staging.drfop.org/files/original/c599282a2fc78c845b5ea8aa7131a727.jpg 31b347ffccbc9edae996d86890b9da0b https://staging.drfop.org/files/original/029b578bf376ed522eb4c2d61cf0c294.jpg fc7a8ae579056009c2a5d7a4ba31565d https://staging.drfop.org/files/original/1d68b4e019c469ee6451cc4198e3c440.jpg 24d57eb839c4d4390db7867c5cfd39ee https://staging.drfop.org/files/original/34f49d2626dbc6668bc1c80ee9b6ba0b.jpg 2bbe6f6750eaaf23a56b3a8d7682dfb4 https://staging.drfop.org/files/original/1711d925a52af68dee82c03968869a24.jpg b69868dbc60d0ed0fd2d5cf02c26f95b https://staging.drfop.org/files/original/53d9fb75ddf043805fe0975c2a67b3e0.jpg 09372d0e9d3b8df08bf515c5ee002e75 https://staging.drfop.org/files/original/b27035ad808ea6507aef71dd844510ab.jpg b40f2eb74bd1024fbb83de02826b6d04 https://staging.drfop.org/files/original/cd4bb2ae68b572c8ea97cacedbdc5ac8.jpg d4dc072e9fb4a64ff00707b0d2881306 https://staging.drfop.org/files/original/8b4ea6699b987d172a9622186bdb2184.jpg 4ddf912a8f315968b93c942cbe408722 https://staging.drfop.org/files/original/43e68efc76978d52a0fae3068d33314c.jpg 5c48d466aeea53a63f4feddca6643bae https://staging.drfop.org/files/original/91b0ef72cda9d858fe92cb61b0ccd5f1.jpg 370c3c9363c960523302e41bfa382199 https://staging.drfop.org/files/original/eed9d01f0ca86895932e527335c22e0f.jpg 3301b3bac2f637a1c7201485e524f707 https://staging.drfop.org/files/original/c3e16779d44ba8c1213419f5b6af944d.jpg 193abb8ce34e7ddd32a90f1b9dc67441 https://staging.drfop.org/files/original/a6a2e88e1625b6c1aa15a4892486a1c4.jpg b3cb5a6642c21726a462d145239c7e6f 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_04_137.pdf Text Any textual data included in the document <h2>Seating for Children and Young Adults with Cerebral Palsy</h2> <h5>J. Martin Carlson, M.S., C.P.O. <a style="text-decoration: none;">*</a> John Lonstein, M.D. <a style="text-decoration: none;">*</a> Karen O. Beck, R.P.T. <a style="text-decoration: none;">*</a> David C. Wilkie, B.F.A. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> This paper will reflect the experience, perspective, and design rationale of one institution rather than attempt to give a comprehensive survey of the full spectrum of experience and designs. Several examples are given and references made to Duchenne muscular dystrophy (D.M.D). The D.M.D. examples are used when they are particularly good illustrations of a general principle which helps complete our understanding of seating for children with cerebral palsy. For more information on our experience and rationale relative to seating boys with Duchenne Muscular Dystrophy, refer to the reference section.<a></a> The study of seating has many facets (cosmetic, functional, economic, etc.) and many professional perspectives (engineer, therapist, orthotist, physician, manufacturer, etc.). Engineers tend to relate to biomechanics and the economics of standard design. Therapists are concerned with function, development, inhibition of spasticity, etc. Each medical specialist has a different predominant focus. In different settings, it is inevitable that availability of professionals, availability of funds, age and severity of client population culture, etc., vary, and these factors will direct the seating program. Another important factor is that ortho-tists have not traditionally been trained in the provision of special seating, most are not active in special seating, and in most communities, there is a shortage of orthotists. These realities are a major reason why pre-manufactured, easy to assemble, and adjustable designs have predominated in many regions. The potential for commercial success and profit for the manufacturer, the ability to provide a system without the involvement of orthotic professionals (who are scarce and often inexperienced in seating), and the need to minimize costs, all seem to be best served by the wide distribution of pre-manufactured designs. In many communities, that is the best option available at this time. However, there are communities and settings wherein the circumstances make it possible to have a higher average of custom fabricated designs. To help you put this paper into perspective, we need to provide some information on the history of our seating program. The Orthotic/ Prosthetic Laboratory at Gillette Children's Hospital became involved with seating in 1974. Our seating program developed out of almost ideal circumstances. Orthotic services were strong and there was a close working relationship between our orthotists, therapists, and medical specialists. Weekly clinics brought a steady stream of clients through our outpatient clinic where the team members worked together to solve both general and individual problems. Also extremely important was our strong tradition and mechanisms for follow-up, which provided us with excellent feedback. Our early entry into seating, and the growth of the program, quickly gave us a significant volume so that specialists could be assigned and efficient procedures developed. Another factor bearing positively on our program is Gillette's extensive experience in spinal orthopedics. The volume of patients and specialization of our staff enabled us to offer quality care at economical costs. Although we have some experience with people of middle and advanced age, our experience at Gillette Children's Hospital is primarily with people from birth into young adulthood. This younger age group will be the focus of this paper. Our client population with cerebral palsy includes the full spectrum of severity, but the severe cases far out number the less severe. It is important that we all endeavor to recognize and respect the various aspects, perspectives, and variable circumstances mentioned earlier. Two very different seating programs may offer equally excellent care, but both can be even better if they "compare notes." This paper is a compilation of our "notes." <h3>Fundamental Goals</h3> The seating systems we provide must benefit the impaired person, those who care for that person, and society. Balanced against that, every piece of equipment inherently carries costs and disadvantages. Our systems cannot be all things to all people, but we will most nearly approach the ideal by keeping our sights aimed directly at the fundamental benefits and goals, while we endeaver to minimize the negatives. What are the fundamental goals? The main categories are outlined below. <ol> <li> Function </li> <li> Orthopedic/Neurologic </li> <li> Cosmesis </li> <li> Safety </li> <li> Economy </li> </ol> Function is primary. It affects a range of activities and benefits which can be best explained by examples: recreation for the child and family, making it easier for a care worker to feed a youngster, improving the child's field of vision, increasing his comfort, increasing the level of independence, etc. A functional seating system improves the childs development, decreases the amount of work required to take care of the child, and promotes a more enjoyable existence for the entire family. Federal laws passed in the U.S. in the early and mid 1970's mandated that children be transported from their living environments to educational settings. Safe transportation necessitates secure seating. Ultimately, society benefits, both tangibly and intangibly. From an orthopedic/neurologic standpoint, the ideal would be to prevent the progression of hip and spine deformities, and maintain body positions which reduce spastic reflex patterns. The benefits are better voluntary control, less severe deformity, less surgery, and a corresponding decrease in the work and cost of daily care. The advantages are perhaps most apparent to those of us who have visited state hospitals and have seen severely involved adult patients who were maintained only in recumbent positions during their earlier years. Positioning options for these adults are so severely limited that constant and expensive care is required to prevent ulcers and maceration. Also, hospitalization for those problems and pneumonia tend to be more frequent. Cosmetically the ideal is a well camouflaged, hidden, or attractive seating system which helps the youngster sit upright with the head in a position to see and be seen. The aesthetic and emotional benefits of a cosmetically appealing seating system accrue to the child and everyone in his environment. Comparing the costs of various seating approaches is difficult, because of the many costs which should be taken into account and the complexity of the various alternatives. We must take into account the cost of the seat, the cost of wheeled bases, repairs, frequency of replacement, and the cost of therapist involvement. The most important economic factor is the impact of a particular seating decision or system on the long range cost of daily care and health care. Long range costs must be considered, but they are very hard to estimate. <h3>Biomechanics Of Seating</h3> A normal head-trunk complex gets its stability from the spinal column, which acts as a controlled stack of compression elements, and partly from a multitude of muscles, which support it in different ways. The paraspinal muscles have a direct action on the configuration of the spine extention through lateral flexion and rotation. The abdominal (and to some extent, costal) muscles, in addition to being direct skeletal motors, affect the spine's stability and configuration indirectly, but importantly, through their action on the viscera. Muscle action to constrict and control the circumference of the abdomen and thorax allow compressive body weight loads to be taken partly down through the fluid filled abdominothoracic cylinder rather than all acting down through the spinal column. This adds significantly to the stability of the torso. We must note that recent research by Nachemson, et al.<a></a> (indicating that the Valsalva maneuver fails to lower pressure in the intervertebral disks) challenges this classical explanation of Morris,<a></a> but does not propose a new analysis of abdominal muscle function in trunk stabilization. Swedish data suggests that we don't fully understand what the Valsalva maneuver consists of and how it functions biomechanically. (The Valsalva maneuver is a general tensing of abdominal muscles.) The normal activity of sitting consists of a series of frequently changed postures. Each of those postures would be non-functional, uncomfortable, and even injurious if it were the only posture available to us and maintained for hours. It is the frequent voluntary change which makes those postures collectively safe, acceptable and tolerably comfortable for more than ten minutes. It is quite an undertaking to design a seating system in which our client can safely and comfortably sit, with little or no change, for a matter of hours. In the case of a person with cerebral palsy, the abnormally high muscle tone about the pelvis and thighs is the major reason this can be accomplished. It is important to note that when a child has some limited postural alignment capability, that capability is greatest at the head and neck. There is less ability to control the pelvis (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg">Fig. 1</a>). (This capability reflects the early developmental stages of an infant, but when we see it in the older child, it represents delayed or arrested development.) Arm-propping is typically used to stabilize the upper thorax for effective neck and head control. This illustrates two seating principles. The first is that the postural control and use of the superior body elements is dependent on the stability of body elements inferior to them. Second, the seat should bring the stability from the pelvis upward to meet the descending/decreasing voluntary stability of the client. Terminating stability too low will fail to maximize the child's function. Carrying stability too high will deprive the client of his full voluntary movement capability. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg">Figure 1. Alignment capability is greatest at the head and neck, less at the pelvis.</a> Since "normal" sitting postures are so variable and changeable, we cannot relate supported sitting postures to a specific normal posture. We must reason and choose a sitting posture which has the most advantages, and propose it as a "standard." We choose the "sitting at attention" sagittal configuration (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg">Fig. 2</a>), because it represents a mid-range spine configuration, it allows significant weight bearing on the proximal thighs as well as the bottom of the pelvis, it is a cosmetic posture (chest and head upright, facing outward), and it is a functional posture (head in a position to observe and thorax and shoulders forming a secure base for the neck and arms to move). In the sagittal plane, the sacrum is tilted anteriorly a moderate amount. There is moderate lumbar lordosis, thoracic kyphosis, and cervical lordosis. We would further propose that the "standard" posture consists of a pelvis level and the spine straight in the frontal plane. When the left side of the pelvis is elevated, the pelvis is said to be "tilted rightward," and when the right side is elevated, it is "tilted leftward" (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-03.jpg">Fig. 3</a>). Likewise, in the sagittal view, the pelvis is "tilted posteriorly" or "tilted anteriorly" depending on which direction the upper parts of the pelvis are oriented relative to "standard" (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-04.jpg">Fig. 4</a>). In the transverse plane, if the right side of the pelvis is rotated forward relative to the shoulders, we would say the pelvis is "torqued leftward." We do not present this nomenclature as the most correct, but offer it for use in the absence of standard nomenclature. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg">Figure 2. Sitting at attention represents a mid-range spine configuration.</a> Cerebral palsy is a disease that expresses itself in a wide variety of static and dynamic patterns, and we cannot go into the mechanics of all those variations. We will limit ourselves to a discussion of what, in our experience, is the most common combination. Fortunately, even some of the children with severe cerebral palsy do not have a significant deformity or collapse in the frontal plane. This is not to say, however, that scoliosis is rare in this group. Scoliosis is quite common, and we see very severe cases. When we examine a child with scoliosis, we should evaluate whether or not the scoliotic collapse is aggravated by asymetric trunk muscle spasticity. We can expect to be much more effective at controlling a scoliosis deformity when asymetric trunk muscle spasticity appears not to be a significant factor. One of the usual characteristics of scoliosis in neuro-muscularly impaired sitters is lateral tilting of the pelvis in the direction of the convexity of the major scoliosis curve (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg">Fig. 5</a>). This is not surprising when we consider that pelvic orientation is usually not under voluntary control. This characteristic will become more interesting later as we discuss the various methods for generating spine stability. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg">Figure 5. Lateral tilting of the pelvis in the direction of the convexity of the major scoliotic curve.</a> There are several distinct biomechanical schemes for providing spine stability to resist scoliosis. These schemes do not, of course, operate exclusively in the frontal plane. Also, the employment of one scheme does not preclude the simultaneous employment of one or more other schemes. The first and most familiar of these is "three-point-force". We need not explain the principles of this scheme since they are so well known. However, it is appropriate to note that three-point-force schemes are much less effective at stabilizing a multi-joint, multi-axis system such as the spinal column, than stabilizing a single-joint system such as the elbow or knee. The application of the three-point scheme in a spinal support system, which includes a seat, has some advantage over a traditional spinal orthosis in that the most inferior force can be located at greater distance from the more superior forces to give a longer moment arm. However, the more the client functionally moves in his seated position, the less the seat is able to apply three-point support, because it doesn't move with the client. Furthermore, a spinal orthosis can be worn 23 hours per day, if necessary. These latter considerations make the spinal orthosis a stronger orthotic treatment of progressive spine deformity. The second scheme we will discuss has to do with the Valsalva maneuver, given earlier, in which the abdominal and costal muscles function to relieve the spinal column of compression and bending loads. No matter what exactly happens during the Valsalva maneuver, the Morris explanation is a valid biomechanical analysis of how a snug corset contributes to trunk/spine stability in the presence of flaccid paralysis of abdominal and costal muscles. Engineering analysis and empirical evidence indicate that when we passively apply circumferential abdominal constraint (ie. a snug corset), a hydraulic load bearing column is created and we reduce the magnitude of flexible collapse (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg">Fig. 6</a>). In our experience, the corset is seldom used for children with cerebral palsy, but is virtually always useful for children with muscular dystrophy. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg">Figure 6. Reducing the magnitude of flexible collapse.</a> The third scheme for enhancing spine stability derives from the fact that the sacro-pelvic complex forms the foundation on which the flexible spinal column rests. Voluntary pelvic control is an important component of spine stability in the unimpaired trunk. If, by a conforming design about the pelvis and a proper donning procedure, we can increase the foundation (bottom end) constraint conditions, much is added to spinal stability. The pair of diagrams on the left side of <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg">Fig. 7</a> illustrates the similarity between the spinal column in the case of an uncontrolled pelvis and the slender column pin jointed (free to tilt) at its lower end. The two diagrams on the right in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg">Fig. 7</a> illustrate the similarity between the controlled pelvic case and the built-in base end condition. Elastic column buckling equations for the two beams indicate that the built-in beam will withstand almost twice as much load as the other before buckling.<a></a> To achieve this end condition stability, we need a well made seat, as well as a procedure to level the pelvis each time the child is seated. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg">Figure 7. The diagrams on the left illustrate the similarity between the spinal column in the case of an uncontrolled pelvis and the slender column pin-jointed (free to tilt) at its lower end. The two diagrams on the right illustrate the similarity between the controlled pelvic case and the built-in base end condition.</a> To fully appreciate the strength of this scheme in practice, compare the two x-rays in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg">Fig. 8a</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg">Fig. 8b.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg">Fig. 8a</a> is the x-ray taken just before the pelvic leveling procedure was performed and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg">Fig. 8b</a> is the x-ray taken a few minutes later, after the pelvic leveling procedure was performed. The Cobb angle is reduced from 36 degrees to 20 degrees by this quick procedure, which is normally performed as a routine part of positioning the child in the sitting support orthosis. These x-rays are of a boy with Duchenne Muscular Dystrophy; he was not wearing a corset. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg">Figure 8a. An x-ray taken just before the pelvic leveling procedure was performed.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg">Figure 8b. The x-ray taken a few minutes later after the procedure.</a> A second example is given in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg">Fig. 9.</a> The left and center x-rays show the progression which occurred in the eight months following fitting. During this period, the parents did not use the pelvic leveling procedure. The x-ray on the right was taken a short time after the center x-ray, with the only difference being the pelvic leveling procedure was performed before the last film. Note: once a spine deformity has become partially structural, the pelvis can be leveled only to the degree that the deformity is still flexible. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg">Figure 9. The left and center x-rays show the progression which occured in eight months following a fitting. During this period, the parents did not use the pelvic leveling procedure. The x-ray on the right was taken a short time after the center x-ray, and after the pelvic leveling procedure was performed.</a> In summary, maintaining a level pelvis makes it easier to control the spine. Pelvic control and orientation in the frontal plane also relates strongly to the uniformity of pressures in weight bearing areas and minimizing the progressive deterioration of sitting comfort. Let us now look at two examples were these stabilizing schemes have been simultaneously applied. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg">Fig. 10a </a>is a photo of a 12 year old boy with muscular dystrophy, sitting as he was presented to us. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg">Fig. 10b</a> shows the sitting support system properly applied. The corset is entirely independent; it is not attached to the seat. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg">Fig. 10c</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg">Fig. 10d </a>compare his A-P spine x-rays without and with the orthotic system. The lateral tilt of his pelvis is reduced from 30 degrees to 14 degrees. The Cobb angle of his scoliosis was reduced from 65 degrees to 35 degrees. Curve control of this magnitude is not unusual as long as the deformity is still flexible. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg">Fig. 11a</a> is the x-ray of J.S., a 14 year old girl with cerebral palsy. She presented a right thoraco-lumbar scoliosis of 38 degrees and a rightward pelvic tilt of 8 degrees. Her shoulders were tilted 13 degrees to the left partly because she used her right arm for propping to avoid falling to the right. We provided her with a soft corset and the Gillette Sitting Support Orthosis. The Sitting Support Orthosis was to provide pelvic control and bilateral "propping" support. It had no head rest or anterior support. The x-ray taken just after fitting shows pelvic tilt reduced to 2 degrees (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg">Fig. 11b</a>), the Cobb angle of the scoliosis reduced to 22 degrees, and shoulders leveled. Both hands were free to function, and she said she could breathe deeper. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg">Figure 10a. A 12 year old boy with muscular dystrophy as presented.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg">Figure 10b. The Sitting Support System properly applied. Corset is independent.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg">Figure 10c. A-P spine x-rays without the orthotic system.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg">Figure 10d. A-P spine x-rays with the orthotic system.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg">Figure 11a. X-ray of J.S., a 14 year old girl with cerebral palsy.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg">Figure 11b. J.S. provided with a soft corset and the Gillette Sitting Support Orthosis</a>. In cerebral palsy, we occasionally see a case of lateral pelvic tilt and scoliotic posture secondary to a unilateral hip extension contracture. A right hip extension contracture, if not accommodated, will cause the right side of the pelvis to be elevated. The pelvis will be tilted leftward and a compensatory convex left scoliosis will be produced. When we see this problem, it is usually an older child or adult. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg">Fig. 12</a> is an example of a rather extreme case of how the deformity was accommodated to minimize pelvic and spinal malalignment and stress. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg">Figure 12. An extreme case of how pelvic and spinal malalignment and stress is minimized in a cerebral palsy patient.</a> In the sagittal view, we commonly see a posture dominated by the powerful, very active hamstring muscle group. The gluteals are often helping to resist adequate hip flexion for an ideal sitting alignment. To a greater or lesser degree, the pelvis is maintained in a posterior tilt position with weight bearing shifted posteriorly toward the sacrum. This pelvic alignment tends to reduce lumbar lordosis and convert it to a kyphosis (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg">Fig. 13</a>). The loss of lumbar lordosis makes it more difficult for the thoracic extensors to maintain a vertical upper thorax. This explains why a flexible spine, maintained with a pelvic belt and lumbar bolster to restore lumbar lordosis, often produces better active alignment of the upper thorax and head. (We would caution you that different solutions are necessary for people with rigid hyperkyphosis.) <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg">Figure 13. A sagital view illustrating the pelvis in a posterior tilt position with weight bearing shifted posteriorly towards the sacrum, converting lumbar lordosis to a kyphosis.</a> The three forces needed to maintain the position of the pelvis and lumbar spine are the thigh support, lap belt constraint, and lumbar support (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg">Fig. 14</a>). Attention must be given to properly provide all three. The seat bottoms must be configured specifically to provide optimum thigh support. A flat horizontal seat bottom will never maintain hip flexion against active extension (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg">Fig. 15</a>). The anatomy itself calls for a depression under the pelvis to bring the femurs to a horizontal position (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg">Fig. 16</a>). More importantly, the hip flexion required to "break through" the extensor spasticity varies from child to child, but we usually find that some degree of seat bottom incline (pelvis to knees) is needed for the more severely involved children (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg">Fig. 17</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg">Figure 14. The three forces needed to maintain the position of the pelvis and lumbar spine are the thigh support, lap belt constraint, and lumbar support.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg">Figure 15. A flat horizontal seat bottom will never maintain hip flexion against active extension.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg">Figure 16. The anatomy calls for a depression under the pelvis to bring the femurs to a horizontal position.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg">Figures 17a and 17b. We usually find that some degree of seat bottom incline (pelvis to knees) is needed for more severely involved children.</a> The pelvic belt force is perhaps the most critical. The pelvic belt must be perfectly anchored: close to the body posterolaterally for good "wrap around" and at the correct level to achieve a good downward force component (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg">Fig. 18</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg">Fig. 19</a>). The most common mistake is to anchor the lap belt too high. We have never seen one anchored too low. (We must remember that none of the hip/lumbar support forces function properly in service unless the caretakers know why and how to put the pelvis in position and snug up the pelvic belt. Without education and training of the users, our designs are worthless. We must train and retrain on every return visit.) <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg">Figure 18. The pelvic belt force is perhaps the most critical.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg">Figure 19. The pelvic belt must be perfectly anchored: close to the body posterolaterals for "good wrap around" and at the correct level to achieve a good downward force component.</a> A fourth support force is sometimes needed in the area of the upper thorax or shoulders to maintain adequate thoracic extension. This is accomplished with a vest or shoulder straps which must be adjustable for grading the amount of support to fit the need, which may vary through the daily routine of activities. Seating misalignment and deformity problems in the transverse plane are not uncommon among the severely involved cerebral palsy population. The problem consists of the pelvis being torqued right or left by deformities of one or both hips. A severe adduction confracture of the right hip will, for instance, cause a seated misalignment which includes leftward direction of the thighs (with respect to the pelvis), a rightwardly torqued pelvis, and an apparently (not actually) short right femur. This misalignment has been well diagrammed in an article by Mercer Rang, et al.<a></a> A severe abduction contracture of the left hip will cause a similar misalignment. These deformities are often referred to as "wind blown hips." We can see that when such a condition exists, forcing the thighs to be aligned straight forward will obligate the client to sit facing to one side, or the spine will be continuously twisted. In most cases, the direction of the thighs may be altered enough to avoid much of the spinal twist. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg">Fig. 20a </a>is a photo of a top view of a Sitting Support Orthosis we provided for such a client. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg">Fig. 20b</a> is the same view of the client in the orthosis. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg">Figure 20a. Top view of a Sitting Support Orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg">Figure 20b. A client seated in the S.S.O. The direction of the thighs is altered to avoid much of the spinal twist.</a> It is of utmost importance, as we treat these clients, that we keep function and quality of life issues uppermost in our mind. Biomechanics and deformity prevention ideals often must be compromised to avoid undue impingement on any aspect of the child's development or function. <h3>Client Evaluation</h3> Seating evaluations at Gillette always include an orthotist, a therapist, and a physician in addition to the client, parents or caretakers, and, if available, a community therapist. The physical evaluation includes an assessment of orthopedic deformities, spastic reflex patterns, voluntary sitting capability, and other functional abilities. To assess sitting ability, two people manually control the child's thighs, pelvis and lower trunk. If, with this amount of stabilizing assistance, the child still cannot manage an upright sitting posture, we would grade voluntary sitting capability at non-existent to poor. If the child can, with that assistance, struggle to an upright sitting posture and maintain it for fifteen seconds, we would grade voluntary sitting capability at poor to fair. Better performance would be graded accordingly as better than fair. A thorough interview of parents and others with the child is immensely valuable. We want to find out about the child's daily routine, mode of family transportation, what they feel are positive and negative features about their present equipment and routine, and the child's usual status compared to what we are observing. We also seek all concerns and ideas they may have for optimum seating. The interview should gradually become more of an educational session and finally a discussion of options. The child and parents or caretakers should, as much as possible, feel they were heard, were educated, and have participated in the decisions made on the seat, mobility base, accessories, etc. <h3>Seating Design</h3> We currently solve the majority of the seating problems we encounter with variations on two basic designs. Both are custom made. Although there have been many very significant design changes along the way, the Gillette style Sitting Support Orthosis (S.S.O.) has continued, from 1974 to the present, as a portable system utilizing a custom molded unpadded plastic shell mounted in a plastic foam base (Fig. 18 and Fig. 24). We have provided approximately 1100 of these Sitting Support Orthoses. Our present rate of S.S.O. production is about 140 per year. Figure 24. Anterior upper thoracic support provided by shoulder straps. In the early years, we also constructed upholstery and plywood seats. In 1983, we converted that rectangular design to one that used upholstered removeable components attached to the inside surfaces of a plastic seat frame as shown in Fig. 21. (We first saw a design similar to Fig. 21 at the Royal Ottawa Rehabilitation Center. In addition to our own changes, the present design incorporates features also learned from the Rehabilitation Engineering Center at Children's Hospital at Stanford.) To distinquish this design from the contoured plastic shell type S.S.O., we call it an Upholstered Sitting Support Orthosis (U.S.S.O.). We currently construct and fit about 200 of these units annually. Figure 21. A plastic seat frame with upholstered removable components. A more specific discussion of the design of the S.S.O. must start with noting that the main structure is an unpadded, thin plastic shell. Because of the thinness of the supporting shell, the seat is less bulky, less visible, and lighter than other seats. It allows us to provide close thoracic support up to the axillary level and wrap around the thorax, between the arms and chest, and well past mid-line, without impinging on the arms (Fig. 18 and Fig. 19). When properly contoured, the shell can be left almost totally unpadded. The unpadded shell is easier to clean and requires less maintenance. The pelvic portion is contoured and sized to fit the hip/pelvic area quite close, but not snug. At fitting time, we leave adequate space to push our fingers between the Glueteus Medius and the seat bilaterally. About 18 months ago, we began providing room in the shell to install bilateral pelvic growth pads (visable in Fig. 22), which are removed later as the pelvis grows wider. Figure 22. An unpadded shell with room to install bilateral pelvic growth pads, which are removable as the pelvis grows wider. Anterior upper thoracic support is provided by either a special vest (Fig. 23) or shoulder straps (Fig. 24). The shoulder straps are more efficient at keeping the thorax in an extended, upright posture. However, when the child has some arm function, we prefer to use the vest because it can be configured to impinge less on the anterior deltoid muscles. Note that the lower attachment points for the vest or shoulder straps should be in the sub-axillary area to provide good wrap-around and a posteriorly directed holding vector. Some commercially available seats anchor the shoulder straps to the lap belt. That design is seriously flawed because the shoulder straps then pull the lap belt up out of proper position and pull down on the shoulders. Figure 23. Anterior upper thoracic support is provided by a special vest or shoulder straps (see Figure 24). When the S.S.O. is used for people with severe scoliosis or hyperkyphosis, the polypropylene shell accomodates to the contours of the deformity. However, sometimes our best efforts fail to create sufficiently precise contouring to spread pressure evenly over the entire rib prominence. Fig. 25 diagrams how we sometimes solve that problem: an adjustable denim cloth panel is installed through vertical slits in the shell. The panel wraps around the prominence, conforming to the contour. Figure 25. An adjustable denim cloth panel is installed through vertical slits in the shell. The panel wraps around the prominence, conforming to the contour. Head support varies from nothing to a simple occipital prop to a variety of designs, depending on the particular challenge presented. A few of the many designs we have contrived over the years are shown in Fig. 26, Fig. 27, and Fig. 28. We do not have a good solution for the child who persists in actively bringing the head forward and down. In seating children with hydrocephalus, the sheer weight of the head presents special safety and weight bearing problems (Fig. 29 and Fig. 30). We haven't the space to show and explain the wide variety of accoutrements which are variously added for shoulder protraction, arm positioning, etc. We work closely with the therapists so that they can help design the final configuration for best functional positioning. As emphasized earlier, a seating program must consider the sitting functional environment. The seating orthoses we produce are re-moveably mounted in wheelchairs, strollers, buggies, and other bases as the circumstances indicate. Being portable, they are also utilized as car seats, or to place the child very near the floor to facilitate peer interaction (Fig. 31). We have found that a seating program, to be effective, must address the full spectrum of life activities. It must also address related equipment in the sitting environment. Footrests, wheelchair upholstery, laptrays, and control boxes are some of the most common things which must be modified, moved, or completely replaced with special designs. It seems to us that the "standard" wheelchair was designed to be "slouched" into (Fig. 32) rather than to be sat erect in. Those chairs are not adequate, as manufactured, for extended use by anyone. In spite of the newer, more enlightened designs coming along, those "standard" wheelchairs are still part of the scene and must be dealt with. When we sit a client erect on a firm seat, and then place that seat in a wheelchair, the client's shoulders are far from the center of the drive wheels (Fig. 33). For clients who self-propel, the seat must be sized or shaped to sit between the upholstery mounting bars. The standard upholstry must be removed and replaced with straps so that the seat can be recessed down and back between the bars (Fig. 34 and Fig. 35). Figure 31. The seating orthoses we produce are removable and made to mount in a variety of bases as the circumstances indicate. Figure 32. Lateral view of typical posture produced by hypotonic spine extensors and tight hamstrings. Figure 33. Lateral view of a patient positioned too high and forward. Figure 34. For clients who self-propel, the seat must be sized or shaped to sit between the upholstery mounting bars. Figure 35. Standard upholstery is removed and replaced with straps so the seat can be recessed down and back between the bars. At semi-annual follow-up visits, we accommodate the child's growth by adjusting the size of the S.S.O. Thigh length is added as necessary. The bilateral pelvic growth pads are thinned or removed when appropriate. The back and sides of the shell can be heated to widen the shell width across the chest. Axillary extensions are welded on as necessary to accommodate increase in thoracic height. Head rests and the anchor points for vests and shoulder straps are also elevated as necessary. Presently, the basic S.S.O. shell is serving for an average of 37 months for children between 3 years and 14 years of age. We expect the use of the pelvic growth pads to push that service life even higher. For adults, the average useful life of S.S.O.'s is much greater. We recommend the S.S.O. for children who have non-existent to poor voluntary sitting capability. Other factors which would indicate a need for the S.S.O., in our program, would be significant orthopedic deformities (of the hips and spine) and moderate to severe spastic reflex patterns. Completed physical growth may also be an indication for the S.S.O., because the polypropylene shell is very durable. It requires less repair maintenance than the upholstered systems. There is complete freedom within the design to reduce the level and amount of support or match the client's need: it may not include a head support, vest, or shoulder straps, and bilateral thoracic support may be terminated at a lower level and leave more room for movement as appropriate. Provision of a good quality S.S.O. requires a relatively high level of specific orthotic skill and practice. This may be considered a disadvantage, but we feel the adaptability and quality which results more than justifies the necessary investment. The structural components of the Upholstered Sitting Support Orthosis are made of ABS plastic. The upholstered firm inserts are removable to facilitate cleaning and adjustments for growth. Thoracic supports are thin (of metal) and can be easily adjusted to change height and spacing. The pelvic belt is used on every U.S.S.O. Lumbar bolsters, vests or shoulder straps, and head rests are used when appropriate. Fig. 31 shows some of these design features. During therapy sessions, and for certain daily time periods, therapists or parents may wish to work specifically on improving upper trunk or head control. For this reason, shoulder straps and vests are designed for partial or complete loosening. Head rests can be easily removed from the unit (true of the S.S.O. as well as the U.S.S.O.). The U.S.S.O. is most appropriate for children with poor-to-fair voluntary sitting capability, minimal orthopedic deformities, and less severe spastic reflex patterns. The easy size-adjustability of this design gives it some advantage over the S.S.O. for younger, rapidly growing children. For children under two years, we often utilize one of the commercial infant seat or car seat frames to which we can add support bolsters, lap belt, etc. (Fig. 36). Figure 36. A commercial infant car seat can be supplemented with bolsters, lap belt, etc. <h3>Fabrication</h3> Much about the fabrication of these orthoses can be inferred from the photos and design information given earlier. Some information on fabrication of the "Gillette" S.S.O. has been discussed in earlier articles on that orthosis.<a></a> However, there are some serious errors in the S.S.O. fabrication process we made in the very beginning. Other orthotic labs might repeat those errors unless we reiterate a couple of the procedural steps and more clearly explain the rationale for those steps. The polypropylene shell is obtained by covering a pattern developed from an impression of the child. To obtain the impression, we position the child, on a supporting fixture (Fig. 37) in a face-down, hips-flexed, knees-flexed configuration (Fig. 38). We use the weight relieving (horizontal) trunk alignment, support under the knees, and a waist belt for the precise purpose of achieving an impression which does not possess the poor alignment characteristics we are trying to avoid. The support under the knees allows us to locate the pelvis as directly as possible in alignment with the spine. For the child with tight hamstring muscles, a waist belt on the fixture helps reduce lumbar kyphosis and perhaps achieve a little lumbar lordosis, if possible. The contrasting diagrams in Fig. 39a and Fig. 39b illustrate the critical role of knee support. The hip flexion angle of the fixture can be varied and is adjusted according to the amount of hip flexion we want in the seat shell. On the positive model, plaster is added to create the bulges and contours needed to avoid pressure on bony prominences (Fig. 40). Plaster is added across the back of the upper thorax to give room for extension. Fig. 41a and Fig. 41b are posterior and lateral views of a positive model fully modified and ready for covering. The resulting polypropylene seat shell is mounted in a polyethylene foam base (Fig. 42). Final trim lines, lap belt and vest attachment points, head-rest placement, etc. wait until the child comes for fitting. Figure 37. A supporting fixture. Figure 38. To obtain an impression for a polypropylene shell, the child is positioned facedown, hips-flexed, and knees flexed on a supporting fixture. Figure 39a. Hip flexion angle of the fixture can be varied. Figure 40. On the positive model, plaster is added to create the bulges and contours needed to avoid pressure on bony prominences. Figure 41a. Posterior view of a positive model fully modified and ready for covering. Figure 41b. Lateral view of a positive model fully modified and ready for covering. Figure 42. The polypropylene seat shell. The molded "Chailey Heritage" supportive seat,<a></a> which also utilizes vacuum dilatancy to obtain an impression, creates a positive model, and vacuum forms the seat materials over that model. With the exception of those general similarities, the procedures, materials, and design of the Chailey Heritage seat is very different from the Sitting Support Othosis developed at Gillette Children's Hospital. Fabrication of the U.S.S.O. does not require a pattern and is therefore free of the potential problems inherent in obtaining and modifying a model. <h3>Conclusions</h3> This paper has dealt most heavily with biomechanics and design, but many other programmatic components have been mentioned. Devices do not solve seating problems. A program is required. A truly successful seating program, one that approaches the fundamental goals discussed at the beginning of this paper, must contain at least the following components: <ol> <li> Involvement of all appropiate and available professional disciplines. </li> <li> Comprehensive discussion with, and education of, the client (when possible), the parents and/or other caretakers, and other available community-based professionals. </li> <li> Attention to finding and solving the family-specific functional (including play, recreation, and transportation) problems and opportunities. </li> <li> Provision of effective equipment with thorough instructions on its use. </li> <li> Tenacious follow-up to uncover and solve the inevitable problems and opportunities brought on by growth and functional changes; to obtain feedback necessary to the efficient evolution of the program; and to reinforce, as necessary, the education of the users. </li> </ol> <h3>Acknowledgments</h3> The important roles of some individuals and institutions have been cited earlier and will not be repeated here. Our experience with Duchenne Muscular Dystrophy has come primarily through Dr. Lowell (Hap) Lutter, chief of the Growth and Development Clinic at Gillette, and orthopedic surgeon for the Muscular Dystrophy Clinic at Fairview Hospital. The seating systems were provided at Gillette by Team Leaders, Mark Payette and David Wilkie, and the people they supervise. Those people include (currently, and in the recent past) Tracy Lillehaug, Joe Bieganek, Dannel Friel, John Spielman, Katie Voss, Lee Hegfors, Bruce Tew, Wendy Schifsky, Rick Weber, Paul Swanlund, Paul Lemke, and Marcia Munson. Gene Berglund is orthotic group manager at Gillette. Former Therapy Superivsors, Diane Twedt and Jan Headley were very involved and important during the early years of the program. Gillette therapists significantly involved with the program currently (or in the recent past) include Rebecca Lucas, Lynn Bowman-Bathke, Cindy Theisen, Patricia Mathie, Gail Graff, Marilyn Kochsiek, and Ellen Kratz. Over the years, we have been privileged to work with many outstanding individuals and institutions in various communities in our referral area. Three institutions which have been especially cooperative and capable are the Cambridge Regional Human Services Center (formerly Cambridge State Hospital), People's Child Care Residence, Homeward Bound, Brainerd State Hospital, and Moose Lake State Hospital. We have significantly learned from (in addition to centers cited earlier) the professionals associated with seating programs at the Rehabilitation Engineering Center of the University of Tennessee, the Hugh MacMillan Center in Toronto, and the Winnipeg Rehabilitation Center for Children. Address inquires to: J. Martin Carlson, Director of Orthotics and Prostetics, Gillette Children's Hospital, 200 E. University Avenue, St. Paul, MN 55101. References: <ol> <li><a href="http://www.acpoc.org/library/1973_10_007.asp">Bowker, John H. and Reed, "A Vacuum Formed Plastic Insert for Neurologically Handicapped Wheelchair Patients," Inter-Clinic Information Bulletin, 12:10, July, 1973, pp. 7-12.</a></li> <li>Carlson, J. Martin and Payette, Mark, "Seating and Spine Support for Boys with Duchenne Muscular Dystrophy," Program and Proceedings of the Rehabilitation Engineering Society of North America, Memphis, Tennessee, June, 1985.</li> <li>Carlson, J. Martin and Winter, Robert, "The Gillette Sitting Support Orthosis," Orthotics and Prosthetics, 32:4, December, 1978, pp. 35-45.</li> <li>Crandall, Stephen H. and Dahl, Norman C, "Stability of Equilibrium," An Introduction to the Mechanics of Solids, McGraw-Hill, 1959, Chapter 9, p. 420.</li> <li>Morris, J.M., Lucas, D.B., and Bresler, B., "Role of the Trunk in Stability of the Spine," The Journal of Bone and Joint Surgery, 43-A:3, April, 1961, pp. 327-351.</li> <li>Nachemson, Alf L., Andersson, Gunnar, B.J., and Schultz, Albert B., "Valsalva Maneuver Biomechanics: Effects on Lumbar Trunk Loads of Elevated Intra-abdominal Pressures," Spine, 11:5, June, 1986, pp. 476-479.</li> <li>Rang, M, Douglas, G., Bennet, G.C., and Koreska, J., "Seating for Children with Cerebral Palsy," Journal of Pediatric Orthopedics, 1:3, 1981.</li> <li><a href="poi/1978_01_030.asp">Ring, N.D., Nelham, R.L., and Pearson, F.A., "Moulded Supportive Seating for the Disabled," Prosthetics and Orthotics International, 2:1, April, 1978, pp. 30-34.</a></li> <li>Winter, Robert B., and Carlson, J. Martin, "Modern Orthotics for Spinal Deformities," Clinical Orthopedics, 126:5, July-August, 1977, pp. 74-86.</li> </ol> *David C. Wilkie, B.F.A. David C. Wilkie, B.F.A., is an Adaptive Equipment Team Leader at Gillette Children's Hospital. *Karen O. Beck, R.P.T. Karen O. Beck, R.P.T., is a Senior Physical Therapist at Gillette Children's Hospital. *John Lonstein, M.D. John Lonstein, M.D., is Chief of the Cerebral Palsy Spine Clinic at Gillette Children's Hospital and a Clinical Associate Professor with the Department of Orthopedic Surgery, School of Medicine at the University of Minnesota. *J. Martin Carlson, M.S., C.P.O. J. Martin Carlson, M.S., C.P.O., is Director of Orthotics and Prosthetics at Gillette Children's Hospital, 200 East University Avenue, St. Paul, MN 55101-2598, and Clinical Instructor for The Department of Orthopedic Surgery, School of Medicine at the University of Minnesota. Page Number(s) 137 - 158 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg Figure 8 Figure 8a http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg Figure 8b http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg Figure 10 Figure 10a http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg Figure 10b http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg Figure 10c http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg Figure 10d http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg Figure 11 Figure 11a http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg Figure 11b http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg Figure 19 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg Figure 20 FIGURE 20A http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg FIGURE 20B http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg Figure 21 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-27.jpg Figure 22 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-28.jpg Figure 23 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-29.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 Seating for Children and Young Adults with Cerebral Palsy Creator An entity primarily responsible for making the resource J. Martin Carlson, M.S., C.P.O. * John Lonstein, M.D. * Karen O. Beck, R.P.T. * David C. Wilkie, B.F.A. * https://staging.drfop.org/files/original/83648b0b711c382f195cc6bdaa6ab376.pdf 0d93f48bc78669170b984704c62a93b6 https://staging.drfop.org/files/original/51ee9f592b7e05126ec1e1eeec2c8f87.jpg e2e5e9a0ff445f9d032735045a3720b6 https://staging.drfop.org/files/original/cd87e6b8e63780897953794d33b1a88f.jpg 611cb47da091fa4220b0a84a5621f946 https://staging.drfop.org/files/original/ee0b549a0ac2ac1213258d9a7cf6bde6.jpg 13dc19f7b6d5ad835d26c445b688647b https://staging.drfop.org/files/original/9268367df64346914dfcd44ac7f8e280.jpg dccae3622fdb0d507ef88c33387b8ecf https://staging.drfop.org/files/original/748805f5859f6d87f7e3d2763cbd306e.jpg 4dd495359ed8ab36487f3abc0abf6221 https://staging.drfop.org/files/original/46b2b805c5456f6a9b6763b29e69dd6e.jpg c6ddf3929559d51cb9a4c5ac217b757d 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_04_130.pdf Text Any textual data included in the document <h2>Adaptive Seating in Pediatrics</h2> <h5>Robert S. Lin, C.P.O. <a style="text-decoration: none;">*</a> Susan S. Lin, O.T.R. <a style="text-decoration: none;">*</a></h5> Adaptive seating represents one of the most complex areas of orthotic management. No other area of clinical practice requires the degree of knowledge and application of biomechanics, design engineering, tissue physiology, wheelchair design and the clinical manifestation of the many neuromuscular disorders involved. No other area of management effects as many aspects of the patient's life and treatment programs initiated by other professionals. Therefore, it is imperative to solicit input from all members of the multidisciplinary team (<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-1.jpg">Fig. 1</a>). The orthotist, physician, physical therapist, occupational therapist, educator, speech pathologist, social worker, psychologist, and wheelchair vendor must all take part in the prescription formulation (<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-2.jpg">Fig. 2</a>). Unfortunately, formal training for the aforementioned professionals provides very little, if any, information for the evaluation, assessment, and design of adaptive seating systems. <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-1.jpg">Figure 1.</a> Input from all members of the rehabilitation team is solicited. <h3>Development</h3> To compound the difficulty of equipment provision, pediatrics offers additional complications that aren't as prevalent in management of the adult population. Because the child is still undergoing physical development and maturation, the clinical picture he/she presents is expected to change. Some of the changes are due to growth (longitudinal and/or circumferential), yet some are due to disease progression, developmental abnormalities, and psycho-social problems that result from an increasing awareness of the physically handicapping condition. The adaptive seating system must be able to accommodate growth, environmental, and clinical changes in the child. This is particularly important in view of the funding restrictions on equipment replacement set by state or private payment sources. <h3>Education</h3> Another very important consideration in positioning a child is the child's educational goals and limitations. Aside from the physical barriers that a school may present, safe transportation to and from the school in a bus or van must be achieved. Few wheelchair bases are compatible with the lock down mechanism used by local transportation systems. This basic mechanical problem can hamper the educational process even before it begins. Once the child is in the school environment, many subtle factors can influence the success and acceptance of the adaptive seating system. These factors include whether or not the child is mainstreamed or in a special education program; the physical design of the school such as elevators for multilevel institutions and overall wheelchair accessibility; whether the communication needs of the child are met in a group setting; desk height, which can profoundly effect actual integration; whether medical/nursing facilities are available; and the kinds of recreational provisions offered for physical education. <h3>Information Collection</h3> Because the breadth of information concerning the patient can be extensive, there must be a mechanism to facilitate the collection of this critical data. It is imperative that the primary treating professionals provide this input because of familiarity with the patient and pre-established goals. The following In-take form was developed by author Susan Lin, O.T.R. in an effort to provide a concise patient data collection sheet. While the completion of this form can be time consuming, we have found that access to this information is essential (<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-3.jpg">Fig. 3</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-4.jpg">Fig. 4</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-5.jpg">Fig. 5</a>, and<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-6.jpg"> Fig. 6</a>). <h3>One Approach To Adaptive Equipment Provision</h3> In 1981, Newington Children's Hospital initiated its first formal Adaptive Equipment Clinic. The clinic is covered by seven members of the core team with three others forming the ancillary team. The core consists of a physician, orthotist, seating specialist, physical therapist, occupational therapist (who serves a dual function as the Adaptive Equipment Coordinator), speech pathologist, and social worker. The ancillary team is comprised of an educator, psychologist, and durable medical equipment vendor. The clinic is held one morning per week, divided into four one-hour appointments. Every third week of each month is reserved for a re-check clinic and follow-up care is provided every six months. The follow-up appointments are one half hour long, with eight patients checked in a morning. Prior to the first patient evaluation, the In-take forms for all new patients scheduled that day are reviewed and discussed. This enables us to establish a preliminary game plan as well as discuss certain confidential factors that may influence management. Formulation of the actual prescription occurs during the hour appointment, with various tasks assigned to appropriate team members to ensure follow-up of our recommendations. Over the past five years, the NCH Adaptive Equipment Clinic has provided an ideal forum for patient and equipment evaluation and prescription. The aforementioned protocol evolved slowly and has worked very well considering our resources, patient population, time and cost constraints. Those factors that have universal application are the need for a multidisciplinary approach, the need for follow-up appointments, and a sound understanding of seating principles. The recent emphasis on adaptive seating has finally enabled the orthotist to assist in management of the entire spectrum of patients, not just those who are candidates for ambulation. The appropriate seating system can be a therapeutic tool which enhances the quality of life and serves as an adjunct to other rehabilitation efforts. *Susan S. Lin, O.T.R. Susan Lin, O.T.R., is the Director of Occupational Therapy at Forestville Nursing Center and an Adaptive Equipment Consultant at Hudson Home Health Care. She was the primary developer of the Adaptive Equipment Clinic at Newington Children's Hospital and was the Hospital's first Adaptive Equipment Clinic Coordinator from 1981 to 1985. *Robert S. Lin, C.P.O. Robert Lin is the Clinical Coordinator of Orthotics at Newington Children's Hospital, 181 East Cedar Street, Newington, Connecticut 06111. Page Number(s) 130 - 136 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-5.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_04_130/1986_04_130-6.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 Adaptive Seating in Pediatrics Creator An entity primarily responsible for making the resource Robert S. Lin, C.P.O. * Susan S. Lin, O.T.R. * https://staging.drfop.org/files/original/1d0b1902a4d7fb7cc437f75ca2c997b1.pdf f5ec7dfc784092ec4c05b42b0a9ca722 https://staging.drfop.org/files/original/07c03e80401b5c87d8d82c363e054d8c.jpg 53dd0b9a9b94ba4619665e0dc21d6fd3 https://staging.drfop.org/files/original/ace09578c7da7ee48bdd67c240b778fe.jpg f52289221839e24d1976512808b88d40 https://staging.drfop.org/files/original/ad5dc9979c8c97cb0bd8047ec31bc02f.jpg 5bf470bdcf3132b882ae78d66b4fd38d 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_04_122.pdf Text Any textual data included in the document <h2>Research and Development Considerations and Engineering Perspective</h2> <h5>Douglas A. Hobson, P. Eng. <a style="text-decoration: none;">* </a></h5> <h3>Background And Introduction</h3> Contrary to the impression given by a segment of current literature, the rapidly emerging field of specialized seating remains largely an art rather than a science. Established clinical principles, supported by a documented knowledge base are sparse, and clinical decision making remains largely subjective. That is, seating practice is not promulgated by an organized educational process. Specialized seating is still in the 1950's era. At that time, significant advances in prosthetics and orthotics were being made. Prosthetics advancements included below knee and above knee socket fitting, fabrication, and alignment principles. In the 1970's, orthotics introduced vacuum formable plastics to the field. Only in the last five years has specialized seating offered more than one or two commercial options for individuals requiring custom contoured body support. Specialized seating is still a comparatively young, but now a rapidly developing sub-specialty of rehabilitation technology. It is probably of value to attempt to define what is meant by the field of specialized seating. First, it is a clinical process which attempts to maximize function through the provision of appropriate "body support" for a nonambulatory person, usually in the seated posture, and usually in combination with a wheeled device, such as a wheelchair. The nature of the body support is dependent largely on the needs arising from the individual's disability. It can be thought of as providing seated body support in a manner that is usually less intimate and technically demanding than is required by conventional spinal orthotics (i.e., a body jacket). Specialized seating has been an exciting area for involvement and research and development, especially during the last ten years or so. Engineers first became clinically involved in specialized seating in the late 1960's in Canada. During the intervening years, other professionals such as prosthetists, orthotists, therapists, and technicians throughout North America and Europe have been actively involved in specialized seating developments. This article attempts to focus on the research and development process that has led to the emerging principles and products that are now becoming common place throughout the delivery system, especially for individuals with cerebral palsy. Perhaps of importance are the experiences that have shaped the views (and biases) of the author regarding the research and development process in the rehabilitation field. Firstly, early design experience in lower extremity modular prosthetics (Winnipeg, 1963-69), strongly reinforced the opinion that research and development should ideally take place in close proximity to an ongoing clinical commitment. Secondly, design and development must take place with a sense of reality towards the strengths and limitations of the manufacturing, marketing, and delivery system associated with the particular technology. This later view is the result of many frustrations, failures, and sometimes successes, in attempting to guide approximately a dozen "ideas" from conceptualization through clinical application over the past 15 years. The R&D process for the field of rehabilitation engineering technology may be viewed as consisting of three interrelated phases of activity, a) research, b) design and development, and c) clinical utilization. The approach taken in this article will be to examine each of these activities as they relate to the development of principles and devices currently employed in the field of specialized seating. Emphasis will be given to applied clinical research versus basic research. The final section will address the current status of the field and suggest future needs for its continued growth. Along the way, developments familiar to the author will be used to illustrate key points. The flowchart (<a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg">Fig. 1</a>) illustrates the process and suggests the primary outcomes from each step of the process. <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg">Figure 1. The three steps in the seating product development process, suggesting the major outcome for each step.</a> <h3>Research Contributions</h3> The engineer, especially when entering new clinical areas, can be overwhelmed by the apparent opportunities to employ engineering principles towards what appear to be readily resolvable problems. With the passing of time, the realization emerges that most problems are much more complex than they first appeared and the best solutions involve creativity, simplicity of design, patience and a good deal of perserverance. Applied research, as it applies to technology and rehabilitation, could be defined as "a logical process which attempts to reduce chaos in favor of logical problems solving, during which time a few significant principles and related devices can be developed." This definition may appear rather non-scientific; however, most developments of significance to date have resulted from attempts to solve a morass of seating problems. From these attempts we see repeated positive results become positioning principles and related successful devices become commercial products. At this point the question could be asked, What, of significance, has been learned about meeting the needs of individuals requiring specialized seating over the past 15 years? First, every person has a unique set of needs, therefore one generalized solution does not work for all. Second, it has been possible to group needs, or residual abilities, which can greatly assist in clinical decision making regarding the choice and provision of technical options. Third, there are three disability related (intrinsic) factors that dictate both research and clinical activities in specialized seating. These are a) lack of postural control (i.e., resulting from spasticity); b) existing or potential deformity; and c) the degree of loss of tissue sensation. The schematic diagram (<a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg">Fig. 2</a>) combines these intrinsic factors in a three dimensional array. As can be seen, postural control can be graded as good, fair, or poor; deformity as mild, moderate, and severe; and sensation as normal, impaired, or asensitive. The groupings that result (Groups 1, 2, 3) give an indication of the degree of body support that the seating system must provide to compensate for the patient's intrinsic deficiencies. For example, a child with cerebral palsy, with a mild deformity, good postural control, and essentially normal sensation falls into Group 1. Individuals with Group 1 needs usually do not require custom contoured body support and often only need a simple seat insert (standardized modular insert) that can provide midline orientation and improve the fit of the wheelchair. Whereas a teenager with Duchenne Muscular Dystrophy, who has poor postural control, severe deformity, but normal sensation, would be in Group 3. This individual would require extensive custom contoured support, including pressure relief throughout the seating surface to accommodate for the discomfort associated with prolonged stationary sitting. A person with a low level spinal cord lesion (paraplegic) with only moderate deformity and fair postural control would fall into Group 2. In this case, some contoured support may be necessary to compensate for deformity and loss of postural control. Also, a primary concern may be the loss of tissue sensation, so pressure redistribution over the seat surface would be necessary. <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg">Figure 2. A three-dimensional representation of the key intrinsic factors (control, deformity, and sensation) that guide decision-making in specialized seating.</a> Let us now go a step further and briefly look at a few disabilities in more depth. For example, individuals with cerebral palsy typically demonstrate a wide range of symptomatic intrinsic factors. It's usually obvious what group (i.e., Group 1, 2, or 3) they fall into for their general seating needs. However, what will be the short and long term postural needs for the child, how these needs can best be met through the seating system, and how the whole seating system must relate to the child's primary environments are all extrinsic factors that are best addressed by our therapy colleagues. That is, not only does one type of seating device not work for all, the manner in which it is configured for an individual, as well as how well it compliments the broader needs of the individual and the families are equally important. Experience has shown that specialized seating is best accomplished through a multidisci-plinary approach in which the technical and therapy contributions are orchestrated within a medical environment, with a physician assuming primary medical responsibility. In recent years, clinical research has begun to scientifically investigate the therapeutic principles related to positioning children with cerebral palsy. For example, Nwaobi<a></a> has shown that under certain conditions approximately 90° of hip flexion tends to minimize spasticity and optimize upper extremity function. More recent work by the same group<a></a> has also shown the importance of posturing in order to improve respiratory function in children with cerebral palsy. Present studies are looking at the potential contributions of posturing and seating support to reduce asymmetrical spinal muscle activity, which is thought to be a caustive factor in spinal deformity in the child with cerebral palsy. Earlier work in Rehabilitation Engineering at Rancho Los Amigos Hospital with the spinal cord injured<a></a> established safe pressure level thresholds for the tissue over the bony prominences, such as the ischial, coccyx, and the greater trochanters. These thresholds provide guidelines for clinicians when fitting cushions for individuals who require pressure relief in order to prevent development of pressure sores. This early work has paved the way to more recent work that is now modifying and refining these principles.<a></a> Clinical programs employing these techniques have significantly reduced the onset and development of pressure sores. For example, Ferguson-Pell<a></a> has developed a computer program which assists therapists and others in decision-making regarding the selection and fitting of wheelchair cushions. This system combines and integrates much of the existing knowledge in terms of pressure sore prevention and guides the clinician towards a logical solution in which the chances for error are minimized. Research in recent years has also developed other useful clinical tools. Again, for the spinal cord injured, there are now at least three commercially available devices (Scimedics TIPE, Oxford Pressure Monitor) that will measure and record the pressure that exists between the seated person and his support surface.<a></a> Other seating approaches use what is termed a "simulator approach" to assist in evaluation and fabrication of seating devices. For example, the MPI system<a></a> for cerebral palsy in children uses a multiadjustable frame and quickly detachable seat and back modules to allow the therapist to rapidly simulate the definitive seating arrangement. Tools of this type help in terms of therapy decision making and the subsequent communication with the technical staff responsible for the fabrication and fit of the device. Another research effort<a></a> is concerned with the collection of anthropometric data derived from taking measurements of a patient positioned in a subjectively good posture. This information will eventually be useful in the design of standardized componentry that will better match the dimensions and shapes of the individual. Another outcome of research activities has been the classification of seating devices into five generic groups based on their methods of fabrication. Space does not permit detailed discussion of this classification scheme, especially since it has been published elsewhere.<a></a> The following table is a synopsis of the classification scheme as it applies primarily to individuals with cerebral palsy. The table also incorporates the needs groupings discussed previously. This overall scheme has proven useful in helping inexperienced clinicians to better understand the key issues involved to match a client's needs with available commercial options. In addition, the above classification scheme provides a framework through which a student in the field of specialized seating can begin to appreciate the differences that exist between the various technical options; and more importantly, what general needs each system is designed to meet. Further study involves learning the fabrication steps involved in the various systems, the positive and negative features associated each approach, and how features from various types can be combined to produce hybrid devices for meeting very specialized user needs. Probably the most significant advancement is that both research and clinical experiences are now being brought together in the form of educational manuals<a></a> and instructional courses. This development is a major step towards establishing the body of knowledge that is so crucial if specialized seating is to progress from an "art" to a recognized field of professional endeavor. <h3>Design And Development</h3> One of the obvious benefits of a research team working in close proximity to clinical activities is the potential for identification of "real" needs requiring technological intervention. Once these needs are identified, they then form the basis of design specifications which become the goals for the initial phase of the design and development process. Of all the endeavors involving rehabilitation engineering technology over the past twenty years, this step of defining what needs to be done has probably been the most poorly managed. There is probably no greater waste of technological resources than to solve problems for which there is either already an existing solution, or for which a solution cannot be sufficiently generalized to meet the needs of a commercially viable segment of the population. Assuming a "green light" is still on after the "real" needs are identified, the next step is to develop a prototype solution, which in this context could be a technique, a clinical tool, or a seating device. The development is usually very "fragile" at this time, and the sooner it can be subjected to clinical trials and critique in a positive environment the better. Invariably, modifications and design refinements are required until a solution is developed that is acceptable to both the clinicians and their test subjects. Ideally, the development should then be exposed to wider critique within environments different from those in which the development took place. Also, manufacturing, marketing, and costing analysis should take place in preparation for the preproduction phase. Assuming all these steps yield positive outcomes, an initial preproduction run is made so controlled evaluations can be done in selected external environments. The results of the external evaluations should be carefully monitored, documented and made available to the production design team. Over the past six years, four such developments from the University of Tennessee Rehabilitation Engineering Program have gone through this process, some more rigorously than others. These developments, the Modular Plastic Insert, the Spherical Thoracic Support, the Foam-In-Place, and the Bead Seat System, are now all commercial products being marketed by three different commercial firms. The final stages of the design and development process can vary depending on development and the resources of the commercial firm involved. In general, the market volume for seating devices is still relatively low. Therefore, it is important that the "front end" cost to the commercial firm be minimized. This can be accomplished in several ways by the development team. First, it is crucial that the design be "elegantly simple" so that it can be reproduced in relatively low volumes inexpensively. Secondly, design refinements and problems solving support should be provided well into the commercialization phase. Royalty arrangements and other "front end" type payments to the developer should be minimized and based on product sales. And finally, support in terms of providing educational materials, publications, and instructional seminars all assist in creating a receptive market place. <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-3.jpg">Table</a> <h3>Clinical Utilization</h3> This final phase of the R&D process is most often neglected, since it is usually not very exciting to the development team. From the R&D perspective, this design activity addresses those features of the development that will make it an attractive alternative to existing methods or devices being used. Again, development of instructional materials, provision of evaluation prototypes to "trend setters" and conducting instructional courses have already been mentioned. However, these supporting activities in themselves are usually not the key influencing factor. The development team must address the question, Why would a service provider working within a particular service delivery system choose the new development over another technical option? The answer usually is that the service provider can provide a higher quality service at equal or lower cost. Therefore, the new development must provide improved function to the user, and possibly increased status for the clinic/provider, at costs that can be paid for by the payment structure in which the service is provided. Failure by the design and development team to recognize the realities of the delivery system in which the development must be marketed is probably a primary reason why so many developments fail to make the transition from laboratory to widespread clinical application. <h3>Current Trends In Specialized Seating</h3> A 1985 survey of 26 facilities in 17 states<a></a> provides considerable insight into the state of maturity of the field of specialized seating. Of the 26 respondents, 12 were hospital based, six were state funded programs or institutions, and 8 were from private industry. The majority reported the use of plywood and foam technology (61 percent) or custom produced molded plastic parts (17 percent). The payment was received primarily from Medicaid, State Crippled Chil-drens Services, or private insurance carriers. The average number of clients fitted with new devices per year/facility was 185, with a total number fitted of 3,293. The importance of this survey, in the context of design and development, is that the majority of the facilities reported the use of basic "bench" fabricated technology (78 percent). This is not surprising since the majority of the new developments have only been available commercially for less than three years, and related educational programs are just beginning to have a significant clinical impact. Continuing education programs supported by the American Academy of Orthotists and Prosthetists, the Rehabilitation Engineering Society of North America, and institutions like the University of Tennessee Rehabilitation Engineering Program, Newington Children's Hospital, and Elizabethtown Children's Hospital, and private firms, such as Pin Dot Products, and Mobility Plus have been the primary sources for training in the new concepts and seating systems. As these efforts are expanded to involve larger numbers of clinicians, the newer technology in seating will permeate into the service delivery system. Of importance to the prosthetic and orthotic professions is that many of the professional skills and shop resources required to deliver improved specialized seating services are already in place. Also, specialized seating is now becoming recognized by many of the major third party payment sources as a recognized clinical service. The new commercial systems have been designed to be less labor intensive and to permit the provision of a quality product at a reduced cost. The overall result is that it is now feasible to invest in the education and inventory required to enter the field and expect to realize a return on that investment over a 2 to 3 year period. That is, specialized seating now presents a viable growth area for the prosthetic and orthotic field. Projecting into the future, one may speculate as to what developments are likely to take place in the field. As far as design and development, it is likely that refinements to the newer commercial products will preoccupy the efforts and available development resources over the next two to three years. New and ongoing basic research will continue to develop or validate positioning principles for the cerebral palsy population. We should see refinement and expansion in the use of computerized expert systems, primarily by institutional settings that are doing larger volumes of evaluation and prescription of seating devices. Educational courses should become more available on a regional basis through several of the participating professional associations. Hopefully, the American Academy of Orthotists and Prosthetists will continue its continuing education efforts in this area. Probably the most urgent and difficult issue to be resolved is the further education of third party payment sources, so that seating services can be provided and reimbursed throughout the country. In this regard, initial efforts by the Rehabilitation Engineering Society of North America appear promising. Similar, and probably coordinated, efforts by other organizations such as the American Occupational Therapy Association, the American Orthotic and Prosthetic Association, and the American Academy of Orthotists and Prosthetists would be most timely. In summary, research and development has made significant contributions to the field of specialized seating. This statement is based in the fact that there are not less than six new seating developments that have become available to the practitioner over the past five years. Basic studies, published articles, and manuals are establishing the foundation for educational activities that are becoming more widely disseminated. Third party payment sources have been slow to respond, but diverse efforts throughout the country have been successful at receiving reimbursement for seating services. In conclusion, more remains to be accomplished, and research and development can be expected to continue its contribution. Specialized seating is being transformed from an "art" to a recognized field of professional endeavor. References: <ol> <li>Nwaobi, O.M., Hobson, D.A., Trefler, E., "Hip Angle and Upper Extremity Movement Time in Children with Cerebral Palsy," Proceedings of the Eight Annual Conference of the Rehabilitation Engineering Society of North America, Memphis, Tennessee, June, 1985, pp. 39.</li> <li>Nwaobi, O.M., Smith, P.D., "Effect of Adaptive Seating on Pulmonary Function of Children with Cerebral Palsy," Develop. Med. Child Neurol., 28, 1986, pp. 351-354.</li> <li>Rodgers, J.E., Rewsick, J., "Program for Prevention of Tissue Breakdown," Annual Report, Rancho Los Amigos Hospital-REC, 1974/75, pp. 24-31.</li> <li>Paterson, R., "Is Pressure the Most Important Parameter," Proceedings, National Symposium on Care Treatment and Prevention of Decubitus Ulcers, Paralyzed Veterans of America, Washington, D.C., November, 1984, pp. 73-74.</li> <li>Ferguson-Pell, M., "Research Relating to Pressure Sore Prevention," Proceedings, National Symposium on Care Treatment and Prevention of Decubitus Ulcers, Paralyzed Veterans of America, Washington, D.C., November, 1984, pp. 53-54.</li> <li>—Scimedics, 170 Vander St., Units A & B, Corona, California 91720.  —TIPE-Tee Kay Applied Technology, 11915 Meadow Trail Lane, Stafford, Texas 77477.  —Oxford Pressure Monitor-International Medical Equipment Corporation, 11000 E. Rush Street, Suite 4, South El Monte, California 91733; (213) 350-1410.</li> <li>Modular Plastic Insert System marketed by Pin Dot Products, Inc., 2215 Belmont Street, Chicago, Illinois 60618.</li> <li>Reger, S., Hobson, D.A., "Seat Design Factors for Wheelchairs," Annual Report, University of Virginia- REC, 1985, pp. 25028. Charlottesville, Virginia.</li> <li>Hobson, D.A., Trefler, E., "Towards Matching Needs with Technical Approaches in Specialized Seating," Proceedings of the Seventh Annual Conference of the Rehabilitation Engineering Society of North America, June, 1984, Ottawa, Canada, pp. 486-488.</li> <li>Bergen, A., Colangelo, C, Positioning the Client with CNS Deficits: The Wheelchair and Other Adapted Equipment, Valhalla Rehabilitation Publications, Ltd., New York, 1982.</li> <li>Trefler, E. (Ed.), Seating for Children with Cerebral Palsy: A Resource Manual, University of Tennessee Center for the Health Sciences-Rehabilitation Engineering Program, Memphis, Tennessee, 1984.</li> <li>Ward, D., "Positioning the Handicapped Child for Function," Pin Dot Products, Chicago, Illinois, 1983.</li> <li>Holte, R., Shapcott, N., "A Survey of Wheelchair Seating Service Delivery Programs in the USA," Proceedings of the Eighth Annual Conference of Rehabilitation Engineering Society of North America, Memphis, Tennessee, June, 1985, pp. 157-159.</li> </ol> *Douglas A. Hobson, P. Eng. Douglas A. Hobson, P. Eng., is Technical Director at the Rehabilitation Engineering Center, for the University of Tennessee Health Science Center, 682 Court Avenue, Memphis, Tennessee 38163. <div style="width: 400px;"></div> Page Number(s) 122 - 129 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg Figure 3 TABLE http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-3.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 Research and Development Considerations and Engineering Perspective Creator An entity primarily responsible for making the resource Douglas A. Hobson, P. Eng. * 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. <a style="text-decoration: none;">*</a></h5> 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. 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. <h3>Method</h3> 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. 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. 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">Fig. 1</a>). This is preferable to a commercial sabre saw blade, because its wide, thin shape creates a smoother, less irregular cut. <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. 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. 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">Fig. 2</a>). Place the brim back onto the socket to be certain it fits properly, with minimal gapping along the cut edge. <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. <h3>Reinforcement</h3> 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. 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">Fig. 3</a>). Lubricate the cut edge with petroleum jelly and reapply the wedge carefully to avoid gapping. <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. 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. 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">Fig. 4</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. <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. 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. 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">Fig. 5</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">Fig. 6</a>). This unobtrusive lip will significantly reinforce the wedge, particularly against malrotation. <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. <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. <h3>Finishing</h3> 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. 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. <h3>Summary</h3> 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. References: <ol> <li>Durr-Fillauer Medical, Inc.  P.O. Box 5189  Chattanooga, TN 37406  RMB Hardware Kit  Catalog #127019 (Heavy Duty)  Catalog #127001 (Standard Duty)</li> <li>S.C. Johnson & Sons, Inc.  Racine, WI 53403  #140 Stik-Wax-15 oz. container</li> <li>Otto Bock Industries  4130 Highway 55  Minneapolis, MN 55422  Coroplast PVC tape  Catalog #616F8</li> <li>Durr-Fillauer Medical, Inc.  P.O. Box 5189  Chattanooga, TN 37406  Xynole-Polyester cloth  Catalog #211094</li> </ol> *Robert O. Gooch, CP. Robert O. Gooch, CP., is with the Department of Prosthetics and Orthotics at the Duke University Medical Center. <div style="width: 400px;"> </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/b95e5342fe7eaaa21c950572d787fbda.pdf 22900e4b73ce0e89c1e8e6b35ce978e9 https://staging.drfop.org/files/original/69a206a2aa84ed680056a9fdc2139438.jpg d2cf4a108bb4637b1831508eed43a6bb https://staging.drfop.org/files/original/bbdcebf3e88af2b9c4154c6ab8600941.jpg 1742853ff042c4f63024eb1c3f70a128 https://staging.drfop.org/files/original/f6b252668fde0f741327f4ce578605b4.jpg d7e17f3201c463458fb90ab1fc6ed3c9 https://staging.drfop.org/files/original/072c8063021ab7603ec812365ca28462.jpg 844e15bf47ec63eb59e4d48548c2ffda https://staging.drfop.org/files/original/3f19c0d013a453a5a3aac4a18fd62be7.jpg 059db7ef417cd22394cde20c77c23ff8 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_115.pdf Text Any textual data included in the document <h2>An Alternative Technique for Fabricating Flexor Hinge Hand Orthoses Using Total Contact Molded Plastic Finger Pieces</h2> <h5>Greg Moore, R.T.O. <a style="text-decoration: none;">*</a></h5> The flexor hinge hand orthosis is one of the most demanding orthoses for the orthotist to fit properly. The slightest error can result in failure of the orthosis and loss of patient confidence in the orthotist. Presented here is a technique for fabricating the orthosis with increased fitting accuracy and reduction of patient-practitioner contact time. The procedures presented here have been accumulated from the measurement and fabrication techniques of various practitioners (see acknowledgments) and assimilated into this single technique. <h3>History</h3> The flexor hinge hand splint was originally based on the principle of the flexor hinge hand as described by Nickel, Perry, and Garrett in 1955.<a></a> In the years that followed, it was developed by them and their co-workers, using the principle of the modified three-jaw chuck, in which the index and middle fingers move together towards the thumb. This is accomplished by immobilizing the thumb in a position of opposition and placing the index and middle fingers in a position of semiflexion at the inter-phalangeal joints. To prevent slippage of the object grasped, the thumb pad must oppose the pads of the two fingers. The flexor hinge is that part of the orthosis which hinges at the MP joint and holds the index and middle fingers in a functional position. The range of motion is from a position of full extension of the MP joints to a point where the finger pads contact the thumb. The orthosis is operated in one direction by internal or external power under voluntary control, and returned to the starting position passively, usually by a spring or gravity. The orthosis was originally developed to restore upper extremity function of patients with poliomyelitis. As the incidence of poliomyelitis decreased, the orthosis was used with other patients with severe upper-extremity paralysis such as cervical spine injury, hemiplegia, and brachial plexus injury. The results of treatment in these patients indicated that it is the degree of functional loss rather than the diagnosis that is significant. To a large degree, management of upper-extremity paralysis is the same regardless of the cause.<a></a> <h3>Fabrication Technique</h3> After the patient has been assessed by the rehabilitation team and the orthotic design has been determined, the patient is seen by the orthotist. Appropriate measurements are taken and recorded for fabrication of the forearm and/or palmar pieces. Following this initial visit, the orthotist shapes and assembles the pieces according to the measurements, with special attention to accurate placement of the MP mounting plate for the flexor hinge finger piece. Temporary straps are also attached to the orthosis to eliminate migration of the orthosis during trial fitting. Other fabrication steps that can be completed at this time are the placement of temporary padding (if used) and the attachment of the adjustable actuating lever kit (Rancho style wrist-driven). The thumb post can be shaped, but should not be attached to the palmar piece until it has been properly fitted to the patient on the second visit. With the patient's second visit, the forearm and/or the palmar pieces should be fit to the patient and necessary adjustments made to provide for optimal fit and function. The thumb post is fit and attached to the palmar piece in the normal manner at this time. With this accomplished, the orthosis is placed on the patient's hand and secured with the temporary straps. The index and middle fingers are taped together at the distal phalanges using 1/4" masking tape, so as to keep the middle finger slightly longer than the index finger. A position of 35-40° of flexion at the MP joint, 30° of flexion at the proximal interphalangeal joint, and 5-10° of flexion of the distal interphalangeal joint is needed to position the fingers in opposition with the thumb.<a></a> When the positioning of the fingers has been accomplished to the satisfaction of the orthotist, the fingers and thumb are coated with a thin layer of petroleum jelly in preparation for casting. Four layers of 4" plaster bandage material are measured and cut so that the ends of the bandage extend over the ends of the fingers by 3/4" and at the other end over the proximal edge of the MP mounting plate by 3/4" (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg">Fig. 1</a>). The plaster bandage is then dipped in water and with the fingers held in a position of opposition to the thumb, the plaster bandage is placed over the dorsal aspect of the fingers. The edge of the bandage extends distally so that the tip of the thumb is included in the impression. Proxi-mally, the bandage extends over the MP mounting plate so that an impression of this is included. The bandage should not cover the volar (palmar) side of the fingers. The bandage is rubbed into the fingers, tip of the thumb, and the MP mounting plate to obtain a clear impression, and the edges of the bandage should be folded back approximately 1/4" to reinforce the borders (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-2.jpg">Fig. 2</a>). After the bandage has hardened, it can be removed without the use of a cast saw by gently disengaging it from the MP mounting plate area and tilting it up over the fingers. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg">Figure 1.</a> Preparation for casting fingers. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-2.jpg">Figure 2</a>. Cast impression incorporating MP joint plate and fingers. The proper length of the temporary straps should be marked and the fitted forearm and palmar pieces removed. The patient's hand can now be cleaned, and he/she can be scheduled for a final return visit. The impression is prepared for filling by enclosing it in plaster bandage and coating the inside with a thin layer of liquid soap. A small mandrel should be contoured to fit the inside of the impression, extending as far distally as the tips of the fingers to prevent fracturing of the positive model (a length of 1/2" O.D. aluminum tubing works well for this). The impression is filled with plaster of Paris and stripped, using great care not to fracture the positive model. The model will have good detail, showing the contours of the finger nails, skin lines, and MP mounting plate. The positive model is prepared for vacuum forming, using a length of nylon stocking as the interface for the 1/8" polyethylene. If Surlyn® is used, the Surlyn® is vacuum formed directly over the lightly smoothed impression without an interface. The clarity of Surlyn® facilitates visual assessment of pressure distribution when used with a sensation impaired hand. The plastic should be vacuum formed and not drape formed to insure an exact fit. Once the vacuum forming has been completed, the plastic piece can be removed by using a cast saw and carefully avoiding excessive damage to the impression. The finger piece is now ready to be trimmed using the following general guidelines. The distal border should be 1/8" distal to the proximal edge of the fingernails of the index and middle fingers. The proximal border should be trimmed to the proximal aspect of the proximal phalanges. In the coronal plane, the plastic piece is trimmed along the midline of the fingers. The plastic finger piece is then placed back on the positive impression and a stainless steel superstructure is fabricated using the MP mounting plate impression as the reference for the MP operating lever (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-3.jpg">Fig. 3</a>). This saves an enormous amount of time since the reference between the palmar piece and finger piece is part of the positive impression. A regular Jaeco style proximal finger piece is used for the proximal bar of the superstructure, and a 3/32" rod connects it to a distal stainless bar located at the middle of the middle phalange. Both of the bars are silver soldered to the 3/32" rod and simply bent to the contours of the plastic finger piece. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-3.jpg">Figure 3</a>. Shows ease of aligning MP joint and finger pieces with MP joint included in the cast. The proximal finger piece is connected to the MP operating lever in the usual manner. A Velcro® closure can be attached to the distal superstructure bar on a stainless steel closure and can be fabricated using the bar as the dorsal half of the closure. With the finger piece completed and the remainder of the orthosis finished, the patient can be fitted and the orthosis delivered (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-4.jpg">Fig. 4</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.jpg">Fig. 5</a>). Patient training and minor adjustments are done following regular rehabilitation procedures. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-4.jpg">Figure 4.</a> Complete orthosis wih polyethylene finger piece. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.jpg">Figure 5.</a> Orthosis showing use of Surlyn® finger-piece for observation of the skin. <h3>Summary</h3> Fabrication of the intimate fitting flexor hinge component of the flexor hinge wrist hand orthosis can be tedious. The procedure detailed here can facilitate fabrication of a more accurately fitting flexor hinge. The use of a vacuum formed finger section assures a total contact fit resulting in fewer pressure problems on the fingers. The optional use of Surlyn® for fabrication of the plastic finger piece permits direct skin observation when deemed beneficial. <h3>Acknowledgments</h3> I would like to express my special thanks and admiration to Jack E. Greenfield, CO. at Rancho Los Amigos Hospital and David Bird, CO. at University of Michigan Hospitals for their willingness to share their experience and knowledge. References: <ol> <li>Nickel, V.L., Perry, J., and Garrett, A.L., "Development of Useful Function in the Severely Paralyzed Hand," Journal of Bone and Joint Surgery, 45:933, 1963.</li> <li>Rae, J.W., Jr.: Personal communication. Conference on Upper Extremity Devices, Rancho Los Amigos Hospital, Downey, California, May 15-16, 1957.</li> <li>Malick, M.H., and Meyer, C.M.H., "Manual on Management of the Quadriplegic Upper Extremity," Har-marville Rehabilitation Center, 1978, p. 39.</li> <li>Engel, W.H., Kmiotek, M.A., Hohf, J.P., French, J., Barnerias, M.J., and Sievens, A.A., "A Functional Splint for Grasp Driven by Wrist Extension." Archives of Physical Medicine & Rehabilitation, January, 1967, pp. 43-52.</li> <li>Bisgrove, J.G., "A New Functional Dynamic Wrist Extension-Finger Flexion Hand Splint-A preliminary report, Journal of Ass. Phys. Ment. Rehab., 8, September-October 1954, pp. 162-163.</li> <li>Redford, J.B., ed. Orthotics Etcetera. Baltimore, Md. Williams and Wilkins, 1980, pp. 238-248.</li> </ol> Greg Moore, R.T.O. At the time of writing, Greg Moore, R.T.O., was a student in the Long Term Orthotic Practitioner Program at 916 Vo-Tech. He may be reached at: c/o Bill Moore, 7366 S. Bannock Drive, Littleton, CO 80110. <div style="width: 400px;"> </div> Page Number(s) 115 - 118 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.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 An Alternative Technique for Fabricating Flexor Hinge Hand Orthoses Using Total Contact Molded Plastic Finger Pieces Creator An entity primarily responsible for making the resource Greg Moore, R.T.O. * https://staging.drfop.org/files/original/a75bb5af32b91c1f69b33d56c8e8c13c.pdf 7038d74466afb3f6db7db53e207d99f1 https://staging.drfop.org/files/original/83201447bfbcd1b4e9c4e43420cb46c0.jpg bbea9d1c00254560b22e2b807b1c8d08 https://staging.drfop.org/files/original/7ea7735793548661de0e6720877337e8.jpg b400e6e9832514b4295b6404a02ba862 https://staging.drfop.org/files/original/0dd26f7dd4ed5f35fb0c91028a1a8e1d.jpg 366678f0b5ceb5eadc4f020eee144577 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_111.pdf Text Any textual data included in the document <h2>Restoration of Walking in Patients with Incomplete Spinal Cord Injuries by Use of Surface Electrical Stimulation: Preliminary Results</h2> <h5>T. Bajd <a style="text-decoration: none;">*</a> B.J. Andrews <a style="text-decoration: none;">*</a> A. Kralj <a style="text-decoration: none;">*</a> J. Katakis <a style="text-decoration: none;">*</a></h5> This article was reprinted with permission from Prosthetics and Orthotics International, 9, 1985, pp. 109-111. Further information about Prosthetics and Orthotics International can be obtained from Joan E. Edelstein, Secretary-Treasurer, US Member Society ISPO, 317 East 34th Street, New York, N.Y. 10016. <h3>Introduction</h3> A group of patients who are good candidates for the application of Functional Electrical Stimulation (FES) to restore reciprocal walking is described. They have incomplete lesions of the spinal cord. Because of the degree of preserved voluntary control, proprioception and sensation, some of these patients can achieve crutch assisted walking by means of multichannel electrical stimulation. In a number of cases the patient has sufficient strength and voluntary control in the upper limbs and at least one leg to provide safe standing for short periods in forearm crutches. For these patients a two channel stimulator controlled by a hand-switch was applied to achive safe and practical crutch assisted walking in a relatively short period of time. <h3>Background</h3> A new group of patient which can benefit from the orthotic use of functional electrical stimulation (FES) has been identified. These are incomplete spinal cord injured patients. This group of patients is increasing in numbers mainly due to improvements in primary care. The clinically incomplete lesion of their spinal cord results in preservation of some voluntary movements of the lower extremities. Some of these patients are able to walk with the help of various short-leg or long-leg orthoses which fix the knee and ankle joints. Support of the foot is often provided by the addition of a toe spring. Locomotion of most other incomplete spinal cord injured (SCI) patients is performed with the help of a wheelchair. They can walk only for very short distances, usually in their homes. Some tetraplegic patients are totally confined to a wheelchair. The reason is often very strong spasticity or developed contractures. The upper extremities are also partially paralyzed. Nevertheless, the arms and hands are strong enough to provide support on crutches. Wrist and finger movements are often limited and the grip is rather weak. However, the patients are in most cases able to hold the handle of the crutch. It was found that a minimum of four channels of FES was required for synthesis of a simple reciprocal gait pattern in the complete thoracic patient (Bajd et al., 1983; Kralj et al., 1983). During the stance phase, knee extensor muscles are stimulated, while the swing phase is accomplished by eliciting a synergistic flexor response in hip, knee and ankle joints through electrical stimulation of an afferent nerve. It was observed in the present study that in most of the incomplete tetraplegic patients one leg was almost completely paralyzed while the other leg was under voluntary control and sufficiently strong to provide safe standing for short periods using only crutches. Unilateral stimulation of knee extensors and an afferent nerve was helpful in these patients. Less frequently it was found that the patients could stand but were unable to take a step with one or both legs. Unilateral or bilateral stimulation of afferent nerves proved helpful for them. There are also patients whose extension and flexion capabilities in both lower extremities are so poor that they need three or even four channels of stimulation. <h3>The Fes Orthosis</h3> From the point of view of control of the patient, the gait cycle was divided into stance and swing phase. The transition from one phase to another was achieved by pressing a hand switch mounted on the handle of the crutch. When the switch was not pressed, knee extensors were stimulated. When the switch was pressed, the afferent nerve was excited, resulting in the swing phase of walking. The duration of the swing phase was regulated by the time of pressing the switch. In the present investigation the peroneal nerve was stimulated near fossa poplitea. The stimulation of this mixed, sensory and motor, nerve provided direct dorsi-flexion and eversion of the foot and simultaneously also the reflex knee and hip flexion. The gait of most of the incomplete SCI patients can be restored by the two-channel stimulator only. Any stimulator can be used for the described application where the stimulation parameters can be adjusted close to the following values: 0.3 ms pulse duration, 20 Hz pulse repetition frequency, and an amplitude up to 120 volts (measured with a 1k Ω load. Surface electrical stimulation of the knee extensors was delivered to the muscles through large (6 x 4 cm) sheet metal electrodes covered with water soaked layers of gauze. When stimulating the common peroneal nerve, two small round electrodes (diameter 2.5 cm) made of sheet metal and covered by gauze saturated with water were used. The interconnection of the hand switch with the outputs of the stimulator to the electrodes can be readily accomplished. The hand switch was attached to the handle of the crutch by adhesive tape for trial purposes. <h3>Patient Tests</h3> Five patients with incomplete spinal cord lesions have so far been included in the program of FES assisted walking. Only a short strengthening program was required for disuse atrophy of their thigh muscles. The learning program of walking was extremely fast and simple. After the first few days the patients were able to go from mobile parallel bars to crutches (<a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg">Fig. 1</a>). The difference between walking with and without FES was evident. The patients were not able to take a single step with their severely paralyzed extremity when the stimulator was switched off. After a few days of training they were able to rise from the sitting to the standing position independently with the help of the crutch support and knee extensor stimulation only. Soon they were able to walk on uneven ground (<a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg">Fig. 3</a>) and go up and down steps (<a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg">Fig. 2</a>). The subject shown in <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg">Fig. 3</a> has an incomplete lesion at the level T6/7 (age 36 yrs., height 168 cm., mass 61 kg., 7 yrs. post injury). The subject shown in <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg">Fig. 1</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg">Fig. 2</a> has an incomplete lesion at the level C6 (age 21 yrs., height 188 cm., mass 70 kg., 3 yrs. post injury). In both cases one leg was paralysed while the other had sufficient voluntary control to maintain safe standing with crutches without stimulation. <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg">Figure 1.</a> Paraplegic subject with incomplete lesions at T6/7 walking on a level surface. <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg">Figure 2</a>. Tetraplegic subject with incomplete lesion at C6 negotiating uneven steps. <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg">Figure 3</a>. Patient walking on uneven ground; end of swing phase for the paralyzed leg. <h3>Discussion</h3> Such activities can only be achieved in a few completely paraplegic patients after many months in the training program. These differences between incomplete and complete spinal cord injured patients are due not only to the remaining voluntary movements of their lower extremities, but also to the preserved sensation and proprioception. The present FES orthotic systems provide active movements at the joints of the limbs, but no feedback is available in practical clinical systems. The patients feel safe and secure when unattended because in the event of a failure of the orthosis, they are able to support themselves. For these reasons the incomplete SCI patients appear to be the most appropriate candidates for FES. The FES assisted walking may require less energy from the SCI patients with incomplete lesions than walking with passive mechanical knee and ankle orthoses, because no hip hiking is necessary with active FES systems. Finally, FES assisted walking is much more aesthetic to the observer than orthoses assisted and is preferred by the patients. There may be a number of therapeutic benefits to be gained from the use of FES orthoses such as the prevention of pressure sores, contractures, muscle atrophy and bone demineralisation. <h3>Acknowledgments</h3> The authors wish to acknowledge the financial support of the Multiple Sclerosis Society and the A. Onasis, Public Benefit Foundation. The work was conducted at the Bioengineering Unit, University of Strathclyde, Head, Prof. J.P. Paul and in collaboration with Mr. P.A. Freeman F.R.C.S. and staff of the West of Scotland Spinal Injuries Unit at the Philipshill Hospital, Glasgow. References: <ol> <li> Bajd, T., Kralj, A., Turk, R., Benko, H., Sega, J., "The use of a four channel electrical stimulator as an ambulatory aid for paraplegic patients," Phys. Ther., 63, pp. 1116-1120, 1983. </li> <li> Kralj, A., Bajd, T., Turk, R., Krajnik, J., Benko, H., "Gait restoration in paraplegic patients. A feasibility demonstration using multichannel surface electrodes FES," J. Rehabil. Res. Dev., 20, pp. 3-20, 1983. </li> </ol> *J. Katakis Member of the Bioengineering Unit at the University of Strathclyde in Glasgow. *A. Kralj Member of the faculty of Electrical Engineering at Edvarda Kardelja University in Ljublana. *B.J. Andrews Member of the Bioengineering Unit at the University of Strathclyde in Glasgow. *T. Bajd Member of the faculty of Electrical Engineering at Edvarda Kardelja University in Ljublana. Page Number(s) 111 - 114 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.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 Restoration of Walking in Patients with Incomplete Spinal Cord Injuries by Use of Surface Electrical Stimulation: Preliminary Results Creator An entity primarily responsible for making the resource T. Bajd * B.J. Andrews * A. Kralj * J. Katakis * https://staging.drfop.org/files/original/37c3fec692e2b57f47245df169887b35.pdf 4946ee134a3401f408e0f322622aa167 https://staging.drfop.org/files/original/cda236ac9cde9b85325e3b96250a8f34.jpg 26aeac3a42f4a49224918f719d96a7bf https://staging.drfop.org/files/original/61e5df6689a2f5df64d735ec336e8dd7.jpg 25e56e96ed63a1d92e654c1dfd5447c9 https://staging.drfop.org/files/original/fd0fd82498d9cf6124c858bd221e6da0.jpg ceb9e4d935e7a64a1a6b54d44300cd2f https://staging.drfop.org/files/original/d3c8b0e372904833805dd1044f5bb20f.jpg b836b034c8fba7dd52dcbf61c62f7557 https://staging.drfop.org/files/original/c807aa7a3fefd3330cb672958e4f9744.jpg cef35b057b604843a8fda814493e07bd https://staging.drfop.org/files/original/ef44f82ae71f82036a91bd66e369ab5f.jpg 0a8cf7b7df88f1f5875f99e02d60f2a1 https://staging.drfop.org/files/original/aae5019d6873ca6c365835a4c4706720.jpg ebaef7afe5ead98ddf0119032fb488da https://staging.drfop.org/files/original/00f96c383c511633e3f05f8c9f266f5b.jpg 17c8c67c8c1a64cd510eedfe1639eb79 https://staging.drfop.org/files/original/0b29948807ab4359f31ff27cd2112168.jpg 1cafb32b82c0b235dc700d48c8dcba50 https://staging.drfop.org/files/original/9500eb71d186ca76e567a337583202af.jpg e86c2a546d0bea141aba88885bd080ed https://staging.drfop.org/files/original/5644f8d878cf4491ab0b287029eb3741.jpg 0d76a9bdf9ccd33b508307f1bd262151 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_105.pdf Text Any textual data included in the document <h2>The Use of Surlyn and Polypropylene in Flexible Brim Socket Designs for Below-knee Prostheses</h2> <h5>C. Michael Schlich, C.P.O. <a style="text-decoration: none;">*</a> A. Bennett Wilson, Jr. <a style="text-decoration: none;">*</a></h5> The need for improved prosthetic socket designs to increase amputee comfort and function has long been recognized by prosthetists and other health care professionals involved in amputee rehabilitation. Reduction of the hardness and stiffness of wood and plastic laminate sockets has been addressed with various soft liners or inserts in an attempt to improve comfort and function. The subject is well covered in literature from Radcliffe's and Foort's initial description of leather and Kemblo® liners in 1961,<a></a> through Leon Bennett's work with gel liners in 1974,<a></a> to Tim Staats' description of multi-durometer liners in 1984.<a></a> Liners have no doubt been useful in below-knee prosthetics, but the proponents of soft liners seem to have overlooked the potentials offered by flexible brims. At least two engineers active in prosthetics research have for some time raised questions concerning socket brim stiffness as a negative factor with respect to socket comfort. Dr. Eugene Murphy first considered this theme as early as 1957<a></a> when he proposed, "minimize the stiffness gradient between the rigid socket wall and the flexible skin, i.e., taper flexibility of the socket brim." As Dr. Murphy<a></a> later relates: <blockquote> "This theme was eventually published as the introduction to an extensive series of theoretical and experimental papers by Bennett. The series ended with limited clinical trials of sockets with flexible brims made of plastic laminates. These sockets appeared to be helpful for patients previously troubled by chronic or recurrent cysts, but the mechanical durability of the laminate was so poor that the sockets often lasted only six months."<a></a> </blockquote> In the course of developing the ultralight weight below-knee prosthesis at Moss Rehabilitation Hospital,<a></a> A. Bennett Wilson, Jr. recognized the possibilities afforded by the use of thermoplastics to achieve flexible brims that would be sufficiently durable. During the past year, we have been funded by the Veterans Administration Rehabilitation Research and Development Service to carry this idea further. After reviewing the theories set forth previously and considering the properties of new materials and techniques now available, a set of criteria for socket design was established: <ol> <li> Flexible brim </li> <li> Tapering flexibility of the socket in the brim area </li> <li> Flexibility options in other areas of the socket </li> <li> Light weight, but durable </li> <li> Thermoplastic and modular (i.e. no lamination, no epoxy, no glue, etc.) </li> <li> Compatibility with existing modular component systems </li> </ol> The resulting socket design (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg">Fig. 1</a>) consists of the following components: (1) a Surlyn® inner socket or liner; (2) a polypropylene frame for socket support and attachment; (3) silastic foam soft end pad for establishing total contact; (4) United States Manufacturing Company<a></a> adaptor hardware<a style="text-decoration: none;">*</a> for attachment to Otto Bock<a></a> modular systems; and (5) neoprene sleeve suspension. <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg">Figure 1. Complete prosthesis, except for cos-mesis and suspension, incorporating a socket with flexible brims.</a> Fabrication of this socket system is as follows: <ol> <li> The cast is modified for a PTB-supracon-dylar socket design, and the distal end of the model is extended approximately one inch to allow for a silastic foam end pad and the modular adaptor (U.S. Mgf. Co.) for connection of the pylon to the socket (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg">Fig. 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg">Figure 2. The modi-fled plaster model of the stump is extended to allow for location and alignment of the U.S.M.C. adaptor connector plate for the pylon.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg">Figure 3. The modified plaster model complete with adaptor, ready for vacuum-forming of the Surlyn® inner socket.</a></li> <li> An inner liner of Surlyn® is vacuum formed using either 12" x 12" x 3/16" Surlyn® for light to regular duty sockets, or 12" x 12" x 1/4" Surlyn® for heavy duty sockets (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg">Figure 4. Vacuum-forming the Surlyn® inner socket.</a></li> <li> One layer of thick stockinette and a nylon stocking are applied over the vacuum-formed Surlyn® liner to facilitate separation of socket frame and liner (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg">Figure 5. Application of stockinette and nylon sock over Surlyn® inner socket to provide for separation of the polypropylene outer socket to be vacuum-formed over it.</a></li> <li> The socket frame is vacuum formed of polypropylene directly over the inner socket. A piece 12" x 12" x 3/8" is suitable for light duty while a piece 1/2" thick is usually adequate for heavy duty (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg">Figure 6. The outer socket frame is vacuum-formed over the inner socket</a> </li> <li> After the final vacuum forming stage, the socket liner and socket frame are separated from each other and from the cast model (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg">Figure 7. The inner socket and socket frame before trimming</a></li> <li> The Surlyn® liner is trimmed for a PTB-SC design and the polypropylene frame is trimmed for a PTB socket design and is fenestrated over the tibial crest anteriorly and the gastrocnemius area posteriorly (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg">Figure 8. The socket frame and inner socket after trimming</a></li> <li> The Surlyn® liner is now inserted into the polypropylene frame (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.jpg">Fig. 9</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.jpg">Figure 9. The socket frame and inner socket assembled.</a></li> <li> The U.S. Manufacturing Co.<a></a> adaptor hardware is used to attach the socket to the Otto Bock<a></a> titanium modular endo-skeletal components and an appropriate foot. </li> <li> During initial fitting, the distal end pad is foamed in place while the patient stands to provide total contact. </li> </ol> The Otto Bock modular system has sufficient range of adjustment to suffice for alignment of prostheses for most geriatric patients. However, the use of the Berkeley BK alignment device might be desirable for some of the more active patients (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg">Fig. 10</a>). A special adaptor plate is made of 1/8" aluminum sheet so the Otto Bock 4R22 adaptor component can be used between the socket and the alignment device. <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg">Figure 10. View showing adaptor needed when the UCB adjustable below-knee "leg" is used for alignment trials.</a> Cosmetic finishing may make use of any of several foam cover systems available, such as the round styrofoam cover available from the U.S. Manufacturing Company (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg">Fig. 11</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg">Figure 11. The completed prosthesis with cosmetic stocking pulled down to show the carved styrofoam cover.</a> Below-knee patients fitted at the University of Virginia during the past two years, who voluntarily agree, are being refitted by their original prosthetist with the flexible brim thermoplastic system described here. Our initial conclusions are very positive. To date, eight flexible brim thermoplastic sockets have been fit on seven patients, with one patient having worn his for over one year. There have been six fittings since February, 1986. Only one socket failure has been noted, that of the Surlyn® inner flexible socket which split along the tibial crest on a patient weighing over 350 pounds. That particular socket lasted approximately four months. Though not indicated for use on someone of this weight, we were interested in determining its durability limits. Subjective evaluation includes patient questionnaires and comments, comparing their existing prosthesis with the new flexible brim thermoplastic socket system. Patient reaction, thus far, indicates enhancement of patient comfort and awareness of reduced prosthesis weight, especially with our geriatric subjects. Although not originally designed for geriatrics, this patient population has specific needs that can be met by this socket design, such as socket flexibility, less confining brim, reduced proximal shear forces, and extreme light weight. When used with Otto Bock titanium modular components and a "Lite" SACH foot, this system weighs between one and a half and two pounds. Current objective evaluation includes collecting heart rate and step count data in the patient's home environment, using a newly developed ambulatory physiological monitoring system. This includes physiological data with the patient's existing prosthesis in addition to that collected with the flexible brim thermoplastic socket system. This system of patient monitoring, or surveillance, electronically records heart beats (EKG), standing versus sitting posture, and step count, plotted against time up to 24 hours. The goal is to document any changes in activity level and energy expenditure that occur with use of new prostheses, such as the flexible brim thermoplastic socket system presented in this paper. In conclusion, a new socket design rationale and system utilizing existing thermoplastic materials has been presented. Patients fit with this system are currently being evaluated both subjectively and physiologically. Fittings and evaluations will continue until a significant number are completed and related data gathered. A follow up report will follow with final conclusions and statistical data presented. References: <ol> <li>Bennett, Leon, "Gel liner effects," Bulletin of Prosthetic Research, BPR 10:21; Spring, 1974, pp. 23-53.</li> <li>Otto Bock Orthopedic Industries, Inc., 4130 Highway 55, Minneapolis, MN 55422.</li> <li><a href="cpo/1984_03_004.asp">Murphy, Eugene F., "Sockets, Linings, and Interfaces," Clinical Prosthetics and Orthotics, 8:3, Summer, 1984, pp. 4-10.</a></li> <li>Murphy, Eugene F., "Transferring Load to Flesh," Bulletin of Prosthetic Research, BPR 10:16; Fall, 1971, pp. 38-44.</li> <li>Radcliffe, C. W., and J. Foort, "The Patellar-Tendon-Bearing Below-knee Prosthesis," Biomechanics Laboratory, Dept. of Engineering, Univ. of Calif., Berkeley, and School of Medicine, Univ. of Calif., San Francisco, 1961.</li> <li>Staats, Timothy B., "Multiple Durometer Socket Liners for P.T.B. Prostheses," Orthotics and Prosthetics, 38:4, Winter, 1984, pp. 63-68.</li> <li>United States Manufacturing Co., 180 North San Gabriel Boulevard, Pasadena, Calif., 91107.</li> <li>Wilson, A. Bennett, Jr., "Ultralight Prostheses for Below-knee Amputees," Orthotics and Prosthetics, 30:1, March, 1976, pp. 43-48.</li> </ol> <div style="width: 400px;">Footnote USMC Part Nos. 41014, 42012, 43026, and 29316 </div> *A. Bennett Wilson, Jr. The Department of Orthopedics and Rehabilitation at the University of Virginia. *C. Michael Schlich, C.P.O. The Department of Orthopedics and Rehabilitation at the University of Virginia. <div style="width: 400px;"> </div> <div style="width: 400px;"></div> Page Number(s) 105 - 110 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 10 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.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 The Use of Surlyn and Polypropylene in Flexible Brim Socket Designs for Below-knee Prostheses Creator An entity primarily responsible for making the resource C. Michael Schlich, C.P.O. * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/0bbc53a6aa62aebf038a53dd53472ffc.pdf 54b8c595e4ec188d6a8b8159ebc5c71f https://staging.drfop.org/files/original/b31f453e857faf7e7c85a9dc242a2129.jpg 9df96fc4ee9a837d85bbaece371c46fc https://staging.drfop.org/files/original/0ee976b743595cde154bc870afa7a224.jpg a3b8fbd6a6cea81286d669f3a25bd448 https://staging.drfop.org/files/original/63c4901b6d5f332233ffdb0f2c00b116.jpg 1c1cb3009b38e53630bde0cda90c9c89 https://staging.drfop.org/files/original/37f7edd8f4b869d37f92eb967037f82a.jpg 117dc9625d7e146431f643fdb0d17f6d https://staging.drfop.org/files/original/79cc93918eb2d23f152ee4043b75be4e.jpg cc9511daf3e04fdecb2f5c18ed011951 https://staging.drfop.org/files/original/a3b0d6d764f90dc9b9f455667be76a39.jpg 27c4183a32ace08a6dfa6980ba988b0c 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_101.pdf Text Any textual data included in the document <h2>Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets</h2> <h5>C. Michael Schlich, C.P.O. <a style="text-decoration: none;">*</a> Tony Lucy </h5> Transparent test sockets have been available in various materials for more than ten years,<a></a> but their use has not been as widespread or as routine as one would expect. Only recently has the emergence of new materials and new evaluation techniques, as well as third-party awareness and reimbursement, made the use of test or check sockets more appealing. The objective of this article is to present a refined technique for using test sockets and aliginate to guarantee that total contact exists between socket and stump. This technique has been developed as a standard procedure for each and every below-knee amputee fitted with a prosthesis at the University of Virginia. We consider it to be the single most important and recent technique for enhancing the fit of prostheses for our below-knee amputees. Robert Hayes, CP., described his alginate technique first in 1975 in Orthotics and Prosthetics<a></a> and more recently in an updated version in Clinical Prosthetics and Orthotics.<a></a> In 1984, Timothy Staats, CP.,<a></a> described a technique for introducing alginate into the negative cast mold, which is used as a test socket after molding. No doubt there are other prosthetists using similar or variations of these techniques. However, the important point is not who or how many are using the technique, but how many still do not use this technique for refining below-knee socket fit. Equally important is the fact that any system of diagnostic socket evaluation should be more than just algination. The routine use of multiple, transparent, skin-fit sockets, evaluated both statically and dynamically as a progressive system, will provide assurance of optimum socket fit. It seems rather obvious that if amputees can ambulate successfully with a skin-fit, hard socket, then use of a definitive socket with a minimal number of prosthetic socks, with or without a soft liner, will be that much more comfortable and successful. A 12" x 12" sheet of 3/8" thick Durr-Plex<a></a> or Thermocheck<a></a> is used for the average below-knee socket. This material is transparent, strong and rigid, is easily vacuum formed (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg">Fig. 1</a>) using the frame and platen technique, and can be modified later by spot heating. Of course, any other transparent material that can be vacuum formed is equally suitable. <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg">Figure 1.</a> A transparent socket is vacuum-formed over a plaster cast that has been modified in the usual manner. Lubrication of the stump with petroleum jelly, or equivalent lubricant, is necessary for donning the check socket when it is used without a prosthetic sock. The patient then stands bearing weight in the test socket, which rests on a platform or stand that can be adjusted in height so that weight-bearing is the same on each side and the pelvis is level (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg">Fig. 2</a>). While the patient continues to stand, the stump in the transparent socket is evaluated by identifying changes in skin color. Blanching, or even whiteness, indicates that the pressure levels are acceptable. Excessive shiny blanching indicates increased pressure, which is perhaps excessive. Redness indicates voids or lack of total contact. If a patient complains of too much pressure when an area is surrounded by red, then algina-tion should provide relief by establishing total contact. If the patient complains of too much pressure when an area is surrounded by white and blanching, relief is provided by spot heating and stretching the socket in the area of complaint. A thin flat probe, like a corset stay, is often useful for specifically locating pressure areas for purging small pockets of trapped air, or gauging skin tensions within the socket (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg">Figure 2</a>. The patient bears one half of his weight in the transparent socket for evaluation of fit by the prosthetist observing the color of the skin <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg">Figure 3.</a> Evaluation of fit by observation can be augmented by use of a flat slender probe. A reliable technique for the evaluation and modification of the fit of below-knee diagnostic test sockets is available using the dental material, alginate. The viscosity and other properties of alginate makes it suitable for: (1) filling any voids between the socket and stump to insure total contact, or total surface bearing; (2) providing proper compression of soft tissues for better distribution of weight-bearing pressures. A mixture of 20 grams of powdered alginate<a style="text-decoration: none;">*</a> and 6 ounces of water provides the proper ratio and amount for most below-knee patients. The water should be lukewarm and dyed with food coloring to provide a definite contrast in color to the skin and socket. The socket is sanded lightly on the inside to promote adherence of the alginate, and escape holes are drilled medially and laterally approximately one inch proximal to the distal end. Small pin holes are also drilled over void areas to allow air to escape as the alginate fills. The water and powder are mixed with an electric drill and paint stirrer, and then poured into the test socket and slushed around the walls to completely coat the inside of the socket. The patient then enters the socket and stands with equal weight-bearing bilaterally. The alginate fills void areas, establishing total contact. The excess is evacuated, and gelling occurs in one to three minutes (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg">Fig. 4</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg">Fig. 5</a>). The patient is then seated and the socket is carefully removed, after breaking the suction seal. The alginate will adhere to the inside of the socket. <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg">Figure 4.</a> Alginate fills void areas while patient bears one half of his weight into the socket. Excess alginate flows through small relief holes drilled for this purpose. <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg">Figure 5.</a> Alginate solution cures between one and three minutes. When the socket is filled with plaster, a positive model that has been redefined by the alginate under weight-bearing conditions is obtained. When the plaster has set, the test socket is removed by cutting it off. The alginate will adhere to the cured plaster model (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg">Figure 6.</a> Alginate is removed from new positive model before smoothing and vacuum-forming definitive socket or a new check socket. The new positive model is now evaluated. Information such as location and thickness of the alginate fill is useful feedback concerning the original casting and model modification. At this point the alginate is removed and the new positive model is smoothed using sand screen. The model is now ready either for use as a follow-up transparent test socket or for fabricating a definitive socket. If one chooses to proceed with the definitive socket, prosthetic socks are added over the model before the liner or socket is fabricated to allow for the thickness of socks desired in the final fit. <h3>Results</h3> Records were kept and studied for a series of 40 below-knee amputees fitted using the alginate test socket system. The data recorded were: (1) location of areas filled by alginate (i.e. voids in the prealginated socket); (2) thickness of fill with respect to location; and (3) results of dynamic and final fittings (i.e. adjustments required to improve socket fit at post-algination fitting sessions). Areas filled with alginate were very consistent and included the posterior distal soft tissue area, the tibial tubercle, the lateral tibial flare, and the anterior distal tibia. As the series progressed, the model modification technique changed based on this previous experience. As a result, the thickness of the alginate fillers gradually decreased, as did the plaster build-up over bony prominences on the original model. None of the 40 subjects required socket adjustments to improve comfort or fit at the time of dynamic alignment, delivery alignment, or delivery of the prosthesis. We have been involved, either directly or indirectly, with fitting more than 150 patients in this manner. The use of alginate with multiple transparent test sockets is a valuable tool in patient management and helps provide better below-knee sockets through improved weight-bearing pressure distribution. References: <ol> <li>Durr-Fillauer Medical, Inc. 2710 Amnicola Highway, Chattanooga, Tennessee 37406.</li> <li>Friddle's Orthopedic Appliance, P.O. Box AR, Honea Path, South Carolina 29654.</li> <li><a href="cpo/1985_03_013.asp">Hayes, Robert F., "A Below-Knee Weight-Bearing Pressure Formed Socket Technique," Clinical Prosthetics and Orthotics, 9:3, Summer, 1985, pp. 13-16.</a></li> <li>Hayes, Robert, F., "A Below-Knee Weight-Bearing Pressure Formed Socket Technique, Orthotics and Prosthetics, 26:1, March, 1972, pp. 1-13.</li> <li>Mooney, V. and R. Snelson, "Fabrication and Application Of Transparent Polycarbonate Sockets, Orthotics and Prosthetics, 26:1, March, 1972, pp. 1-13.</li> <li>Staats, Timothy, "Advanced Prosthetic Techniques For Below-Knee Amputation," Orthopedics, 8:2, February, 1985, pp. 249-258.</li> <li><a href="cpo/1985_03_011.asp">Quigley, Michael, Jr., "The Role of Test Socket Procedures In Today's Prosthetic Practices," Clinical Prosthetics and Orthotics, 9:3, pp. 11-12.</a></li> </ol> Footnote Type II, Normal Set Alginate, Coe Laboratories, Inc. Chicago, Illinois 60658 *C. Michael Schlich, C.P.O. C. Michael Schuch, C.P.O., and Tony Lucy are with the Department of Orthopedics and Rehabilitation at the University of Virginia. Page Number(s) 101 - 104 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.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_101/1986_03_101-6.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 Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets Creator An entity primarily responsible for making the resource C. Michael Schlich, C.P.O. * Tony Lucy 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. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> 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. 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. 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. <h3>Soft Socket Rationale</h3> 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. 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. <h3>Case Study</h3> 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. 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">Fig. 1</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">Fig. 2</a>). The patient has been wearing this prosthesis and is quite satisfied. <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. <a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.jpg">Figure 2.</a> The completed prosthesis. <h3> Conclusion</h3> 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. <h3>Acknowledgments</h3> 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. *Arthur Forman, B.S., M.A. 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/527606029dde597c9241e01480a56072.pdf 4c755f2a1ca5cf1398a468e307fd2dea 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_087.pdf Text Any textual data included in the document <h2>Upper Extremity Cosmetic Gloves</h2> <h5>Sandra Bilotto, M.A., C.P.O. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> Upper extremity rehabilitation includes the restoration of function and cosmesis to simulate the human hand.<a></a> Producing a replica of the hand which is functionally and psychologically beneficial to the amputee and quite importantly, acceptable to those with whom the amputee socially interacts,<a></a> is both challenging and of high priority. The technology for producing either custom made or mass produced cosmetic gloves has changed little in more than 20 years.<a></a> However, within the last several years, with the advent of new materials, there have been new developments. More specifically, there have been developments in a family of silicone elastomers the application of which offers solutions to problems associated with existing cosmetic glove technology. Briefly, cosmetic gloves have been made with latex, urethanes, and RTV silicones, but these materials were not successful because they had serious drawbacks. Latex skins were impermanent, coloration was unacceptable, tear strength was very low, absorption of clothing dyes was common,<a></a> and they did not last very long before deteriorating. Urethanes held promise, but the components to produce a plastic film are very difficult to control in small laboratories. They are too sensitive to moisture and extraneous contaminants, and require precise measuring. After limited use, they are weakened by ultraviolet light and thus their useful life as terminal device coverings is limited.<a></a> RTV or room temperature curing silicones, when first utilized in prosthetic restorations and glove-making, proved ineffective because the material required complicated molding procedures, was often manufactured pre-colored, had extremely low tear strength, and had very low elasticity and flexibility. In addition, one small tear would easily propagate, rendering the glove useless. <h3>PVC Gloves</h3> PVC, or polyvinyl chloride, has dominated glove making and still does to the present. Historically PVC is inexpensive and readily available. Gloves can be fabricated en masse in metal molds or custom made in flexible slush molds. In either technique, the plastisol cures against the wall of the mold, producing a thin skin of vinyl which can either be intrinsically and/or extrinsically colored.<a></a> Stabilizers and plasticizers are introduced to make the cosmetic glove flexible and resistant to degradation by ultraviolet light. Replication of the human hand has been adequate using PVC and thus these gloves have been widely available for most amputees. However, there are disadvantages associated with PVC as a material for use in prosthetic gloves. First and foremost is the inability of PVC to resist attack by most chemicals, soiling and staining agents, and newsprint. These substances are absorbed by the plasticizing agents and are impossible to remove. At temperatures close to freezing, the PVC stiffens and its flexibility is greatly reduced. This can inhibit the proper functioning of an electric or mechanical hand as the inability to open a finger or thumb can render a terminal device useless.<a></a> In warm temperatures, the plasticizers and stabilizers tend to bleed to the surface of the glove, causing peeling of the extrinsic coloring, as well as darkening and stiffening. PVC "feels" like plastic and not like human tissue, and for the most part, unless a PVC glove is custom made and tinted, the surface is rather opaque and cadaverous looking. Custom made PVC gloves present all of the above problems, but do match skin tone, hand shape, and surface characterization of the intact hand better. The time required to fabricate a custom glove is much longer because the technique is more elaborate, and as a result more expensive. Of course, the success of the glove is directly proportional to the ability of the prosthetist to make the cosmetic glove appear natural and reasonably well matched to the other hand. No matter what technique is utilized, the consensus is that PVC gloves are rather short lived: two weeks to eight months on average. Efforts to strengthen the glove with nylon fabric reinforcement or to retard discoloration by spraying clear solutions on the surface of the glove produce disappointing results.<a></a> Finally, there is a problem donning and doffing a PVC glove due to the inflexibility of the material proximal to the wrist. This gave rise to the practice of sewing zippers into gloves. Besides being bulky and unsightly, zipper installation is time consuming and the zipper may be easily jammed or broken. Thus, a better material which might resolve some of the above problems is needed. <h3>Silicone Gloves</h3> Silicone rubber offers excellent solutions to some of the aforementioned problems, and they now have properties which make them more readily processed in glove making.<a></a> In general, the new generation of silicones are tougher, more resilient, more durable, and more permanent than previously utilized materials. While not ideal, the silicone gloves presently being developed resist chemicals, dyes, soiling, and staining almost completely. The skins may be washed with mild detergents and water for cleaning. Unlike PVC, lower or higher temperatures have little effect on the strength, flexibility, or elasticity of the glove.<a></a> The result is better functioning of electro/mechanical hands, and in some cases, the elastic resistance of gloves can actually enhance functioning of the terminal device. Unlike PVC, silicone rubber may be modified to increase its elasticity where necessary without loss of tear strength. Cosmetic gloves of silicone elastomers may be intrinsically or extrinsically colored as with PVC. However, there is much greater adhesion of external pigments to silicone gloves and the resultant glove rarely sheds its external tinting. It is more color stable and is less affected by ultraviolet light than its PVC counterpart; Silicone neither darkens nor stiffens with the passage of time. Once fabricated, the glove is non-toxic as compared with PVC. This is an obvious advantage when fabricating gloves for babies and toddlers, as harmful agents do not leach out to the surface of the glove to enter the baby's mouth. Silicone can be formulated to reflect and absorb light in much the same way human skin does, producing a more natural and life like appearance. Likewise, silicone also simulates the "feel" of skin more closely as it relates to softness and texture.<a></a> Its higher coefficient of friction helps prevent glasses and other objects from falling out of the hand's grasp. <h3>Discussion</h3> There are some disadvantages in the production of silicone gloves which need to be addressed. The cost of manufacturing, the increase in fabrication time, and the slightly higher cost of silicone rubber<a></a> is retarding the availability of such gloves. However, if the technology to produce silicone gloves improves, and if they become more widely available, their cost and fabrication time should decrease. They have greater durability and esthetic appeal than PVC, and there can be no doubt that silicone offers possibilities heretofore unavailable with PVC. Silicone cosmetic coverings for the lower extremity are a future possibility. Swim and sport legs could be greatly inhanced by these tough, resilient and cosmetic coverings. Silicone compounds are presently used in maxillofacial prosthetics, breast prostheses, partial hands, partial feet, leg and arm buildups, and other body restorations.<a></a> There is no doubt that a more natural, functional, esthetically and psychologically appealing cosmetic glove is needed by upper extremity amputees and that silicone gloves, despite some imperfections, will prove to be more promising and acceptable than PVC gloves. References: <ol> <li>Arkles, B., "Look what you can make out of Silicones," Chemteck, Vol. 13, No. 9, pp. 542-555, September 1983.</li> <li><a href="al/1955_02_057.asp">Carnelli, W.A.; Defries, M.G.; and Leonard, F., "Color Realism in the Cosmetic Glove," Artificial Limbs, Vol. 2, pp. 57-65, May 1955.</a></li> <li>Davies, E.W.; Douglas, W.B.; and Small, A.D., "A Cosmetic Functional Hand Incorporating a Silicone Glove," Journal of International Society of Prosthetics and Orthotics, Vol. 1, No. 2, pp. 89-93, September 1977.</li> <li><a href="al/1955_02_047.asp">Dembo, T. and Tane-Baskin, E., "The Noticeability of the Cosmetic Glove," Artificial Limbs, Vol. 2 pp. 47-56, May 1955.</a></li> <li>Fillauer, C and Quigley, M., "Clinical Evaluation of an Acrylic Latex Material used as a Prosthetic Skin on Limb Prostheses," Orthotics and Prosthetics, Vol. 33, No. 4, pp. 30-38, December 1979.</li> <li><a href="al/1955_02_078.asp">Fletcher, M. and Leonard, F., "Principles of Artificial Hand Design," Artificial Limbs, Vol. 2, pp. 78-94. May 1955.</a></li> <li>Lee, D. and Harlan, W., "Medical Sculpture: A Valuable Aid to Patient Rehabilitation," American Family Physician, Vol. 15, pp. 110-114, February 1977.</li> <li>Journal American Dental Assoc., "Maxillofacial Prosthetic Materials," Council on Dental Materials and Devices, Vol. 90, pp. 834-848, April 1975.</li> <li>Klasson, Bo, Personal communication, Een-Holmgren, Stockholm, Sweden.</li> </ol> *Sandra Bilotto, M.A., C.P.O. Sandra Bilotto, M.A., C.P.O., currently resides in Yonkers, N.Y. She received her education in prosthetics and orthotics at N.Y.U. Prior to that she received training in sculpture. Cosmetic restoration is a particular interest of hers. <div style="width: 400px;"></div> Page Number(s) 87 - 89 Year 1986 Volume 10 Issue 2 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 Upper Extremity Cosmetic Gloves Creator An entity primarily responsible for making the resource Sandra Bilotto, M.A., C.P.O. *