2 20 371 https://staging.drfop.org/files/original/52f7d266c544d7b057ce3f61ff421222.jpeg c442d8b15660c8c79d4df71065ad319d https://staging.drfop.org/files/original/cecb22a00897ba34f840608eed75219c.jpeg 1dad83a740d94fdf8668227e6d78ec45 https://staging.drfop.org/files/original/4840e49061168dd070be6b5f910136d0.jpg bc55027014a65d697e997b2b937c2821 https://staging.drfop.org/files/original/23866a9c822d0eb399417ae71c53afde.jpg de5956ea11e10351dd0edbc4eb3964c7 https://staging.drfop.org/files/original/9654f5f19860f0e88b033d410589d261.jpg 32b34b3e40ced6807f3639dbaa1dc46a https://staging.drfop.org/files/original/208783458811d4c978eb476b9ddc2a62.jpg 1c8a4fce56522125a18f83d04e40f32b 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 Text Any textual data included in the document <h2>A Solution For Split-Size Shoes</h2> <h5>Eugenio Lamberty&nbsp;<a style="text-decoration: none;">*</a><br />John Milani&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Despite the almost daily occurrence of new concepts and improvements in Orthotics, many problems remain to be solved. A significant number of these problems result from congenital factors or acquired diseases during childhood. The severely deformed leg and foot have been of major concern, particularly when the deformed foot has been significantly shorter in length than the sound foot (<a href="/files/original/52f7d266c544d7b057ce3f61ff421222.jpeg"><b>Fig. 1</b></a>).</p> <p>In some cases the feet may vary in shoe size by as much as three or four sizes (<a href="/files/original/cecb22a00897ba34f840608eed75219c.jpeg"><b>Fig. 2</b></a>). This becomes quite expensive for the patient, who must either purchase two pairs of shoes to fit each foot properly or custom-made shoes. To reduce this financial burden and yet greatly improve cosmesis, a method of fabrication had to be found whereby the patient would be required to purchase only one pair of ordinary shoes that would be the size of the normal foot.</p> <p>A shoe filler (<a href="/files/original/4840e49061168dd070be6b5f910136d0.jpg"><b>Fig. 3</b></a>), conceived, designed and developed by the authors through the Veterans Administration Prosthetics Center, has solved this problem. This device is placed in the shoe (<a href="/files/original/23866a9c822d0eb399417ae71c53afde.jpg"><b>Fig. 4</b></a>) to take up the excess space of the shortened foot. Then the shoe insert portion of the orthosis is placed into the filler and shoe (<a href="/files/original/9654f5f19860f0e88b033d410589d261.jpg"><b>Fig. 5</b></a>). This results in a highly-cosmetic arrangement (<a href="/files/original/208783458811d4c978eb476b9ddc2a62.jpg"><b>Fig. 6</b></a>) that is also financially beneficial to the patient.</p> <h3>Method of Fabrication</h3> <p>To construct the shoe filler, proceed as follows:</p> <ol> <li> <p>Secure a SACH foot that will fit the size shoe to be worn by the patient. Ensure that the plantar surface of the SACH foot is flat, to prevent the shoe insert portion of the orthosis from rocking. An immediate post-op foot can be used.</p> </li> <li> <p>Vacuum mold the SACH foot with 1/4-inch low density polyethylene. Polyethylene is ideal since it provides good strength and flexibility.</p> </li> <li> <p>When the plastic has cooled, remove it from the SACH foot and initially trim it so that it does not protrude beyond the borders of the shoe. Refer to <a href="/files/original/4840e49061168dd070be6b5f910136d0.jpg"><b>Fig. 3</b></a>.</p> </li> <li> <p>Use standard methods and techniques to fabricate the orthosis.</p> </li> <li> <p>Place the orthosis on the patient. Then place the orthosis on the patient into the shoe and shoe filler while ensuring that the shoe filler does not hinder this process.</p> </li> <li> <p>Further trim the shoe filler along its medial and lateral sides, behind what would normally be the metatarsal heads of the sound foot. This allows the normal toe break of the shoe to function properly and thereby ensure unrestricted motions of the ankle and foot.</p> </li> </ol> <h3>Notes</h3> <p><i>To prevent the orthosis from slipping forward in the filler, the filler should curve around slightly, onto the dorsum of the foot. Refer to<a href="/files/original/4840e49061168dd070be6b5f910136d0.jpg"> <b>Fig. 3</b></a>. This trim, together with a properly laced shoe or a shoe laced with micro straps, should provide the required counterforce to prevent the orthosis from slipping forward in the filler. It is further noted that one patient, who had worn the new orthotic system for one month, required foam padding that was placed anteriorly into the filler to prevent the orthosis from slipping.</i></p> <h3>Summary</h3> <p>The design and development of a shoe filler when bracing the shortened foot is cosmetically appealing and financially beneficial to the patient who is consequently required to purchase only a single pair of ordinary shoes. In addition, fabricating the filler is a relatively simple procedure for the orthotist.</p> <h3>Acknowledgements</h3> <p>The authors would like to express their appreciation to Max Nacht, Technical Writer-Editor, VAPC, for his cooperation and assistance in preparing this article; and to Charles Berman and Anthony Morales, Photographers, VAPC, for their fine photographic work.</p> <div style="width: 400px;"><em><b>John Milani<br /></b>Orthotist-Prosthetist, Veterans Administration Prosthetics Center, 252 Seventh Avenue, New York, NY 10001<br /><b><br />*Eugenio Lamberty<br /></b>Orthotist. Veterans Administration Prosthetics Center, 252 Seventh Avenue, New York, NY 10001</em></div> <br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1979 Volume 3 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 5 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-6.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 A Solution For Split-Size Shoes Creator An entity primarily responsible for making the resource Eugenio Lamberty * John Milani * https://staging.drfop.org/files/original/9f82190e18cf5ca09443da6fd68df3b9.pdf 43555eca290035ea7155e9a0312babce https://staging.drfop.org/files/original/41b75dea6e7a15877cc0a8243b4c4874.jpg b6438828e00e3ff265f4c6c3376559b7 https://staging.drfop.org/files/original/41ffa86db5a06c67178da1fe6aee4968.jpg 20d75a09605e3e2b68d200f44cc3f96a https://staging.drfop.org/files/original/402a3a26ceb04de8b1318dcabf4f5b30.jpg e1b78c19f91d79fac7635c1e04b7cb5b https://staging.drfop.org/files/original/5965cf7dfd7eb969f1a55b331bba978f.jpg 0f5897ea65b406960ef356aae8745014 https://staging.drfop.org/files/original/ce3704752c65bafb933002528b66de97.jpg 303919967c08f033368701a299f0dca1 https://staging.drfop.org/files/original/f3eaed68459cebb323caf8eac4f369f5.jpg b0b7b29cc73946063cd1cb85e8b07b5c https://staging.drfop.org/files/original/26d45afef759ecc508cb2fa1d00073fa.jpg def29cc322ce2288598609261fc453e6 https://staging.drfop.org/files/original/59d21c2e70e154cf05aebf3b2e8f05f2.jpg 3e4a48d0000f890a2ee4e1e639e6ca9f https://staging.drfop.org/files/original/058fa502bdf14434b5d3e4059b53c36b.jpg f86fdd1ac02b515fee07f9d0a83b6086 https://staging.drfop.org/files/original/15c2883e9508c92984a80cc01fb90f85.jpg 220753ac354d321682550677971639e4 https://staging.drfop.org/files/original/1599535e386e2026f4cc72d91bfd2cca.jpg 44adc9faa4fbe64b6d148b43dc5bacc2 https://staging.drfop.org/files/original/51e5edca62a38d9594e025c03ccac11b.jpg bb869d0a8ea128b30044b3213c4ca4fc https://staging.drfop.org/files/original/3598305f5c89bedf991c4f6548c90cf5.jpg 6d9b445e128c0fec74c50bf67157e15d https://staging.drfop.org/files/original/42655d7b96617f3031e4cfe4b384377a.jpg fca7110d2166127a2bad387fed992c5a https://staging.drfop.org/files/original/1637b57b9c0c9bd6f3aecc78d40064ba.jpg 28995acfac6dc5b1e438cc86f3f50219 https://staging.drfop.org/files/original/a28f64fb749dd90466694e6f74a7a7da.jpg 5405cbe2389ef56b993d6396a98106ac https://staging.drfop.org/files/original/d1f903fa6ec56d3011b93c35b07b5284.jpg be76fb64fc2e1785acd322b5062bda99 https://staging.drfop.org/files/original/0677d944077501669f0b3fdbb2af91fa.jpg 739231039457e940d8d4a1cb1bea9428 https://staging.drfop.org/files/original/799403b2935896e2bb5d55a38e9779f2.jpg 4739ce28a1715e3bf9ef1d2d7e7c9d51 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_027.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 27 - 45 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_027.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Technique for Fitting Converted Proximal Femoral Focal Deficiencies</h2> <h5>Carman Tablada. C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>Proximal femoral focal deficiency (PFFD) is a congenital limb deficiency affecting the proximal end of the femur and, usually, the iliofemoral joint. The condition is characterized by shortness of the affected limb; flexion, abduction, and external rotation of the extremity; inadequate proximal musculature; and unstable proximal joints. <a></a> The condition may be unilateral or bilateral, and other anomalies may be present (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Aitken <a></a> has demonstrated four types of PFFD based on serial X-rays of patients before and after skeletal maturity:</p> <ul> <li><i>Class A: </i>Adequate acetabulum and femoral head. Short femoral shaft. Femoral head and shaft are joined at maturity.</li> <li><i>Class B: </i>Adequate acetabulum and femoral head. Short femoral shaft. Femoral head and shaft are not joined at maturity.</li> <li><i>Class C: </i>Severely dysplastic acetabulum. Femoral head never ossifies. Short femur.</li> <li><i>Class D: </i>No acetabulum or femoral head. Short, deformed femoral segment.</li> </ul> <p>At the Child Amputee Prosthetics Project (CAPP) in Los Angeles, the preferred treatment for children who have unilateral PFFD and functional upper extremities is conversion of the limb deficiency to an above-knee amputation. The surgical procedure consists of a Syme's amputation of the foot in all cases, and fusion of the knee in selected cases to give a single skeletal lever (<b>Fig. 2</b>). The children are then fitted as above-knee amputees, using a specially designed socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since 1967, the prosthetists at CAPP have used a socket with a flexible inner wall to fit PFFD patients who have had the surgical conversion described above. This paper describes the total fabrication and fitting procedure as it is done at CAPP. Only its application to the patient with PFFD will be considered here, although we have used the same principle with success in fitting other amputees who have a stump with a bulbous end.</p> <h4>The Stump</h4> <p>The converted PFFD stump is relatively fleshy in the proximal area. The shape of the proximal portion is related to the patient's classification: In those with class A or B involvement, the shape is normal enough for the usual anatomic landmarks to be seen, and in those with class C or D involvement, the proximal stump is cylindrical.</p> <p>The shaft is usually narrow and bony, and the distal end is bulbous, with soft tissue padding its inferior surface. There are bony projections in the bulb which may not be seen but which can be located by palpation. These projections are sensitive to pressure.</p> <p><i>Telescoping</i></p> <p>When the structures in the hip region do not provide adequate articulation between the pelvis and the lower-extremity elements, upward pressure under the end of the stump causes upward displacement of the bony elements and apparent shortening of the limb. This motion is called "telescoping," and is frequently seen in patients with PFFD. As much as three inches of telescoping can be demonstrated in some patients.</p> <p>Telescoping can be a passive or an active motion. In varied cases, some patients can voluntarily retract their limbs and others cannot; they can, however, voluntarily lengthen it beyond the resting position by thrusting down. Traction on the stump also causes lengthening. This apparent shortening and lengthening of the stump in response to pressure and traction has important implications for measuring the stump length, for making the cast, and for weight-bearing (<b>Fig. 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Socket</h4> <p>The socket consists of a rigid outer shell and a three-layered flexible inner wall, with an air space between the flexible layers and the hard socket. The flexible layers extend from the bottom of the socket to at least the level at which the bulbous end can pass through freely, comparable to the placement of the window in a standard Syme prosthesis. This arrangement provides room for expansion of the flexible wall as the bulb is inserted into the socket. Once the stump is fully inserted, the flexible wall closes around it, giving a total-contact fit without using a window and making it possible to use the bulb for suspension.</p> <p>Since the patient has a Syme's amputation, it would seem logical to fit him with an end-bearing socket. However, if this were done, pressure under the end of the stump during the stance phase of gait would cause telescoping and relative shortening of the leg. The patient would then have excessive lateral trunk bending during stance. For this reason, the socket is designed to be ischial weight-bearing, with the patient taking light contact on the end of the stump. The ischial weight-bearing minimizes the amount of telescoping and therefore decreases the lateral trunk bending. The light contact at the distal end gives him better control over the prosthesis.</p> <h4>Materials and Components</h4> <p>The hard outer socket is formed with 4110 polyester resin.</p> <p>Considerable thought was given to selecting the materials for the flexible layers. Our clinical experience has shown that, with continued use, RTV develops an odor and the material becomes fuzzy; nor will RTV bond to the rigid shell of the outside socket.</p> <p>Therefore, flexible polyester resin was selected for the layer closest to the skin. It is durable, is easy to keep clean and free of odor, and has a surface that is relatively friction-free. 384 RTV was used for the center layer because it laminates readily and will stretch and return to the same shape repeatedly. Flexible polyester resin was also used for the layer next to the outer socket, for it bonds to the hard material if the polyester resin is "roughed up" sufficiently. The polyester resin also protects the RTV from impregnation by wax during socket fabrication. In all the cases in our experience, the materials have retained these properties until the child outgrew the prosthesis.</p> <p>Primary suspension is provided by closure of the flexible layers over the bulbous end of the stump. A Silesian bandage, worn about an inch below the iliac crest, gives lateral support and secondary suspension.</p> <p>We have used a constant-friction knee and SACH foot for all children fitted with this type of prosthesis. The constant-friction knee is light in weight and has provided good function. All of the children have had adequate strength to lock the knee joint during stance.</p> <h4>Special Measurements</h4> <p>Before describing the fabrication procedure, a brief discussion of the measurements is in order, for much of the success of this method of fitting depends upon having ischial weight-bearing and a total-contact fit.</p> <p><i>Socket Brim Aand Ischial Seat</i></p> <p>In patients with class A or B involvement, the shape of the proximal thigh is normal enough to enable the prosthetist to make the A-P and M-L measurements as he would for a patient with a standard above-knee amputation. The socket will have a modified quadrilateral shape at the ischial level.</p> <p>In patients with class C or D involvement, the shape of the proximal stump is cylindrical, and there is no area comparable to the adductor-longus-tendon area of the standard above-knee amputee. In these cases, the M-L dimension is measured with outside calipers at the level of the adductor fold, and the ischial-seat measurement is made on a horizontal line from the ischium to the lateral edge of the stump at the ischial level.</p> <p>The inside measurements of the socket must be the same as the circumferential measurements of the stump. The prosthe-tist must reproduce the size and shape of the stump in the cast, positive mold, and socket to insure total contact without looseness or constriction.</p> <p>The stump length is measured from the ischium to the distal end of the stump with the stump at its greatest stretched length. The importance of measuring the length and taking the wrap with the stump fully elongated cannot be overemphasized, for two reasons: First, it helps ensure that the patient will take most of his weight on the ischium so that telescoping will be minimal; second, the length of the cast can be modified by only 3/8 in. in either direction.</p> <h3>Measurements</h3> <h4>Brim</h4> <p><i>Mediolateral</i></p> <p>In class A and B patients, take the M-L measurement as for a standard above-knee amputee.</p> <p>In class C and D patients, caliper the horizontal distance from the adductor fold to the lateral aspect of the stump (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Anteroposterior</i></p> <p>Take standard above-knee A-P measurements for classes A and B.</p> <p>For classes C and D, to measure the ischial seat, caliper the horizontal distance from the inferior edge of the ischium to the lateral aspect of the stump (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Socket Length</h4> <p>With the stump at its greatest length and vertical to the floor, measure from the ischium to the end of the stump (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Circumference</h4> <ol> <li>Measure the circumference of the largest part of the bulb, and from this point to the distal end of the stump (<b>Fig. 7</b>).</li><li>Measure the circumference of the narrowest part of the shaft, and from this point to the distal end of the stump (<b>Fig. 8</b>)</li><li>Beginning at the narrowest part of the shaft, measure the circumference at one-inch intervals to the adductor fold (<b>Fig. 9</b>).</li></ol> <h4>Bulb</h4> <ol> <li>Caliper the A-P and M-L dimensions at the largest part of the bulb (<b>Fig. 10</b>).</li><li>Palpate the bulb to locate the bony prominences and mark them with indelible pen.</li></ol> <h4>Overall Length</h4> <p>Measure the sound side as for a standard above-knee amputee.</p> <h4>Stump Sock</h4> <p>Make a tracing of the stump to accompany the measurements for ordering stump socks.</p> <h3>Cast Fabrication</h3> <h4>Materials</h4> <ul> <li>Fast-setting Johnson and Johnson plaster bandage</li> <li>Elastic plaster bandage (Johnson and Johnson Orthoflex)</li> <li>Cast sock</li> <li>Stockinette</li> <li>1-in. elastic webbing</li> <li>A-P caliper</li> <li>Yates clamp</li> </ul> <h4>Fitting The Cast Sock</h4> <ol> <li>Mark the shaft at the level where the A-P or M-L dimension is slightly larger than the A-P or M-L dimension of the bulb.</li><li>Measure the distance between the two points selected and cut one piece of stockinette that length (<b>Fig. 11</b>).</li><li>Cut five more pieces of stockinette, each 1/2 in. shorter than the last, and place them on the stump to fill in the narrow part. Place the shortest piece on the stump first, then the longer ones over it, <i>in reverse of what is shown in <b>Fig. 12</b>. </i>This facilitates removal of the cast.</li></ol> <h4>Making The Cast</h4> <p>The patient should stand with his stump vertical to the floor.</p> <ol> <li>Using the same technique as for a standard above-knee amputee, make the brim with the 4-in. elastic bandage, beginning at the lateral side of the stump at the level of the iliac crest (<b>Fig. 13</b>).</li><li>Complete the wrap with the 3-in. regular plaster bandage (<b>Fig. 14</b>).</li><li>Form the ischial seat while the bandage is still wet. With the A-P caliper set to the length measurement of the stump plus 3/16 in., place the short end under the ischium and line up the long end under the end of the stump. Then apply pressure under the ischium and have the patient thrust down until the stump end touches the caliper (<b>Fig. 15</b>).</li><li>At the same time, apply three-fingers' firm pressure to the proximal anterior medial aspect of the cast (<b>Fig. 16</b>). This prevents the socket from rotating internally on the stump.</li><li>The patient must remain in this position and the pressures must be maintained until the plaster sets.</li><li>Remove the cast.</li></ol> <h4>Checking The Cast</h4> <ol> <li>Check the M-L and ischial-seat measurements of the cast against those of the patient. Be sure that the ischial seat has a large enough surface for the patient to sit firmly upon it. If necessary, build up the seat with plaster before filling the cast (<b>Fig. 17</b>).</li><li>Check the length of the cast against the patient's stump length. They should be the same. If the cast is longer than the stump, pressure was not applied directly under the ischium. If the cast is shorter than the stump, the patient was not thrusting down to maximal stretch. If the difference does not exceed 3/8 in., the mold can be modified. If there is a greater than 3/8-in. difference, a new cast should be made.</li></ol> <h4>Modifying The Mold</h4> <p>To correct the length measurement:</p> <ol> <li>Measure from the ischial seat to the end of the mold.</li><li>Remove or add enough plaster (but no more than 3/8 in.) to the ischial seat to correct the length.</li></ol> <p>To correct the flexion or extension angle (<b>Fig. 18</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Draw a line down the medial aspect of the mold, bisecting it into medial and posterior halves.</li><li>Set the goniometer at 90 deg.; hold one arm on the line described and the other arm at the level of the ischium. Draw a line at right angles to the line on the medial aspect of the mold.</li><li>Shape the surface of the seat along this line. The shaft should be at 0 deg. of flexion and extension.</li></ol> <p>To correct the abduction or adduction angle (<b>Fig. 19</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Draw a line down the posterior aspect of the mold, bisecting it into medial and lateral halves.</li><li>Set the goniometer at 90 degrees ; hold one arm on the line described and the other arm at the level of the ischium. Draw a line at right angles to the line on the posterior aspect of the mold.</li><li>If the shaft is in <i>adduction, </i>remove plaster from the outside edge of the ischial seat. If the shaft is in <i>abduction, </i>add plaster to the outside edge of the ischial seat. The shaft should be at 0 degrees of abduction or adduction.</li></ol> <p>To modify the anterior brim (<b>Fig. 20</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Form the height of the anterior brim: Draw a line at the ischial level across the anterior aspect of the mold from point A to point B. Divide the line in half at point C. From point C, draw a line at right angles to AB, extending it two inches proximal to point D. Line CD forms the height of the anterior brim.</li><li>To establish the anterior brim line, extend a line from point B one inch medially to point E. Point E should be in line with the ischial seat when viewed from the front. Draw a line on a smooth curve from point D to point E (<b>Fig. 20</b>).</li><li>Form a reverse curve along line DE to facilitate sitting and bending. Using a rasp or gouge, remove up to 1/4 in. of plaster from the area medial to line CD. This will ensure good contact along the anterior brim wall with the stump. If necessary, build up with plaster along line DE to form the reverse flare (<b>Fig. 21</b>).</li></ol> <p>To modify the lateral brim:</p> <ol> <li>Continue line DE from the anterior brim proximally to encompass two-thirds of the distance between the ischium and the iliac crest. Continue laterally, following the contour of the lip, then distally to the posterior-lateral corner of the ischial seat (<b>Fig. 22</b>).</li><li>Contour the lateral wall. Do not remove plaster below the ischial level (<b>Fig. 23</b>). Establish flare along the lateral brim line.</li></ol> <p>To modify the shaft:</p> <ol> <li>Correct the circumference measurements. Mark off the levels at which the circumference measurements were obtained. Note each measurement on the mold. Where it is necessary, the circumference measurements of the mold should be modified to be the same as those of the stump (<b>Fig. 24</b>).</li><li>At the brim area, blend the medial and posterior walls smoothly with the medial brim and ischial seat (<b>Fig. 25</b>).</li></ol> <p>To modify the bulb:</p> <p>Build up over the bony projections no less than 1/4 in. (These projections should be marked during the measurement and casting procedure.) <i>Be extremely careful while accomplishing this, as attempting relief in this area is extremely difficult </i>(<b>Fig. 26</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Recheck the mold measurements. Smooth the entire mold (<b>Fig. 27</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Flexible-Socket Fabrication</h3> <h4>Materials</h4> <ul> <li>Ambroid varnish or the equivalent</li> <li>Five PVA sleeves (regular size and shape)</li> <li>Two 1-oz. fitted Dacron (TM) sleeves</li> <li>Four or five regular-length fitted nylon stockinettes (for fabricating the flexible layers)</li> <li>Three extra-long fitted nylon stockinettes (for fabricating the hard socket)</li> <li>Cast sock(s) (to equalize the stump sock)</li> <li>Flexible polyester resin #4134</li> <li>RTV elastomer Dow Corning #384</li> <li>Rigid polyester resin #4110</li> <li>150-A yellow wax (available from E. S. Browning Co., Los Angeles, Calif.) or any wax suitable for shaping</li> <li>Outside calipers</li> <li>Wood rasp</li> <li>Vacuum machine</li> <li>Oven with at least 200 degrees F temperature range</li> </ul> <p>Make the Dacron sleeves to fit the entire brim area. The Dacron must not be incorporated in the flexible layers.</p> <p>The number of stockinettes needed depends upon the size and activeness of the patient. Four are used on the less active patient, and five on the more active. These are separate pieces, sewn on one end and trimmed to 1/2 in. of the stitching. The width of the stockinette should be such that it stretches very minimally in what is to be the flexible wall.</p> <p>The three extra-length stockinettes must be long enough to double over in the brim area.</p> <p>One heavy and one lightweight cast sock are used for a 3-ply wool sock; two heavy and one lightweight cast sock are used for a 5-ply wool socket, etc.; or an old wool stump sock of the same weight can be used.</p> <p>The 150-A yellow wax is heated until it is soft enough to work with a spatula. With this type of wax, it is never necessary to melt it completely and pour it into a cone.</p> <h4>Procedure</h4> <ol> <li>With the outside calipers, measure for the area where the bulb can pass through freely. Mark this area heavily with a pencil (<b>Fig. 28</b>).</li><li>If the cast is wet, seal it with three coats of ambroid varnish.</li><li>Apply the appropriate number of cast socks (or an old stump sock) needed for stump-sock clearance. Tie them off securely on the mandrel.</li><li>Apply the first PVA sleeve, which will be the parting agent. Cap it on the end and tie it off on the mandrel.</li><li>Apply two Dacron sleeves, being sure not to overlap into the flexible walled area which starts at the mark made in step 1. It is advisable to leave at least 1 in. between the mark and the Dacron sleeves (<b>Fig. 29</b>).</li><li>Apply one layer of stockinette and tie it off on the mandrel. If necessary, separate and smooth the extra half-inch of material. With the outside calipers, measure again for the area where the bulb can pass through freely, and mark this area with a pencil.</li><li>With pressure-sensitive tape, make a full turn around the model at the mark made in the previous step (<b>Fig. 30</b>). This seals off the proximal end of the flexible wall.</li><li>Attach the vacuum line.</li><li>Apply the second PVA sleeve and seal it off on the mandrel, then repeat step 7.</li><li>Mix thoroughly enough 4134 flexible polyester resin to cover the area from the tape to the end of the model. Using vacuum, laminate this area <i>only. </i>(It is helpful if, at the end of each laminating step, the excess is tied off, thus saving the time of grinding it away.) Allow to set well (<b>Fig. 31</b>).</li><li>Remove the second PVA sleeve. Remove the pressure-sensitive tape around the model. With the wood rasp, roughen the bulbous end enough to raise the half-inch of stockinette. Do not break through to the parting PVA (<b>Fig. 32</b>). Apply two more layers of stockinette, again separating and smoothing down the extra half-inch of material. Tie them off on the mandrel, then repeat step 7.</li><li>Apply the third PVA sleeve, seal it off at the mandrel, and repeat step 7.</li><li>Mix thoroughly enough 384 RTV to cover the laminated area. Using vacuum, laminate this area only. Allow to set well (<b>Fig. 33</b>).</li><li>Remove the third PVA sleeve. Remove the pressure-sensitive tape around the model. With the wood rasp, roughen the bulbous end enough to raise the half-inch of stockinette beyond the stitching (as in <b>Fig. 32</b>).</li><li>Apply one or two more layers of stockinette, again separating and smoothing the extra half-inch of material. Tie them off on the mandrel, then repeat step 7.</li><li>Apply the fourth PVA sleeve, seal it off on the mandrel, and repeat step 7.</li><li>Repeat step 10.</li><li>Remove the fourth PVA sleeve. Remove the pressure-sensitive tape around the model.</li><li>For the wax build-up (<b>Fig. 34</b>), apply wax to the model from the proximal end of the flexible wall distally to the <i>largest </i>circumference of the bulb end. The thickness of the build-up should be sufficient to allow the bulb to expand the flexible wall through the narrow area. Use the outside calipers to measure the thickness of the build-up. Allow 3/16-in. thickness for the flexible-wall lamination. (Keeping in mind some goals for the finished prosthesis, such as cosmesis and lightness in weight, in most cases it is possible and advisable to "go overboard" on the wax build-up. Cosmetic build-up is kept to a minimum, and air space is weightless.) Allow the wax to cool and harden (<b>Fig. 35</b>).</li><li>Smooth the surface and taper the proximal and distal edges (<b>Fig. 36</b>).</li><li>Using the wood rasp, roughen the exposed tip of the bulb end enough to cut through to the RTV layer and to raise the half-inch of stockinette beyond the stitching on the final 4134 resin layers. <i>This step is extremely important, </i>as it will securely bond the flexible portion of the socket to the rigid outside shell (<b>Fig. 37</b>).</li><li>Apply the three extra-long nylon stockinettes, doubling the first two layers back at the brim (<b>Fig. 38</b>).</li><li>Apply the fifth PVA sleeve and seal it off on the mandrel. Mix enough 4110 polyester resin to cover the entire mold. Using vacuum, laminate the entire mold. Allow it to set (<b>Fig. 39</b>).</li><li>After the resin has set, cut a flap through it 3/4 in. in diameter at the distal edge of the wax build-up. Tape the flap back (<b>Fig. 40</b>).</li><li>Hang the entire laminated cast in the oven (heated to 175 degrees F) and allow <i>all </i>the wax to drain out.</li><li>Remove the laminated cast from the oven after the wax has drained. Allow the lamination to cool just enough for the rigid shell portion to harden. Mark the approximate trim line and cut along it with a Stryker saw. A strong tug, along with use of a hammer and piece of wood when needed, will separate the socket from the cast (<b>Fig. 41</b>).</li><li>To complete the socket, finish sanding the brim down to the trim lines.</li></ol> <h3>Fitting</h3> <h4>Materials</h4> <ul> <li>Fitting stool</li> <li>Talcum powder</li> <li>Stump sock</li> <li>Mandrel padded at the end with stockinette in the shape of a bulb</li> <li>Heat gun</li> <li>Silicone amputation-stump spray</li> </ul> <h4>Procedure</h4> <ol> <li>Set the socket in a wood block with the seat level.</li><li>Place the block on a fitting stool to get the correct ischium-to-floor length.</li><li>Lightly powder the socket.</li><li>Have the patient apply the stump sock and hold it firmly at the top as he pushes his stump into the socket (<b>Fig. 42</b>). (If the patient cannot push all the way into the socket, the flexible layers will need to be stretched as described in the next section.)</li><li>Check to see that the patient's ischium is firmly on the seat, and that he has light contact at the end of the stump. Do this by having him bear weight on the socket and by requesting him to "reach down into the socket" with his stump. If as he does this, he loses firm contact with the seat, the socket is too short. If he cannot feel contact on the bottom, the socket is too long. A sponge pad in the bottom of the socket may give the necessary light contact.</li><li>Have the patient lift his hip to take weight off the socket. There should be no more than 1/4 in. of piston action (<b>Fig. 43</b>).</li><li>Check for pressure areas in the bulb. With the patient standing, have him flex his hip while you apply resistance to the distal anterior end of the socket. Then have the patient abduct, extend, and ad-duct the hip, each time applying resistance to the distal end of the socket. There should be no pain from these maneuvers. (Pain may be caused by a wrinkle in the sock, by the presence of wax in the air space, or from inadequate relief over the bony prominences in the bulb.)</li><li>Establish the anterior and posterior trim lines. In the posterior lateral area, trim the socket so that it does not encase the gluteal area. Then have the patient sit in a chair and lean forward. Check for discomfort in the anterior area, and trim the socket to fit. There should be no gapping of the lateral wall. The anterior brim of the socket should be in firm contact with the skin, for looseness here would allow the socket to rotate internally on the stump when the patient walks.</li><li>To remove the socket, the patient should pull up on the top of the stump sock while pulling down on the socket. In a few cases, this was the only way in which the socket could be removed (<b>Fig. 44</b>).</li></ol> <p><i>Stretching the Flexible Layers</i></p> <p>If the patient cannot push his stump all the way into the socket, it will be necessary to stretch the flexible layers to allow the bulb to pass through the narrow part of the socket. This can be accomplished as follows:</p> <ol> <li>Place the padded mandrel in a vise.</li><li>Heat the inside of the socket to soften the flexible layers.</li><li>Work the socket back and forth on the mandrel, stretching the flexible layers.</li><li>Let the socket cool on the mandrel, with the padded end of the mandrel at the narrowest part of the socket.</li><li>Refit as in the preceding section, using silicone spray in the socket if necessary.</li></ol> <h3>Alignment</h3> <h4>Bench</h4> <p>The initial set-up is made with the ischial seat level. The posterior plumb line for the heel center passes between the center of the end of the socket and the point where the ischium rests on the ischial seat (<b>Fig. 45a</b>). The lateral plumb is taken from the center of the end of the socket and passes % in. anterior to the knee center (<b>Fig. 45b</b>). The socket is set in 15 degrees -30 degrees of internal rotation to the line of progression to compensate for the patient's tendency to internally rotate the pelvis to advance the prosthetic leg (<b>Fig. 45c</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45a. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45b. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45c. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional</h4> <p>The prosthesis is the correct length when the patient's spine is as straight as possible when he stands with his weight on both legs, i.e., in the finished prosthesis. The iliac crests of these patients are not always symmetrical, and it may not be a reliable reference point for judging the length of the prosthesis (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dynamic alignment is done with the socket set on a child-size above-knee jig. Optimal dynamic alignment is based on standards set for the standard above-knee amputee.</p> <h3>Summary</h3> <p>This fitting technique can also be used on other stumps with bulbous ends: Syme's and above-elbow amputations and wrist disarticulations, for example.</p> <p>At CAPP, more than 20 patients have been fitted in this manner: 18 PFFD's, 2 bilateral Syme's amputations, 1 wrist disarticulation, and 1 above-elbow amputation. All of these patients' deficiencies were congenital in origin.</p> <p>The procedure described does require more fabrication time and material. Once the technique is mastered, it requires about three hours of the prosthetist's time, whereas a solid socket can be fabricated in an hour. However, the CAPP patients have shown a marked preference for this type of socket. It provides a very precise fitting, and in every case the child has expressed a feeling of greater security when wearing this socket (<b>Fig. 47</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another advantage is the apparent absence of skin breakdown. When the patient comes to the clinic for post-fitting examination, the characteristic blanching of the stump skin is absent, as are signs of rubbing, blistering, or callousing so often seen with use of the solid socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</li> <li>Marx, Herbert W., An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</li> <li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, Spring 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Carman Tablada. C.P. </b></td></tr><tr><td class="clsTextSmall">Mr. Tablada is a clinical prosthetist at the Child Amputee Prosthetics Project, University of California, Los Angeles. This study was made under MCH Project No. 204, Division of Health Services and Mental Health Administration, Maternal and Child Health Service, Department of Health, Education, and Welfare. The photographs were taken by Mary Louise Histon.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-18.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-19.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-20.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-26.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-27.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-45.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-46.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-47.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-48.jpg Figure 16 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-49.jpg Figure 17 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-07.jpg Figure 18 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-08.jpg Figure 19 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-09.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 A Technique for Fitting Converted Proximal Femoral Focal Deficiencies Creator An entity primarily responsible for making the resource Carman Tablada. C.P. * https://staging.drfop.org/files/original/5e9f050c02d96432d8f104ec812ace8c.pdf da0d38d9a804a332fd9a3207062a9f1a https://staging.drfop.org/files/original/08e07425408bf41c87dc2c93b224fb5b.jpg 5c092b58ef2060d68e7424b84d6116a0 https://staging.drfop.org/files/original/e346dec2bedf92a857e59abd1ffd7248.jpg 7ee5ff43fa419c57bc4fd8cc6391d463 https://staging.drfop.org/files/original/f61adfb1b17552120e234743993ec28c.jpg ab766cfcc2786236a2c9260ce284e2f4 https://staging.drfop.org/files/original/273c55454cc1bf885d5d972065422824.jpg 2bd9f6a2c4b4d4dc4605e3164b28a1a4 https://staging.drfop.org/files/original/d7748887e1fa845160bc8a5ed9a0b605.jpg a6a917a2af2d7d7b9c2aaf4fe33859dc https://staging.drfop.org/files/original/66af61cdb008228dfacfa6384bb43a35.jpg 4526ad7811f6fb0b5ab5e82c5898c111 https://staging.drfop.org/files/original/ec901e8f405550f48f40e16d73cb2668.jpg f6a4b8e029d8a483756ef3093ef5b526 https://staging.drfop.org/files/original/4f6d845321f89277e90d05be3717d8c6.jpg 1b032cda8b3d4109ce6eb11f5a7f1bff https://staging.drfop.org/files/original/8f7da8912d661f332b7e1a1bf78d597d.jpg 674e1d743a9075daacadf8b4dc82e328 https://staging.drfop.org/files/original/259e168640efa7a9e4790687b54c8fe3.jpg f2644041c4e2f5558269baa90c20d8ca https://staging.drfop.org/files/original/0e7f28c6e5f7b709866175e5ccdf4771.jpg a9c7feb31eff0f0a1e47b133085f51fb https://staging.drfop.org/files/original/117acbf788a7d3c1a7c6e8475739c1ed.jpg 415a50b0631ed70cc4f1c6e34ead3306 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/1987_01_011.pdf Text Any textual data included in the document <h2>A Variable Volume Socket for Below-knee Prostheses</h2> <h5>A. Bennett Wilson, Jr.&nbsp;<a style="text-decoration: none;">*</a><br />C. Michael Schuch, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Robert O. Nitschke, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The benefits concerning control of edema by fitting the lower limb amputee as soon as the stitches are removed are well documented,<a></a> yet for a number of reasons, mostly economic, the majority of new amputees are not treated in this manner. As a result, most patients present for their first prosthesis with an edematous residual limb that can be expected to shrink even when it has been wrapped properly with an elastic bandage or with a shrinker sock. Proper management of these patients has usually required the fabrication of several provisional sockets in successively smaller sizes until the soft tissues have reached a point where no further reduction is to be expected. Besides the expense involved in this procedure, a truly proper fit occurs only for a very short period after each new provisional socket is provided, a condition which is bound to have an effect on the activity of the newly fitted patient. Thus, a socket that can be adjusted to accommodate the gradual change in residual limb volume is desirable.</p> <h3>History</h3> <p>Attempts to provide adjustable socket volume are found more commonly at the above-knee level.<a></a> The Irons, et al.<a></a> socket design has evolved to become available as a non-custom fitted, prefabricated socket system, manufactured and distributed by Orthomedics<a></a> and United States Manufacturing Company.<a></a> To quote Mooney,<a></a> a co-author of the paper by Irons, et al.,<a></a> "For the above-knee stump, the design constraints are simpler in that the residual limb usually presents no significant bony contours and adequate soft tissue covers all bony elements. On this basis, the fabrication of a lightweight above knee prosthesis with an adjustable socket is a relatively simple problem." Referring again to the Irons, et al.<a></a> study, Dr. Mooney7 states that, "a significantly higher percentage of amputees became functional users due to the availability of the adjustable above-knee prosthesis than would have been expected by previous experience if they had waited for the maturation time to be considered for a conventional socket. The average time to fitting with a conventional socket in the past was about six months. In this group, using earlier fit of adjustable sockets, which were also lightweight, a higher percentage of patients became functional users."</p> <p>The only volume adjustable below-knee socket system reported on to date is by Mooney, et al.<a></a> from the University of Texas at Dallas, who report early gratifying results with use of this system. However, it is an off-the-shelf item, which inherently presents fitting problems. As opposed to the above-knee limb, the below-knee limb requires more exacting contours of fit due to prominent bony contours, and relatively less soft tissue. In addition, the below-knee amputee often presents with adherent scar tissue in the suture areas. For these reasons, most will agree that a custom fit is mandatory at the below-knee level.</p> <p>An interesting fact can be noted in all of the designs cited: ease of volume adjustments were concentrated in the proximal aspect of the socket as opposed to the distal aspect, where the greatest reduction in volume occurs.</p> <h3>Goals And Design Criteria</h3> <p>After reviewing existing designs in which the volume of the socket can be adjusted, and considering the use of materials and techniques now available, a set of criteria was established for a custom fitted variable volume below-knee socket as follows: 1) the socket would be custom fitted to the individual patient; 2) existing prosthetic molding, modification, and fabrication techniques would be used as appropriate; 3) the volume would be controlled equally or selectively between proximal and distal parts of the residual limb; 4) normal prosthetic cosmesis would be possible and practical; and 5) the finished prosthesis would be light, but durable.</p> <p>The original, primary purpose of the project was to design a socket for use as a preparatory prosthesis, and thus avoid the need for several socket changes before stabilization occurs. However, it appears that the design that has resulted may also be very appropriate for use over extended periods where fluctuation in limb volume is difficult to control, or where the shear stresses normally encountered with present day socket designs present a problem.</p> <p>Because of the two-piece design (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg"><b>Fig. 1</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg"><b>Fig. 2</b></a>), it is possible to don and doff the prosthesis without subjecting the skin of the residual limb to shearing forces, and thus should be considered when it is desirable to avoid shear on the limb. Additionally, the two-piece construction should add a measure of suspension if this element is considered in the individual design.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg"><strong>Figure 1. Exploded schematic view of the variable volume socket showing major components.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg"><strong>Figure 2. Schematic showing relationship of the major components of the variable volume socket.</strong></a><br /> <p>We are confident that the concept is valid and useful. What follows here is, we hope, sufficient information for an experienced prosthetist to try the concept. The materials and dimensions given are those that have been found to work in our still limited experience, but are by no means considered to be the best.</p> <p>Our original method for controlling volume, by use of two conventional hose clamps, is described here, because we have yet to locate a commercially available adjustment buckle that is suitable. We made some progress in designing a buckle especially for this purpose, but have not pursued the idea since the hose clamps can be made to work satisfactorily. However, there is probably a place for a more convenient method of controlling the circumferential dimensions.</p> <h3>Casting And Modifying The Positive Model</h3> <p>As stated in the design criteria, this socket system is intended to make use of existing prosthetic molding, modification, and fabrication techniques. We recommend use of the casting procedure described by Fillauer<a></a> in which an impression of the anterior portion of the limb is made first, using plaster splints to capture the bony definition before enclosing the remainder of the residual limb with plaster. Model modification should be carried out in normal function. We also recommend the use of a transparent diagnostic socket and algination procedure as described by Schuch and Lucy,<a></a> before proceeding with pouring the final positive model and fabrication of the socket.</p> <p><i>Fabrication of the Socket</i></p> <ol> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-03.jpg"><b>Step 1&nbsp;</b></a><br />Place the positive model in a vise horizontally with the anterior section facing up.</p> </li> <li> <p><strong><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-04.jpg">Step 2&nbsp;&amp; 3</a></strong><br />Over the positive model, form a Pelite™ liner for the anterior half of the socket. After heating a proper size sheet of Pelite™, a piece of latex rubber can be used to form the Pelite™ around the cast model.</p> </li> <li> <p>Trim the Pelite™ liner so that it extends posteriorly slightly past the midline, dividing the anterior-posterior halves of the model. Skive all edges that will be inside the socket. Remove the Pelite™ liner from the cast in preparation for the next step.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-05.jpg"><b>Steps 4 and 5</b></a><br />Rotate the model in the vise 180° so that the posterior surface is up.</p> </li> <li> <p>Using conventional drape molding techniques, vacuum form a piece of 1/8 inch polyethylene (or Surlyn®) around the model, posterior side up so the seam is on the anterior side.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-06.jpg"><b>Step 6</b></a><br />Trim the polyethylene to form a posterior socket shell that extends anteriorly just past the midline and "underlaps" the Pelite™ anterior liner by about 3/8-1/2 inch. Again, skive all edges that will be inside the socket.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-07.jpg"><b>Step 7</b></a><br />With the Pelite™ anterior liner and the polyethylene posterior shell in place on the model, pull a thin sheath of nylon over both to hold them in place.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-08.jpg"><b>Step 8</b></a><br />On the posterior aspect of the model, glue a 1/4 inch diameter rope to form the cutout for the posterior volume control panel. Prepare for lamination in the usual manner. For use as a temporary design prosthesis, we use Otto Bock<a></a> modular endoskeletal components and laminate the 4R42 component (socket adaptor with pyramid and lamination anchor) directly into the socket.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-09.jpg"><b>Step 9</b></a></p> <p>Before beginning the lamination procedure, cut two polyethylene strips 1/16 inch thick by 9/16 inch wide by the circumference, plus 1/2 inch of the cast model at the levels shown.</p> <p>The strips are placed in the lamination layup and are removed after the lamination sets up to form channels for the volume control straps. Layup for the lamination is as follows:</p> <blockquote> <p>1 layer of 1/2 oz. dacron felt<br />1 nylon stockinette<br />the 4R42 component (if used)<br />I.P.O.S.<a></a> glass matting over the lamination anchors of the 4R42 component and over the medial, lateral, and posterior aspects of the layup<br />1 nylon stockinette; the two polyethylene strips cut earlier are placed at the appropriate levels;<br />1 nylon stockinette<br />2 nyglass stockinettes; laminate with 80:20 mixtures of acrylic resin</p> </blockquote> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-10.jpg"><b>Steps 10, 11, and 12</b></a><br />When the laminate has set and cured, cut out the window over the rope and trim as shown.</p> </li> <li> <p>Using a pair of needle nose pliers, pull out the two polyethylene strips imbedded in the lamination. This leaves a clean, hidden track for guiding the pull of the control straps.</p> </li> <li> <p>Cut out an area about 1 1/2 inches along each control strap track in the anterior-lateral area of the socket, to allow for exposure of the adjustable part of the control strap.</p> </li> <li> <p>Make up control straps of 1/2 inch da-cron tape and two to three inches of the hose clamps.</p> </li> <li> <p>Put the socket system back on the cast model for determination of the initial volume setting. Insert the dacron straps through the tracks and speedy rivet the hose clamp section so that the hex head of the clamp is exposed in the slots cut in step 12 above (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg"><strong>Figure 3. Photograph of laminated outer socket prior to mounting on adjustable leg. A foam block is shown here but this practice has been superceded by use of the Otto Bock 4R42 component which is laminated into the distal end of the outer socket.</strong></a></li> <li> <p>Attach the pylon and foot and align in the conventional way (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg"><strong>Figure 4. Variable volume socket mounted on an adjustable leg.</strong></a></li> </ol> <h3>Clinical Experience</h3> <p>To date, seven variable volume below-knee sockets have been fitted on six carefully chosen amputees. Five of these patients were new amputees and the variable volume socket prosthesis was their first prosthesis. One of these five had an extremely edematous limb due to a recent infection, and required two successive variable volume sockets before being fitted with a definitive conventional P.T.B, prosthesis. The remaining patient was a young amputee, three years post-amputation, who was having difficulty maintaining consistency in limb volume. The variable volume socket proved to be very useful in managing this patient.</p> <p>Evaluation was basically simple and subjective. The clinic team discussed and recorded any problems that arose with the socket design and documented that atrophy was accommodated by the variable volume socket. In all cases, maintenance of socket fit was made possible by decreasing socket volume as atrophy of the residue limb took place. At no point was comfort compromised by a reduction of socket volume.</p> <p>In addition to the patients fitted at the University of Virginia; trial fittings were made by Mr. Nitschke in the courses of development at Leimkuehler, Inc. in Cleveland, Ohio, American Orthotic and Prosthetic Laboratory, Inc. of Columbus, Ohio, and Rochester Orthopedic Laboratories, Inc. in Rochester, NY where we were given much help and encouragement. In addition, Karl Fillauer, CPO of Fillauer Orthopedic, Inc. in Knoxville, Tennessee has fit two patients and Robert Gooch, CP and John Michael, CPO of Duke University have fit one patient, all of whom are currently being followed.</p> <h3>Summary And Conclusion</h3> <p>Rationale, design criteria, and fabrication techniques for an adjustable volume below-knee socket have been discussed and described. Successful fittings with the system have been noted. It is felt that this system can meet a need by providing new amputees with a durable, cosmetic, and reasonably long lasting preparatory prosthesis that accommodates the familiar problem of residual limb volume shrinkage.</p> <h3>Acknowledgments</h3> <p>This work was made possible by support from the Veterans Administration Rehabilitation Research and Development Service. We are also grateful for the help and encouragement provided by Messrs. Jon Leimkuehler, CPO, Peter Ockenfels, CPO, Karl Fillauer, CPO, Carlton Fillauer, CPO, Robert Klebba, Robert Gooch, CP, John Michael, CPO, and Dr. Frank Clippinger.</p> <p><b>References:</b></p> <ol> <li>Brownsey, ZZ; Fillauer, ZZ: "Temporary Prosthesis with Adjustable Socket," <i>Physical Therapy</i>, 47:12:December, 1967, pp. 1129-1131</li> <li>Fernie, Geoff, R. and Pamela J. Holiday, "Volume Fluctuations in the Residual Limbs of Lower Limb Amputees," <i>Archives of Physical Medicine and Rehabilitation</i>, 63:4:April, 1982, pp. 162-165.</li> <li>Fillauer, Carlton, "A Patella-Tendon-Bearing Socket with a Detachable Media Brim," <i>Orthotics and Prosthetics</i>, 25:4:December 1971, pp. 25</li> <li>Irons, G., V. Mooney, S. Putnam, M. Quigley, "A Lightweight Above Knee Prosthesis With an Adjustable Socket, <i>Orthotics and Prosthetics</i>, 31:1:March 1977, pp. 3-15.</li> <li>Malone, J. et al, "Rehabilitation for Lower Extremity Amputation," <i>Archives of Surgery</i>, 116:1:January 1981, pp. 93-98.</li> <li>Malone, J. et al., "Therapeutic and Economic Impact of a Moderate Amputation Program," <i>Annals of Surgery</i>, 189:6:June 1979, pp. 798-802.</li> <li>Mooney, V., B. McClellan, D. Cummings, P. Smith, "Early Fitting of the Below Knee Amputee," <i>Orthopedics</i>, 8:2:February 1985, pp. 199-202.</li> <li><a href="cpo/1986_03_101.asp">Schuch, C. Michael, and Tony Lucy, "Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets," <i>Clinical Prosthetics and Orthotics</i>, 10:3:Summer 1986, pp. 101-104.</a></li> <li>Orthomedics, Inc., 2950 East Imperial Highway, Brea, California 92621.</li> <li>Otto Bock Orthopedic Industry, Inc., 4130 Highway 55, Minneapolis, Minnesota 55422.</li> <li>United States Manufacturing Company, 180 North San Gabriel Blvd., Pasadena, California 91107.</li> <li>I.P.O.S., U.S.A., 155 Portage Road, Lewiston, New York 14092.</li> </ol> <b>*Robert O. Nitschke, C.P.O. </b> Robert Nitschke is a consultant and lives in Rochester, NY.<br /><b><br />*C. Michael Schuch, C.P.O. </b> Department of Orthopedics and Rehabilitation at the University of Virginia.<br /><b><br />*A. Bennett Wilson, Jr. </b> Department of Orthopedics and Rehabilitation at the University of Virginia.<br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 11 - 19 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg Figure 3 STEP 1 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-03.jpg Figure 4 STEP 2 &3 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-04.jpg Figure 5 STEP 4&5 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-05.jpg Figure 6 STEP 6 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-06.jpg Figure 7 STEP 7 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-07.jpg Figure 8 STEP 8 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-08.jpg Figure 9 STEP 9 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-09.jpg Figure 10 STEP 10,11&12 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-10.jpg Figure 11 FIGURE 3 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg Figure 12 FIGURE 4 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.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 Variable Volume Socket for Below-knee Prostheses Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * C. Michael Schuch, C.P.O. * Robert O. Nitschke, C.P.O. * https://staging.drfop.org/files/original/527872ee9190fb7a616b0cc70410fbe0.pdf f629c37fa67f701c4b6aea78de76a2a8 https://staging.drfop.org/files/original/a6f09a9bde0aec6c464fbc7043e3fe3b.jpg 8ddc8354987eee1ddb5c98b5d7c77ca5 https://staging.drfop.org/files/original/626f567e943aaa264fa84b5f0333edda.jpg 63014457b9280ffcc858cd9079ba37fd https://staging.drfop.org/files/original/01833bc5541285c909871999020cb9b4.jpg 5fa7af520e891c8f39caf1685065aa51 https://staging.drfop.org/files/original/c3e424fe1ec3be458e58896700d78c4d.jpg 989474fa8119838ea695f94be3cd81cc https://staging.drfop.org/files/original/7a548b290f3da58ff06158588e81e48b.jpg bbbff8ef694a7d53e8ff5f8cf4f70251 https://staging.drfop.org/files/original/4c93630c0224b3c1f43af6f6fbfba87d.jpg 70057c8df762d2494a1232ee7ec2e860 https://staging.drfop.org/files/original/9eabbcd76d348b28f55b9cd7bd0c370a.jpg 03f397225e0cf2ba7432c561fb26e3c9 https://staging.drfop.org/files/original/d3a357f008aed8a49e631b01e0fc41f2.jpg ab424dfa71fd3027cd0b18f150597dc7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_028.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 28 - 43 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_028.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Acceptability of a Functional-Cosmetic Artificial Hand for Young Children, Part I</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>The need for a functional and cosmetically acceptable artificial hand for juvenile amputees has existed for many years. A voluntary-opening hook which has been available for a number of years in a variety of sizes was until recently invariably prescribed for children. In response to the demand on the part of both children and parents for a functional device with a more natural appearance, the Army Prosthetics Research Laboratory (now known as the Army Medical Biomechanical Research Laboratory) undertook in 1958 to develop a child's voluntary-opening hand. Earlier studies<a></a> had shown that a spectrum of five sizes should satisfy the needs of the entire arm-amputee population from childhood to maturity. Size No. 1 was the designation given to the smallest. Because it was hoped that a mechanism developed for the Size No. 1 hand might be suitable for use also in Size No. 2 and perhaps in Size No. 3, the smallest size was given the first priority. The Sierra Engineering Company<a style="text-decoration:none;">*</a> contracted to manufacture this hand and two other companies (Kingsley Manufacturing Company<a style="text-decoration:none;">*</a> and Prosthetic Services of San Francisco<a style="text-decoration:none;">*</a>) were enlisted to manufacture suitable cosmetic gloves.</p> <p>Following preliminary testing of a prototype model, modifications to eliminate certain shortcomings were incorporated in 50 production models. A field test was initiated in April 1960 with evaluation of the cosmetic gloves included as an integral part of the study. Preliminary findings based upon experiences in fitting 20 children indicated that the hand was acceptable cosmetically and provided satisfactory function in the activities typically performed by children.<a></a> The general workmanship and cosmesis of the gloves provided by both manufacturers had also achieved a satisfactory level after certain initial fabrication difficulties. However, several problems had been identified, the most serious of which was a lack of glove durability. Ridges and sharp edges on the exterior of the hand apparently contributed to rapid glove damage.</p> <p>Accordingly, the original production-model hands were modified and then refitted to the subjects of the field study. Modifications included eliminating the glove-cutting edges, strengthening the floating-finger attachments and the spring mechanism of the thumb, and raising the cable exit. In November 1960 "old" hands revised in this manner began arriving at New York University Child Prosthetic Studies, and in April 1961 the manufacturer produced a series of new hands which incorporated all the modifications.</p> <p>An Interim Report<a></a>, summarizing the results of the field study to mid-May 1961, was prepared for the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development, and the results reinforced earlier findings concerning the acceptability of the hand and gloves. The APRL-Sierra Child-Size No. 1 Right Hand was accepted as satisfactory for general use by child amputees on the basis of this report, and the study was terminated in the latter part of 1961.</p> <p>Following the generally successful outcome of the evaluation of the Size No. 1 Right Hand, manufacture of the Size No. 1 Left Hand was initiated. In May 1961 NYU Child Prosthetic Studies reported the results of a preliminary examination of two units manufactured by the Sierra Engineering Company<a></a>. The hands appeared to be of excellent quality and workmanship with minor exceptions, and in June 1961 the manufacture of 55 additional left hands was authorized for field-test purposes.</p> <p>During September and October 1961, NYU Child Prosthetic Studies received two shipments totaling 40 hands from the manufacturer. These were found to be unacceptable because of engineering deficiencies, and all were returned for modification. In February 1962, 37 hands were finally accepted for use in the field study. Another 14 hands submitted later were also found to be acceptable, making a total of 51.</p> <p>Another Interim Report<a></a> on the status of the field study was submitted at the October 1962 meeting of the Subcommittee on Child Prosthetics Problems. It was reported that the APRL-Sierra Child-Size No. 1 Left Hand was considered to be essentially satisfactory both mechanically and functionally, although more rigid quality control in manufacture and assembly was desirable. The recommendation of this report that the hand and cosmetic glove be approved for commercial distribution was accepted by the Subcommittee and the study was terminated in January 1963.</p> <h3>Purposes of the Studies</h3> <p>The APRL-Sierra Child-Size Mo. 1 Hand (both right and left) was developed to provide the juvenile amputee with a cosmetically acceptable terminal device which would closely resemble the normal hand in size, shape, and coloring. Maximum function-commensurate with cosmesis, simplicity of operation, adequate strength, and reasonable cost-was a concomitant objective.</p> <p>Since the field study of the left hand was essentially an extension of the study of the right hand, the general goals of both evaluations were identical:</p> <ol> <li>To introduce the hand into clinical use.</li><li>To corroborate findings of laboratory studies.</li><li>To determine the acceptability, utility, application, and durability of the production-model hand and glove.</li><li>To investigate indications and contraindications for prescription.</li></ol> <p>In the light of the experience gained in the study of the right hand, three considerations were given closer attention in the study of the left hand:</p> Performance differences between the experimental hand and the hooks previously worn were investigated in greater detail than was the case in the study of the right hand. The short wear-life of the cosmetic gloves used in the study of the right hand presented a definite and challenging problem. In the course of the study, the exterior of the experimental hand was extensively modified to eliminate sharp edges which might contribute to glove damage. The effectiveness of these changes was of particular interest in the study of the left hand. The effect of wearing the hand on the child's school behavior was a planned aspect of the study of the right hand. Data secured on this significant subject were limited, however, since the study overlapped two school years. With the earlier commencement of the study of the left hand (February 1962), these data were obtained for some children fitted during March and April 1962. <h3>Description of the Hand</h3> <p> The APRL-Sierra Child-Size No. 1 Hand (both right and left) consists of a monocoque hand shell of cast aluminum, articulated index and middle fingers, a "two-position" thumb, and nonarticulated but flexible ring and little fingers. A voluntary-opening type of mechanism is housed within the hand shell and the entire unit is covered with a thin plastic glove that can be replaced as warranted ( <b>Fig. 2</b> ). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. APRL-Sierra Child Size Model No. 1 Hand.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The index and middle fingers each consist oi three aluminum castings which, along with a portion of the hand shell, form a four-bar linkage to provide coordinated articulation at points corresponding to the metacarpophalangeal and the proximal interphalangeal joints ( <b>Fig. 3</b> ). This arrangement results in a minimum amount of glove distortion through the range of motion required. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3. Cutaway views of the APRL-Sierra Model No. 1 Hand (3). When no tension is applied to the control cable B, spring D forces the index and middle fingers toward the thumb to provide prehension of the three-jaw-chuck type. Tension in the control cable B causes the quadrant C to rotate about point A, a point displaced from the true center of quadrant C. The cam action thus provided by the outer edge of the slot in quadrant C against roller G forces lever E to rotate counterclockwise about point F, in turn causing the index and middle fingers to open. A small brass plate is mounted within lever E in such a fashion that, when little or no tension is applied to the control cable, the plate wedges against the periphery of the quadrant C. The wedging action, known as "Bac-Loc," resists opening of the fingers when force is introduced through the finger linkage but has no effect on the system when force is applied through the control cable.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The thumb is an aluminum casting mounted to the hand shell through a locking mechanism that permits it to be held in either of two positions-one for maximum opening between fingers and thumb, the other for a smaller opening for conservation of excursion.</p> <p>The ring and little fingers, the two consisting of a one-piece casting of foam rubber, are simply fastened to the hand shell and left to move with the cosmetic glove.</p> <p>A threaded stud (1/2 x 20) attached to the wrist section of the hand is provided for use with currently available wrist units.</p> <p>Maximum allowable weight is 6 3/4 oz. (without the glove). Less than 9 lb. of tension in the control cable (measured at the point of entry into the hand) is needed to open the fingers and a minimum of 2 lb. of prehension force is provided.</p> <p>Cosmetic gloves for the hand are available in a minimum of seven Caucasian and six Negroid shades from each manufacturer.</p> <p> <b>Sample</b> </p> <p> The sample, which included a variety of upper-extremity types, consisted of 77 subjects, one of whom was fitted with hands bilaterally. All the children in the study, except two, had previously worn Dorrance-type hooks ( <b>Fig. 4</b> ). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4. Boy wearing Dorrance hook.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A total of 39 children, of whom 36 were unilateral arm amputees, were fitted with the right hand ( <b>Table 1</b> ). Of the three remaining subjects one (with bilateral shoulder-disarticulation amputations) was fitted with a right hand only and continued to wear a hook on the left side; one (with right above-elbow and left short below-elbow amputations) was also fitted with a right hand and retained a hook on the left; and a triple amputee (with bilateral long below-elbow and left knee-disarticulation amputations) was given hands on both sides. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This last subject was included in both the right- and left-hand samples.</p> <p> Thirty-nine children, of whom 36 were also unilateral arm amputees, were fitted with the left hand ( <b>Table 2</b> ). Of the three remaining subjects one amputee (with bilateral shoulder-disarticulation amputations) was given a left hand only; a triple amputee (with bilateral long below-elbow and right below-knee amputations) received a left hand and kept a hook on the right; and the third subject was the aforementioned triple amputee who was included in both samples. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <b>Procedures</b> </p> <p> The fittings in both the Right- and Left-Hand Studies were conducted through the clinics participating in the Child Amputee Research Program. <a style="text-decoration:none;">*</a> In order that wearers of the hand might secure the longest possible wear period before growth of the child caused an objectionable size discrepancy, it was recommended that the clinics select candidates whose nonamputated hand size was such that they should be able to wear the experimental hand for at least a year. </p> <p>The experiences of the clinics were evaluated on the basis of: first, the reactions of the children, their parents, and others to the experimental hand and to other previously worn terminal devices; second, observations of classroom behavior during the treatment period; third, ratings of the children's performance of standard prehensile tasks using the experimental and old terminal devices; and fourth, maintenance.</p> <p>In the course of the studies the children were required to make four visits to the clinic servicing them during a minimum period of five months.</p> <p> <b>First Clinic Visit: Screening</b> </p> <p>A screening session was conducted during the first visit. The children and their parents were oriented to the purpose of the survey, the number of visits required, and the need to follow through with experimental procedures.</p> <p>Parents and children expressing a willingness to participate selected glove shades from shade guides provided by both manufacturers. Neither the experimental hand nor a complete cosmetic glove was shown to the patients or their parents during the first visit. A selection form, recommending the child as a participant in the study and furnishing information concerning him, was completed and sent to the NYU Child Prosthetic Studies.</p> <p>The candidates were evaluated on the basis of information provided on the selection form and sampling requirements. Upon approving a candidate NYU sent the clinic a hand and glove for the child and a questionnaire to be completed by the child's classroom teacher prior to fitting the experimental hand.</p> <p>The questionnaire pertained primarily to the child's psychosocial adjustment to the school environment. The teacher was asked to fill out the questionnaire before the experimental hand was fitted and to fill out a similar form at the conclusion of the study. The purpose of this procedure was to determine whether the child's behavior or performance with a prosthesis in school was affected as a result of wearing the experimental hand. In order to provide comparability of data, it was important that the same teacher provide both pre- and post-fitting observations.</p> <p> <b>Second Clinic Visit: Fitting</b> </p> <p>At the second clinic visit a prosthetic performance test utilizing the old terminal device was administered and the reactions of children and parents to the old device were ascertained. The child was fitted with an experimental hand and initial reactions to the new component were secured from child and parents. The child and parents were then given instructions that the experimental hand was to be worn exclusively until the next clinic visit two months later.</p> <p> <b>Third Clinic Visit: Two-Months Post-Fitting Evaluation</b> </p> <p>Two months after the fitting the reactions of child and parents to the new component were again recorded at the clinic. Comparisons between old and new terminal devices with respect to weight, ease of operation, and usefulness were noted, and a prosthetic performance test, in which first the new hand and then the old terminal device were evaluated, was also conducted. The parents were then told to permit the wearing of either the old or the new terminal device as the child desired and were scheduled for a further clinic visit two months later.</p> <p> <b>Fourth Clinic Visit: Final Evaluation</b> </p> <p>The final evaluation was conducted four months after the initial fitting. The reactions of child and parent to the new hand were again obtained, and the old and new devices were compared in the same manner as earlier. The clinic summarized its data on a form provided for the purpose, and the child's classroom teacher was asked to complete another questionnaire.</p> <h3>Results-Subjective Reactions</h3> <p> <b>Parent and Child Preferences</b> </p> <p>At the conclusion of the test period, the 77 children participating in the study and their parents decided almost unanimously in favor of retaining the experimental hand with only seven rejecting it completely. In contrast to these seven rejections, 21 children expressed a desire to wear the hand exclusively. The remaining 49 children took intermediate positions ranging from a predominantly-hand to a predominantly-hook preference. All in all 42 children and their parents clearly preferred the hand; 15 were ambivalent or offered contradictory opinions; 20 preferred the hook.</p> <p> <b>Hand Used Exclusively</b> </p> <p>Of the 21 children (13 girls and 8 boys) who chose to wear the hand exclusively, 20 were prior hook wearers, one had previously worn a Becker Plylite hand, and one had never worn a prosthesis before because his parents had refused to accept a hook. Cosmesis was extremely important to this group and was often the only factor mentioned by the child.</p> <p>JM, a long below-elbow amputee who was 6 years and 11 months old at the initiation of the study, is typical of the children in this category. When asked what he liked about the hand after four months' wear, he replied, "I like it-the way it looks." He disliked the appearance of the hook and could think of nothing favorable to say about it or anything unfavorable to say about the hand. The hand functioned better, he said, and was important to him for use at school. Schoolmates stared at first, but liked it. JM's mother thought he had better function with the hook, but only because he had not had the new hand very long. She also remarked that he should wear the hand all the time because "it gave him more confidence." The hook's only contribution was that it prepared the child for the hand, she said.</p> <p>Sandra, a short below-elbow amputee, was 5 years and 9 months old at the beginning of the study. She cited better function as the reason for preferring the hand: "...can move things better-holds lots of things better." She disliked nothing about the hand, liked nothing about the hook, and said she wanted to wear the former all the time. Her mother preferred the hand for reasons both of appearance and grasp; schoolmates found it easier to hold on to when playing games, and it didn't slip when the child tied her shoes. Sandra should not wear a hook at her age, her mother declared.</p> <p> <b>Hand Used Predominantly</b> </p> <p>The hand was the terminal device of choice for an additional 21 children (15 girls and 6 boys). The hook was preferred for rough outdoor activities in which hook function was superior.</p> <p>Typical of the group was Curtis, age 5, a very short below-elbow amputee, who liked "everything" about the hand: it resembled his other hand, held paper when he wrote, and grasped a baseball bat better. However, he felt that the hook was lighter, was easier to open, and superior for playing with certain toys. His mother was pleased with the appearance of the hand, Curtis's attitude toward it, and the fact that other children were willing to hold it in games. However, she thought he should wear the hook at home for activities that might damage the glove. During the last two months of experimental wear, when parents and children could choose which device would be worn, Curtis used the hand exclusively, except when repairs were required.</p> <p>Diana, age 5, a short below-elbow amputee, expressed a desire to wear the hand most of the time and the hook only for swimming (sic!). The reason for her preference was that "it looks like my other hand." Earlier she had found the hand somewhat harder to operate and had experienced difficulty releasing it from bicycle handles. Her mother was concerned about tears on the glove fingers, but Diana said, "It doesn't matter what the glove looks like." Her mother agreed that the hand should be worn in most circumstances, but thought the hook could be used for swimming and as a replacement in case the hand broke.</p> <p> <b>Hand and Glove Used About Equally</b> </p> <p>Seven children (5 girls and 2 boys) and their parents desired to retain both hook and hand and to use them on an approximately 50-50 basis. For example, Carol, an 8-year-old short below-elbow amputee who lived on a farm, preferred the appearance of the hand: "It gives me another hand and people don't stare"; and the function of the hook: "I don't drop things with the hook or worry that someone might bump into me and knock them out of my grasp." She also was concerned about tearing the glove. Carol chose to wear the hand both to regular and Sunday school and the hook for farm chores and play. Her father agreed with the child's viewpoint. He thought the glove not rugged enough, but the hook handy and sturdy.</p> <p> <b>Parent and Child Disagreement</b> </p> <p>There were eight children (6 boys and 2 girls) whose primary choice of terminal device differed from that of their parents. In five instances, the child chose the hand and the parent the hook; in the other three cases, the positions were reversed. The basis for disagreement was usually a relative emphasis upon appearance and function.</p> <p>Michael, age 6, whose partial hand amputation was fitted as a wrist disarticulation, was pleased that the hand "looked like my other one," but acknowledged that the hook was lighter and easier to use. If he could retain only one device, he would choose the hook, since he could do much more with it; however, his mother and friends preferred the hand.</p> <p>The latter were sometimes afraid of the hook. Michael's father preferred the hand for cosmetic reasons and cited other advantages: "... more chance to play cowboy and wrestling . . . children not afraid . . . danger of bumping into others when playing with the hook."</p> <p> <b>Hook Used Predominantly</b> </p> <p>Six boys and seven girls preferred the hook for daily use and the hand for dress occasions. Five of the children were under 5 years of age (one, age 3 and four, age 4), and four of these had not yet attended primary school, kindergarten, or play school. Eleven of these children rated the hook function better and ten specifically said the hand was heavy or hard to operate; one older boy complained that the hand did not afford a tight grasp and a younger girl said the hook held things in a better position. Parents of twelve of these children declared hook function was better; the other parent expressed no preference.</p> <p>Danny, with an elbow disarticulation and split-ray hand, was the youngest child in the study-barely 4 years of age when fitted with the hand. To open it, he had to hold his elbow completely extended with maximum tension on the cable. Even in this position, full opening required more effort than he typically cared to exert, although he was pleased that the hand looked like his natural one. Danny stated that the artificial hand was heavier and harder to operate than the hook and did not pick up objects as well. The hook was better for grasping a swing chain and for holding his bread to push food. The child's mother hoped that his skill with the hand would improve, but after four months she reported that he wore it only for "going visiting." She thought the hand would be of greater use when he was older.</p> <p> <b>Hand Rejections</b> </p> <p>In view of the fact that complete rejection of the experimental hand was rare, it is interesting to note the instances when it occurred. Seven children rejected the hand completely; four of these were 4- or 5-year-old boys, one was a 7-year-old girl with bilateral shoulder disarticulations, and the other two were a boy and a girl, both 9 years old, who were excellent users of their hooks and apparently were not concerned with the appearance of this device. Various factors contributed to these rejections. Several of the younger boys and the 9-year-old boy and girl obtained better function with the hook and seemed relatively unmindful of appearance. The bilateral shoulder-disarticulation amputee was a marginal user of any prosthesis and found the increase in operating forces and the difficulty of positioning the hand without a wrist-flexion unit intolerable. Three children experienced excessive hand malfunctions and two others, because of frequency of glove damage or difficulty in getting replacements, wore unsightly gloves for prolonged periods.</p> <p> <b>Age and Sex in Relation to Acceptance Level</b> </p> <p>The data contained in the last two categories of acceptance level (Hook Used Predominantly and Hand Rejections) suggest that age is a strong consideration governing hand or hook preference. Such a relationship would not be surprising, since younger children may be expected to: first, experience difficulty with hand weight and operating forces because of limited physical development, and second, be more careless in their use of a device, less concerned with the niceties of appearance, and would not be subject to the social pressures of the school environment.</p> <p> Age, however, cannot be regarded as an absolute criterion, since several of the children in the study who selected the hand as their primary choice were 4-year-olds. In fact, when the age and sex of the children are tabulated against indicated levels of preference ( <b>Fig. 3</b> ), sex appears to be more significantly related to choice of device than does age. Thus, girls of all ages for whom the hand is of appropriate size appear to be potentially the best candidates for the No. 1 Hand, while younger boys would seem to be less likely to accept the device. </p> <p> <b>Effects on School Adjustment</b> </p> <p>The questionnaire to be completed by the classroom teacher was designed to secure pertinent information concerning the behavior of the child in school while wearing the old terminal device and the experimental hand respectively. It was hypothesized that the child's classmates and teacher might react more positively to a hand than they had to a hook and as a result adjustment of the child to the school situation would show discernible changes. This type of improved behavior had been noted previously when a child who had been a nonprosthesis wearer was fitted for the first time.<a></a></p> <p>Historically, two significant problems frequently encountered by juvenile amputees wearing hooks to school have been the indignity of being called "Captain Hook" and similar names by classmates and refusal by other children to hold their hooks in hand-holding games. Elimination or reduction of these difficulties was anticipated when the child was fitted with a functional terminal device that closely resembled a normal hand.</p> <p>The teacher's opinion was obtained concerning various aspects of the child's school behavior: attendance, homework, conduct, friendships, social participation and leadership, and extent of use of the prosthesis. As provided in the study plan, the teacher's questionnaires were to be completed twice: once while the child was still wearing a hook, and again after four months of hand wear when the child would presumably have acquired sufficient skill in the use of the hand, and changes in school behavior would have had an opportunity to develop.</p> <p>When it became apparent that a majority of the children in the Left-Hand Study would not have worn the hand for four months before the end of the 1961-1962 school year, the original plan was modified to provide for completion of the second questionnaire just prior to the end of the academic year regardless of length of time the hand had been worn.</p> <p>Unfortunately, comparable hook-and-hand questionnaires (that is, both completed by the same teacher) are available for only 16 of the 77 children in the sample. The majority of the remaining 61 children were of pre-school age or were fitted with the hand toward the end of the school year or during the summer, so that they did not have the same teacher at the beginning and the end of the study. The data from the teachers' questionnaires were, therefore, supplemented by information concerning school and personal adjustment from other sources wherever available.</p> <p> <b>Reactions and Representative Comments</b> </p> <p>Of the 29 boys and 21 girls in the sample who were 6 years of age or over, 26 boys and 21 girls were either wearing the hand in school at the termination of the experiment or stated that they intended to do so when the fall term began. Included in this group were four of the children whose preferred device was the hook. Nevertheless, they wore the hand to school. One boy, age 8, summarized the opinion of these four children when he said, "I wear it because the kids like it better."</p> <p>As mentioned previously, a number of children reported that prior to using the hand they had been called "Captain Hook" by other children and that this had disturbed them. There is considerable evidence that the effects of this name-calling can be quite destructive to social relations among children. One girl, in fact, refused to wear the prosthesis to school after such an incident. When the hand was worn these difficulties tended to disappear. The essence of the reaction to and acceptance of the hand may be gathered from the large number of favorable comments made by playmates, schoolmates, teachers, and others.</p> <p> Representative statements <i>reported by the children</i> included the following: </p> <p> "My schoolmates were excited about the hand because I have five fingers on the left hand now." <br /> "It smells nice, looks nice, and works nicer than the hook." <br /> "I like the feel of the hand; it looks real." "One little girl thought my hand had grown back." "They said it was prettv. The girls aren't scared of it." <br /> "I wanted to look at it. I always wanted to know when I was going to get it. It drives me out of my mind." "My school friends stared at first; they liked it." "At school they all liked the looks, especially how real it looked, including the fingernails." <br /> "Kids like to see the way I can bend the fingers (floaters) all the way back. They like to feel it. One boy bit it to see what it would do." </p> <p> Representative reactions <i>reported by the parents</i> included these remarks: </p> <p> "They were surprised when they found out he could move the fingers and thumb." <br /> "Children in school were not aware of his prosthesis until he wore a short-sleeved shirt. They displayed curiosity and then seemed to be very casual." <br /> "In many cases the fact that it is not a natural hand has had to be brought to their attention, even when it was worn without long sleeves." <br /> "Danny will start school this fall and the principal was amazed to see the hand. He said he had to look twice to make sure it was the same child. Danny's playmates were sure he had gotten a 'real' hand." <br /> "His friends are afraid of the hook. But with the hand, they will take hold of it and play games." <br /> "The child said she used to like the hook and wore it all the time, but now some of her friends don't like it and are afraid of it." <br /> "Her schoolmates noticed the change and they completely accepted it. Her sisters were quite proud and anxious for their friends to see she had a new hand." <br /> "When he played games with other children, most of them were afraid to hold his hook. Since he's worn the hand they aren't afraid." <br /> "Cindy is happy about the better attitude of the children around her, especially in school." <br /> "She said that one of her best friends 'almost fainted,' she was so delighted to see her with two hands." <br /> "The appearance has done wonders for her at school." <br /> "The children at school crowded around him and asked to see how it worked." <br /> "Her friends had called her 'Captain Hook' (when she wore the hook). Little ones cried and would run away from her, afraid. We actually had to bribe her to wear the hook to school. Now we have no difficulty getting her to wear her arm with the hand all the time." <br /> "Children don't call him names ('Captain Hook')." <br /> "School children are delighted and fascinated with the hand." <br /> ". . . interested because it is different; want to see how it works. Betsy will show it." <br /> "It is easier to hold on to when playing games." <br /> "The change from the hook to the hand caused a lot of questions to be asked at first. But it was soon accepted." <br /> "Danny wore the hand every day for two weeks and some of his classmates were not aware that it was not his own hand." </p> <p> Only a few <i>children</i> volunteered negative remarks: </p> <p> "His brother got scared of the hand, but later liked it." <br /> "Sister afraid of it at first." <br /> "Pammy (sister) thought it was a 'weirdy.' " </p> <p> <b>Attendance, Preparation, and Conduct in Class</b> </p> <p>The teachers' reports concerning the children's attendance, preparation, and conduct in class yielded very little information of significance. Only one child (a triple amputee) was considered below average in attendance as a result of absences related to his prosthesis. The factors of preparation for class and conduct showed slight changes in ratings from the first to the second questionnaire, but there were no differences specifically attributable to hand wear.</p> <p> <b>Friendships, Participation, and Leadership</b> </p> <p>Ten of the 16 children for whom teachers' questionnaires were available appeared to have achieved excellent to adequate adjustment and participation in class with both the hook and the experimental hand. Despite these satisfactory relationships, these children still found the appearance of the hand advantageous in the school setting as a means of decreasing social prejudice. Several of these 10 children remarked that their classmates were now more willing to hold hands in games and seemed friendlier. This pattern of increased acceptance tended to enhance the self-concept of the children in the study.</p> <p>Five children were reported as improved in class participation or friendships after being fitted with the artificial hand, although the prosthetic performance of two of this group was considered to have deteriorated. However, the improvement in appearance was obviously more important than the decrease in function. For this small group of children regardless of their skill in or amount of hand usage there was a discernible change in the type and extent of their social interactions. This took the form either of an increased number of social contacts with various children or of an improved relationship with one or two selected classmates.</p> <p>An example of the personal importance attached to the hand is apparent in the report of one child's physical therapist which describes his behavior after being fitted:</p> <p>"On the way back on the train, Randy patted his hand against his face and scratched the tip of his nose several times before settling down to sleep. Until then, he couldn't keep his eyes off it, and when he lay down he put the hand on his chest 'for all the world to see.' As we neared Bloomington, he wondered if we shouldn't go by the school because 'perhaps Mrs. Sheveland (the teacher) will still be there.'</p> <p>"After dinner he put his prosthesis on and toured the neighborhood to show everyone his hand. His mother reportedly was greatly pleased; so much so that she could not hold back the tears on more than one occasion during the evening, so that when Randy said his prayers, she had to leave the room. He wanted to wear his hand to bed but when his mother explained that it had to be put into the plastic bag, he accepted the explanation.</p> <p>"This morning he arrived at school in 'clam-digger' pants and a long-sleeved shirt. He had told his father yesterday that if he wore long-sleeved shirts no one would ever know his hand was not real."</p> <p>Other examples of the significance of the hand follow:</p> <p>"The teacher said the boy is actually using the hand more than he had ever used the hook. (This was in spite of the fact that all reports indicated that his functional capabilities with the hook were greatly superior.) His mother said, 'We were very pleased that he had the hand for his first Holy Communion.'</p> <p>"The nun said Randy did not need to hold hands in prayers or going to and from the altar, since she thought this might be a difficult thing to do, but he did as the other children were doing and was very proud."</p> <p>Another child, Sheila, had reconciled herself to the reluctance of other children to hold the hook:</p> <p>"Some children don't like to touch it (the hook), but I know a girl who has long fingernails and I don't like to touch her hands, either. When I first got it, I thought the kids in school will be surprised. They will think I don't belong in a crippled children's school!"</p> <p>Another child, Philip, used his artificial hand to shake hands.</p> <p>The last of the 16 children for whom data were available, a girl of 6, did not have a good relationship with her teacher or with the other children. There was no discernible improvement in the situation after she was fitted with a hand. Still, by the time of the second questionnaire report, she was somewhat more willing to display her prosthesis in public and make use of it.</p> <p> <b>Conclusion</b> </p> <p>Although there was no clear-cut evidence of widespread, dramatic changes in behavior attributable to the use of the APRL-Sierra Hand, the data all point in the direction of improved self-perceptions as well as better social attitudes and relationships. With the exception of the 10 per cent of the sample who rejected the hand for a variety of reasons, the remaining amputee children and their parents, teachers, and classmates reported a variety of positive social consequences related to hand wear. For the most part these reports referred to improved feelings, opinions, and attitudes of the subjects, although a small number of positive behavioral changes could also be documented. In general, the children themselves as well as their classmates and parents were socially more comfortable as a result of the introduction of the hand.</p> <p>The functional limitations of the hand in comparison to a hook will be documented in a subsequent article in Artificial Limbs. In contrast, the evidence concerning the cosmetic benefits of the device, particularly its concomitant psychosocial implications, is most impressive.</p> <h3>Results-Prescription Considerations</h3> <p> <b>Size of Sound Hand and Age</b> </p> <p>For the purposes of the Right-Hand Study, the No. 1 Hand was hypothesized as being appropriate for child amputees between the ages of 4 and 10. Consequently, experimental wearers were selected on the basis of this age range rather than of size. In the course of the study, however, it became apparent that the hand was undersized for many of the children selected.</p> <p>The clinics were then requested to report the following dimensions in all cases of noticeable discrepancy: circumference at the metacarpophalangeal knuckles, excluding the thumb, with hand in closed position (5% in, on the No. 1 Hand); and the length from the styloid process of the radius to the tip of the thumb (3 5/8 in. on the No. 1 Hand). Several clinics also reported hand dimensions of children for whom the No. 1 Hand was considered of appropriate size.</p> <p> <b>Table 4</b> presents the measurements of sound hands of children in the Right-Hand Study for whom the No. 1 Hand was too small; small, but acceptable; and well matched, according to the opinion of clinic personnel. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It would appear difficult to derive a precise range of sound-hand sizes or ages for which the No. 1 Hand provides an acceptable match. In one case, where the sound hand was 6 5/8 in. in circumference and 4 1/2 in. in length, the clinic rated the hand as unacceptably small, but in another instance it was considered suitable for a child whose hand was 7 1/4 in. in circumference and 4 1/2 in. in length. It should also be noted that while the majority of the "oversized" children were 8 years of age or older several younger children fell into this category. Furthermore, even hands regarded as unacceptably small by the clinics were retained by the children and worn, at least for dress, for several months longer.</p> <p>In the selection of candidates for the Left-Hand Study dimensions of the children's sound hands were taken into consideration. In general, an effort was made to accept as wearers only those children with a sound-hand circumference of not over 6 1/4 in. and a length up to 3 7/8 in. It was also anticipated that the majority of such children would fall into the age range of 4 to 8 years. As a consequence, there were few complaints about size in the Left-Hand Study.</p> <p>Christine, age 10, had sound-hand dimensions of 6 3/8 in. circumference and 3 7/8 in. length at the time of selection. These became 6 1/2 in. and 4 1/2 in. by the time of the four months' check and the clinic was then of the opinion that the hand was too small. Christine and her parents agreed, but strongly preferred even a poorly matched hand to the alternative of a hook. There were six other children in the sample with sound hands of excessive circumference or length, i.e., larger than 6 1/4 in. in circumference and 3 7/8 in. in length. There was indication that all the children in this group were not completely satisfied with the size of the No. 1 Hand, but their lack of enthusiasm was generally expressed in the comment, "a little small, but still all right."</p> <p>Thus, as a general guide in considering the prescription of a No. 1 Hand, it is possible to state:</p> <blockquote><p>For children whose remaining hand dimensions do not exceed 6 1/4 in. in circumference and 3 7/8 in. in length, the No. 1 Hand can probably be fitted without objectionable size disparity. Naturally the closer the children are to this level when fitted the faster they will outgrow the No. 1 Hand. 2. Children with these hand dimensions will typically fall into the age range from large 3-year-olds to small 8-year-olds, with a predominance of 4- to 6-year-olds. However, considerations of hand weight and operating forces may exclude some children at the lower end of this age range.</p> </blockquote> <p> <b>Clinic Opinions</b> </p> <p>Clinic opinions concerning various aspects of the No. 1 Hand were obtained in both phases of the study. Clinic personnel were also asked to express themselves on the question: "Are there any contraindications to prescribing this hand (age, sex, performance, etc.)?" Responses, however, were confined primarily to the experiences of the particular child under observation as each questionnaire was completed. Hence the comments made were essentially confirmatory of information gathered from other sources.</p> <p>Expressions of a general attitude toward prescription and use of the No. 1 Hand were relatively rare. Thus, it is possible that the typical reaction of the clinics participating in the study was one of reservation concerning the experimental item-of not wishing to take a strongly positive or negative position until more experience had been acquired and "all the returns were in."</p> <p>This situation reflects the fact that the majority of the clinics participating in the program appeared to be "functionally oriented," some of them strongly so. Hence, a device which historically and in fact provides lesser function was likely to be viewed with skepticism. Some clinics were also concerned about the initial cost of the hand and glove and the expense of repairs and replacements particularly of the glove.</p> <p>If this interpretation of the prevailing frame of reference is correct, such comments as were made concerning "contraindications to prescription" take on added significance by their infrequent occurrence. To cite the Left-Hand Study data again: For only nine of the 36 children discussed was dissatisfaction with some aspect of the hand strong enough to be mentioned as a possible contraindication to use. These instances were:</p> <table> <tbody><tr> <td> <p><b>No. of Children</b></p> </td> <td> <p><b>Contraindications</b></p> </td> </tr> <tr> <td>2</td> <td> <p>Discrepancy in size</p> </td> </tr> <tr> <td>2</td> <td> <p>Frequent breakage or malfunction</p> </td> </tr> <tr> <td>2</td> <td> <p>Force requirements excessive for particular child</p> </td> </tr> <tr> <td>1</td> <td> <p>Functional limitation as compared with hook</p> </td> </tr> <tr> <td>1</td> <td> <p>Rapid wear of glove a possible contraindication for a wry active child</p> </td> </tr> <tr> <td> 1 <a></a> </td> <td> <p>Emotional difficulty</p> </td> </tr> </tbody></table> <p>Excerpts from a letter written by one of the clinic chiefs might be appropriate as a summary statement of prescription considerations. His comments not only reaffirm reactions to the hand which appear to have been fairly typical, but also express an approach to prescription which seems to be conservative yet reasonable:</p> <p>"The mother's comment with regard to cosmesis is that the hand is 'beautiful.' She is perfectly willing to go to all extremes in cosmetic appreciation. The mother feels that the child's reaction to the appearance of the hand was one of 'being proud of it.' This was exemplified by the child's desire to always wear the hand at school. It was interesting to me that, after approximately six months of wear, Debra was anxious to wear the hand all the time and not to wear the hook any more. However, in the recent episode, when the hand became no longer functional, she was perfectly agreeable to return to the use of the hook. This is particularly interesting to me, because the mother feels that Debra actually lost no function in the transition from the hook to the hand.</p> <p>"At age 6, Debra learned to operate the thumb adjustment and, as a consequence, was able to continue with the prosthetic hand as the assisting side at school in such functions as holding a book while reading so that she could turn the pages with her normal hand; holding papers while writing; and holding papers while cutting. At home, she was able to hold fork and knife with the prosthetic hand but, at age 7, is still able to cut only soft meat, such as a hamburger. She uses the hand in all bi-manual activity.</p> <p> "Our own opinion here is that we will prescribe this hand for children who are already using a hook. In the unilateral case where there is reasonable dexterity, I feel that with the prosthetic side being the assisting side we can sacrifice the minimal loss of function which one <a style="text-decoration:none;">*</a> probably gets in the transition from hook to hand. The only criticism is the amount of force necessary to operate the hand." </p> <h3>Acknowledgments</h3> <p>The late Dr. Carleton Dean, former Director of the Michigan Crippled Children Commission, played a prominent role in the early stages of the child's hand program, particularly in the procurement of the experimental units. Colonel Maurice J. Fletcher, Dr. Fred Leonard, Colonel John Butchkosky, and Victor T. Riblett, of the Army Prosthetics Research Laboratory, were responsible for the development of the hand and assisted in the resolution of problems encountered in the study. To all these gentlemen, we express our appreciation.</p> <p>We also acknowledge the valuable cooperation and assistance of the children and personnel associated with the clinics participating in the Child Amputee Research Program.</p> <p>Roberta Bernstein, Alfred Brooks, Herbert Bursky, Bertram Litt, Deborah Osborne, and Dr. Edward Peizer, staff members of New York University Child Prosthetic Studies, have also made significant contributions at various stages during the development and testing of the APRL-Sierra Child Size No. 1 Hand and in the preparation of the report upon which this article and a subsequent article to appear in the Autumn 1964 issue of Artificial Limbs are based.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Child holding swing with artificial hand.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector VV. Kay,<i>Acceptability of a functional-cosmetic artificial hand for young children</i>,Child Prosthetic Studies, Research Division, College of Engineering, New York University, January 1964.</li> <li>Fletcher, M. J., and Fred Leonard,<i>The principles of artificial-hand design</i>, Artificial Limbs, May 1955, p. 78.</li> <li>National Academy of Sciences-National Research Council, Final <i>summary report, APRL-Sierra Child-Size Hand, Size 1, Model A,</i> March 1961.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, field test-APRL-Sierra Child Size No. 1 Hand {right)</i>, October 1960.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, field test-APRL-Sierra Chili Size Model 1 hand (right)</i>, May 1961.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, APRL-Sierra No. 1 Hand {left)</i>, October 1962.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Memorandum report: preliminary considerations of the APRL-Sierra Child Size Model 1A Hand (left)</i>, May 1961.</li> <li>S. Peizer, Edward,<i>The clinical treatment of juvenile amputees, 1953-1956</i>, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">One clinic felt strongly that prescription would be a dubious practice where cosmesis was highly important for child and parent if the next larger hand size was unavailable later.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">S. Peizer, Edward,The clinical treatment of juvenile amputees, 1953-1956, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">S. Peizer, Edward,The clinical treatment of juvenile amputees, 1953-1956, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Area Child Amputee Center, Michigan Crippled Children Commission, Grand Rapids, Mich. Amputee Clinic, Childrens Division, Institute of Physical Medicine and Rehabilitation, New York, N. Y., Amputee Clinic, Newington Hospital for Crippled Children, Newington, Conn., University of Illinois Amputee Clinic, Chicago, Ill., Birmingham Child Amputee Clinic, Birmingham, Ala., Duke Orthopedic Amputee Clinic, Duke Medical Center, Durham, N. C, Georgia Juvenile Amputee Clinic, Crippled Childrens Service, Emory University Branch, Atlanta, Ga., Amputee Clinic, Childrens Rehabilitation Center, Buffalo, N. Y., Child Amputee Prosthetics Project, University of California Medical Center, Los Angeles, Calif., Amputation Clinic, Kernan Hospital, Baltimore, Md., Child Amputee Prosthetic and Congenital Deficiency Clinic, Childrens Orthopedic Hospital, Seattle, Wash., Juvenile Amputee Clinic, Florida Crippled Childrens Commission, Orlando, Fla., Amputee Clinic, Home for Crippled Children, Pittsburgh, Pa., Child Amputee Clinic, State Hospital for Crippled Children, Elizabeth-town, Pa., Juvenile Amputee Clinic, Crippled Childrens Hospital, New Orleans, La.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, APRL-Sierra No. 1 Hand {left), October 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Memorandum report: preliminary considerations of the APRL-Sierra Child Size Model 1A Hand (left), May 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, field test-APRL-Sierra Chili Size Model 1 hand (right), May 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, field test-APRL-Sierra Child Size No. 1 Hand {right), October 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">San Francisco, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Costa Mesa, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Sierra Madre, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fletcher, M. J., and Fred Leonard,The principles of artificial-hand design, Artificial Limbs, May 1955, p. 78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York 10, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York 10, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-02.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-03.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-04.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-05.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-06.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-01.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-07.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 Acceptability of a Functional-Cosmetic Artificial Hand for Young Children, Part I Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/2ba44c5f9ec8c60d3a6423ce01cae5b9.pdf a43fa5236221ccee26a9e5f795227879 https://staging.drfop.org/files/original/9847a895cbb0e47c889cc46b60067737.jpg 174af1515ac8068d3ba651a0676237c2 https://staging.drfop.org/files/original/54cec80f0cecce2e15a82d15081386fa.jpg 268a5deb1dfa2e91ec39e0cda5df9553 https://staging.drfop.org/files/original/cfb040cf84ed9ddf06a4f4bd0d669e8e.jpg 03e8d28df85de2b168de9603bde28d7a https://staging.drfop.org/files/original/318951cdb08cfadc6743ddec4e2731bd.jpg b3cd9eccd9455a345c9ad40f33434a7b https://staging.drfop.org/files/original/62b69d04e8bccad2110030b6b195b6da.jpg c8cdc886c8007ff14e3b4a6fb297c18b https://staging.drfop.org/files/original/6e618a8e4eb7f870507fc74e9dee010f.jpg cccc1fb60da16baf073ba3b9ab9c9710 https://staging.drfop.org/files/original/cd1a4279ea6056e85574a9669843fcd4.jpg 2498b1a659d3ba96b364efe3b8d49b3e https://staging.drfop.org/files/original/bf816b1898815a58c6d64beee92479d4.jpg 8b9e0b5f10a159cb742c129c41ede96f https://staging.drfop.org/files/original/a897c85ba11ff91431544e7f1b757f99.jpg f74eb3b7381ab64121ff3a6577980d2e https://staging.drfop.org/files/original/798f29058b5c15bebdfda8ba6af5110d.jpg 3d0d619d882104d2335f773d7cd1d622 https://staging.drfop.org/files/original/46d27e76db81864a24330ff3846bd3c9.jpg 2b88d140aa0566a6759afdc3509eecac DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_015.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 15 - 27 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Acceptability of Functional-Cosmetic Artificial Hand for Young Children, Part II</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p> In the study of the APRL Sierra No. 1 right hand, which preceded that of the left, the results of comparative performance testing indicated that there was little difference between the hand and the hook on the various test activities. Statements of children participating in the study and of their parents indicated a relatively high level of performance with the experimental hand, but advantages and disadvantages were not clearly defined. </p> <p> These results appeared to be at variance with past clinical impressions, which indicated that a significantly less functional terminal device than a hook. Hence, in the Left Hand Study the performance tests were repeated to check the results of the earlier study. An attempt wa hand wasas also made to delineate more completely the relative usefulness of the two devices by obtaining data concerning their effectiveness in a wide variety of activities. </p> <h3> Performance Tests</h3> <p> As indicated in Part I of this two part series of articles, the child amputees participating in these studies were required to make four visits to the clinics servicing them, during a period of five months. The first visit was a screening session to select suiTable candidates; on the second visit the child was fitted with the experimental hand; the third visit, two months after the fitting, was for the purpose of making evaluative comparisons between the old and the new terminal devices; and the purpose of the fourth visit, four months after the fitting, was to make a final evaluation. </p> <p> A prosthetic performance test, utilizing the old terminal device, was given the child on the second visit. On the third visit the same performance test was administered, utilizing first the APRL Sierra hand and then the old terminal device. The prosthetic performance test required the child to perform six activities, upon each of which he was timed and rated. The activities were: </p> <ol> <li>Unscrewing and reassembling five small plastic barrels ("Kitty in the Kegs") (<b>Fig. 1</b>)</li><li>Drying a wet cup, saucer, and dinner plate, using a dish towel (<b>Fig. 2</b>). </li><li>Putting on a shirt or dress as appropriate and shoes and socks (<b>Fig. 3</b>). </li><li>Assembling a jointed doll ("Loony Links") (<b>Fig. 4</b>). </li><li>Cutting out a printed figure and pasting it to a piece of paper (<b>Fig. 5</b>). </li><li>Eating ice cream from a paper cup, using a metal spoon (<b>Fig. 6</b>). </li></ol> <p> Typically, the test was administered by an occupational therapist. The rating scale employed ranged downward from a score of 5 for performance approximating that of a nonamputee to 1 for performance in which the terminal device was not used, in accordance with the following subjective criteria: </p> <table> <tbody><tr><th><p>Rating</p> </th><th><p>Criteria</p> </th> </tr><tr><td> <p> </p><p>5</p> <p></p> </td> <td> <p> </p><p>A nearly normal bilateral performance in which the terminal device seems essential; that is, it is used to perform active functions in addition to and more advanced than holding, such as grasp and transportation and manipulation of the object. </p> <p></p> </td> </tr> <tr><td> <p> </p><p>4</p> <p></p> </td> <td> <p> </p><p>A bilateral pattern in which the terminal device is a significant aid in grasping or hooking.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>3</p> <p></p> </td> <td> <p> </p><p>The terminal device is used for occasional grasping only, alternating with passive use.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>2</p> <p></p> </td> <td> <p> </p><p>The terminal device is used passively for pushing, weighting, or support, but not for grasp.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>1</p> <p></p> </td> <td> <p> </p><p>The terminal device is not used, although the elbow and forearm may be used as an aid. Ratings of 1.5, 2.5, 3.5, and 4.5 were interpolated to indicate performance whose quality was between two categories.</p> <p></p> </td> </tr> </tbody></table> <p> Each child's performances with hook and hand were compared on the basis of best scores obtained while utilizing each device. In the Left Hand Study performance times with each device were also obtained. The comparative data are presented in Tables <b>Table 1</b>, <b>Table 2</b>, and <b>Table 3</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There are obvious limitations to these data, in that the tests may have differed with individual children (the type of clothing donned, for example), and there were undoubtedly differences in the frames of reference employed by different therapists in rating a given performance. Since the data themselves are of doubtful precision, the application of tests of statistical precision is not indicated. Within these limitations, however, there is evidence that: </p> <ol> <li>Mean performance ratings in all activities were higher for the hook (<b>Table 1</b>), which clearly appeared to be the better device functionally. Its superiority was most evident in the test activities of "Put on Clothes" and "Cut and Paste." The smallest differences in mean ratings were found in the "Kitty in the Kegs" and "Loony Links" tests. Both of these latter activities involve the grasping of objects for which the active fingers and thumb of the hand are relatively well adapted.</li><li>In a total of 408 hook and hand performance comparisons shown in (<b>Table 2</b>) (68 children performing 6 activities with each device), hook performance was rated as superior in almost half the instances (189 times). Interestingly enough, however, hook and hand performances were rated as equal almost as frequently (184 times), although hand performance was considered better in only a relatively insignificant number of cases ²⁹. In this tabulation of the data also, the superiority of the hook appears less marked in the same two test items "Kitty in the Kegs" and "Loony Links." </li><li>The comparative time data (<b>Table 3</b>) indicate that in the majority of instances hook performance was faster as well as more effective than hand performance, although again the results are by no means unanimous.</li></ol> <p> It is interesting to note (<b>Table 1</b> and <b>Table 2</b>) that in the Left Hand Study the performance ratings more clearly reflected the functional superiority of the hook than was the case in the tests with the right hand. For example, only seven children of 32 were rated as performing the "Kitty in the Kegs" test better with the hook in the Right Hand Study. In contrast, 17 of 36 children had better ratings utilizing the hook in this activity in the Left Hand Study. A similar marked difference in comparative ratings is evident in the "Loony Links" task. In the other test activities, the differences diminished until in the "Eat Ice Cream" item the right and left hand data are almost identical. </p> <p> The reasons for these differences are not clear. The subjectivity of the rating scale may, of course, have been a consideration. However, since the trend of the data is consistent, that is, favoring higher comparative hook ratings in the Left Hand Study, it would appear that other than chance factors are operative. </p> <p> Handedness might possibly be a factor, but unfortunately data on this variable were not obtained in the study. It is also possible that in the earlier Right Hand Study the raters were affected by a "halo" factor which had diminished by the time of the later Left Hand Study. </p> <h3> Functional Preferences</h3> <p> In studying child and parent opinions concerning the function provided by the No. 1 hand in comparison to that available in standard hooks, the task is complicated by the strong emotional factors involved. In many instances the excellent acceptance of hand appearance clearly tended to influence the answers to questions concerning its function. In interpreting the responses of children and their parents, therefore, it must be borne in mind that the hand was almost three times as heavy as the hook previously worn by the children; and although operating forces to initiate opening were only somewhat higher than for the hook, the forces required to obtain full opening were significantly higher two factors which should make use of the hand more difficult.<a style="text-decoration:none;">*</a> Pertinent comparative data are presented in (<b>Table 4</b>). Thus, when children report, as some do, that the hand is lighter and easier to operate. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The presentation which follows is based primarily on data from the Left Hand Study, but these are supplemented where appropriate by evidence from the preceding Right Hand Study. </p> <p> All 39 children and parents in the Left Hand Study were asked, "With which terminal device is the child able to perform more activities?" The answers were: </p> <table> <tbody><tr><td> <p> </p> </td> <td> <p>  | Hook |</p> </td> <td> <p>| Hand |</p> </td> <td> <p> | No Preference |</p> </td> </tr> <tr><td> <p>Children</p> </td> <td> <p>    18</p> </td> <td> <p>  14</p> </td> <td> <p>   7 </p> </td> </tr> <tr><td> <p>Parents</p> </td> <td> <p>    16</p> </td> <td> <p>  9</p> </td> <td> <p>  14</p> </td> </tr> </tbody></table> <p> However, two children and two parents in the no preference category added statements which suggested that the hook provided more function and that their no preference choice was motivated by a balance between hook function and the cosmetic appeal of the hand either to the child or to the parent. Furthermore, some children who rated the function of the hand as better than that of the hook made comments indicating the reverse. Joseph: "The hand is heavier and harder." Robin: "The hand can do a couple of things but not too many things." Linda: "The hand is heavier and harder but I like the way it works." The therapist said that this girl's answer was motivated by a strong desire to keep the hand. </p> <p> However, several children who preferred the function of the hand were able to back up their choice by specific examples. Susan, a young above elbow amputee, said the hand was easier to don, better for washing dishes, for holding paper, and to pick things up. Rodney, also an above elbow amputee with an unfitted paraxial hemimelia (ulnar) on the contralateral (right) side, said the hand was heavier but easier to operate. His therapist said the hand did not afford Rodney greater function but he was much more eager to use it. This greater enthusiasm was also noted in Susan, the above elbow amputee previously mentioned. The greater motivation to use the hand on the part of both these youngsters may have actually resulted in a higher level of functioning! </p> <p> Fourteen of the 39 children fitted with the No. 1 left hand reported it to be as heavy as or heavier than their hook, and 17 found it hard to open or otherwise more difficult to operate than their hook had been. There seemed to be a significant relationship here with age, as indicated by the fact that of 17 children, ages 3 to 5, eight found the hand heavy, while of 22 children, ages 6 to 10, only six reported that the hand was heavy. Of those who stated that the hand was difficult to operate, ten were in the 4 to 5 age bracket and only five were in the 6 to 10 age group. </p> <p> A relationship to amputation level was also apparent. The one shoulder disarticulation amputee found the weight accepTable but the hand too hard to operate. He retained the hand, nevertheless, for cosmetic reasons. Of the five above elbow amputees, four found the hand heavy and difficult to operate, and the remaining child rejected it after less than two months' wear. In contrast to these negative reports, two above elbow amputees, only 5 years old, were among those who were most highly motivated to use the prostheses with the hand device. </p> <p> The combination of youth and a higher level of amputation made the use of the hand much too difficult for the youngest child in the study, an elbow disarticulation case who was barely 4 years old when fitted. Consequently, at the conclusion of the study he was wearing the hand only for special occasions. Of the four wrist disarticulation amputees, the two 4 year olds found the hand a little heavy and difficult to operate, while two 8 year olds advised that both weight and operating forces were satisfactory. </p> <h3> Specific Types of Grasp </h3> <p> In the Right Hand Study a general comparison of the functional qualities of hand and hook, based on child and parent opinions, had yielded indecisive results. Therefore, in the Left Hand Study children and parents were requested to rate the suitability of both the old terminal device (hook) and the No. 1 hand, not only for grasping objects in general but also for eleven specific types of grasp or activity areas. Explanatory comments concerning terminal device use for each specific function were also solicited. The eleven activity areas were: </p> <ol> <li>Carrying objects, such as school bags, purses, lunch pails, etc.</li><li>Grasping or picking up very small elongated objects, such as pins, paper clips, etc,</li><li>Grasping or picking up small elongated objects, such as pencils, scissors, etc.</li><li>Grasping paper.</li><li>Grasping or holding soft objects, such as sandwiches, toothpaste tubes, etc.</li><li>Grasping or holding a drinking glass.</li><li>Using silverware while eating.</li><li>Grasping large bulky objects, such as paste jars, books, balls, etc.</li><li>Grasping objects such as bicycle handles, swing chains or ropes, etc.</li><li>Putting on clothes, such as shirts, blouses, etc.</li><li>Putting on shoes and socks.</li></ol> <p> Many of these areas involve the performance of a number of discrete activities. Hence, the data obtained not only provide bases for comparison of hand and hook functions but also supply considerable general information concerning the activities of children with upper extremity prostheses. Since this information may be of significance to clinic personnel, especially to therapists and to persons concerned with the development of devices for children with arm amputations, the data relating to each of the activity areas are presented in some detail (<b>Fig. 7</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Carrying a school bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Carrying objects, such as school bags, purses, lunch pails, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   0</p> </td> <td> <p>   6</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   4</p> </td> <td> <p>   8</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   0</p> </td> <td> <p>   3</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p>Approximately four fifths of the children reported the hook as satisfactory for carrying objects with handles, while only half found the hand satisfactory. Parents, on the other hand, believed the hook and hand functioned about equally well for holding these objects. Where difficulty was experienced with the hand, it was usually because the objects carried were too heavy for the amount of "Bac Loc" provided. Illustrative comments follow. Betsy: "The hand doesn't let me hold heavy things." Linda's mother: "Buckets, lunch pails, and anything of metal or plastic that is heavy slip from her grasp." Gabriel's mother: "The hand is satisfactory provided the handle is not too thick and the object not too heavy." </p> <h5><i>Grasping or picking up very small elongated objects, such as pins, paper clips, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   23</p> </td> <td> <p>   4</p> </td> <td> <p>   9</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   15</p> </td> <td> <p>   13</p> </td> <td> <p>   6</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   20</p> </td> <td> <p>   11</p> </td> <td> <p>   6</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   12</p> </td> <td> <p>   16</p> </td> <td> <p>   10</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> More than half the subjects and parents rated the hook as satisfactory for picking up very small objects. The hand was considered adequate for this function by only about a third of the children and parents. Some children pointed out that the hand was satisfactory for holding very small objects but not for picking them up (<b>Fig. 8</b>). One parent suggested that the child's vision was blocked by the rest of the hand, another that the floating fingers were in the way. Some of the illustrative remarks are quoted. John: "Nails but not pins." Susanne: "I have to hold the object in the other hand to pick it up." Danny's mother: "Too much effort and concentration."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Holding a safety pin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping or picking up small objects, such as pencils, scissors, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   30</p> </td> <td> <p>   1</p> </td> <td> <p>   4</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   26</p> </td> <td> <p>   7</p> </td> <td> <p>   2</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   2</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   6</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Three fourths of the children and parents considered the hook satisfactory for this function, while a slightly smaller proportion also found the hand satisfactory. The objects given particular attention within this category of use were scissors, pencils, crayons, hammers, and put together toys. </p> <p> It was apparently impossible to cut with ordinary scissors held in either a hook or an artificial hand. Thus, unilateral amputees held scissors in their good hand, while bilaterally involved children could not use them at all unless the scissors were especially modified. </p> <p> Concerning pencils, the reports were mixed, with some children rating the hook better for picking up and holding pencils, but with more subjects preferring the hand (<b>Fig. 9</b>). Some illustrative comments follow. Jeff: "I can hold a pencil better with the hook." Danny: "The hand holds a pencil better for sharpening." Randy: "I can pick up pencils easier with the hand." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Holding a pencil. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Only one or two of the children with unilateral amputations made reference to writing with the prosthesis, although this was, of course, necessary for bilateral amputees. In general, the hook was favored for writing. Gail: "I can write better with a hook." Randy's teacher: "He is more secure doing written work when he wears hooks." (Randy is a bilateral upper extremity amputee.) </p> <p> There were only two references to hammers, one favoring each terminal device. Concerning put together toys there were two statements, both favoring the hook. </p> <p> In summary, scissors appeared to be difficult, if not impossible, to grasp with either hook or hand, pencils somewhat easier to handle with the hand, and put together toys easier with the hook, and possibly writing also. </p> <h5><i>Grasping paper</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   37</p> </td> <td> <p>   0</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   30</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   34</p> </td> <td> <p>   2</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p> Nearly all children rated both the hook and hand as satisfactory, with only four rating the hand as unsatisfactory (<b>Fig. 10</b>). Almost all the parents considered both devices satisfactory. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Grasping paper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The comments indicated that grasping paper was not one function but several, each calling for a different application of the terminal device. Involved were such tasks as holding paper for cutting with scissors, holding paper on a desk for writing, picking up paper, selecting one sheet from many, holding playing cards for card games, etc. </p> <p> Two children cited holding paper to cut with scissors to explain their rating of the hook as satisfactory, but in both cases they considered the hand also suiTable for this purpose. The therapist of a third child (Susan) felt that the hand was less helpful: "When cutting paper, Susan usually places the paper in the hook. With the hand she seldom places the paper in the hand; it seems to crush the paper and hold it in an awkward position." Susan herself regarded both devices as satisfactory for grasping paper. </p> <p> The hand was considered better for holding paper on a Table or desk while writing (<b>Fig. 11</b>). Sean's mother: "With the hook the paper tends to slip resulting in ragged print." Danny: "The hand holds down paper better for writing." Gail's mother: "School paperwork seems to be neater with the hand because the paper doesn't slip." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Holding paper while writing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Several remarks seemed to indicate that the hand was better for picking up paper, but one bilateral amputee mentioned difficulty in selecting one sheet from many. </p> <p> Concerning holding playing cards for various games, Susan's therapist made the following comment: "Playing card games is an activity which is performed better with the hand. It is in a better holding position and the cards come out easier when she is taking them from the hand." </p> <h5><i>Grasping or holding soft objects, such as sandwiches, toothpaste tubes, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   20</p> </td> <td> <p>   9</p> </td> <td> <p>   9</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   13</p> </td> <td> <p>   10</p> </td> <td> <p>   12</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   21</p> </td> <td> <p>   10</p> </td> <td> <p>   5</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   24</p> </td> <td> <p>   9</p> </td> <td> <p>   5</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p>Half the children rated the hook as satisfactory, but the number dropped to a third for the hand. Half the parents considered the hook as suiTable and a slightly greater number rated the hand as adequate. More children than parents reported that neither device was used for grasping soft objects. </p> <p>Picking up and holding a tube of toothpaste apparently presented no problem, but difficulties arose with sandwiches, cookies, candy bars, marshmallows, grapes, or raw eggs, all of which were usually held in the sound hand. The majority of the children experienced difficulty in holding soft objects with either device. Debra: "The hand squashes it and I can't eat it the hand squashes the sandwich." Joseph: "The hook might squash them; the hand can pick it up but I'll smash it." There were some children who made comments favoring the hand. Danny: "With the hand I can gel a sandwich better without squeezing it" (<b>Fig. 12</b>). Mother of Randy (triple amputee): "Eating sandwiches is a treat which he was unable to do with hooks." However, a larger number preferred the hook for this purpose. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Grasping a sandwich. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping or holding a drinking glass</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   8</p> </td> <td> <p>   8</p> </td> <td> <p>   18</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   7</p> </td> <td> <p>   12</p> </td> <td> <p>   16</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   13</p> </td> <td> <p>   8</p> </td> <td> <p>   13</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   12</p> </td> <td> <p>   11</p> </td> <td> <p>   15</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Less than a fourth of the subjects rated either hook or hand as satisfactory for holding a drinking glass. The parents were slightly more positive, a third of them rating both hook and hand as suitable. Several of the children who gave a rating of satisfactory explained that they would use a terminal device only to hold a glass by the rim when filling it with water or to carry it while setting the table. </p> <p> Comparisons between hook and hand were few. Some children stated that the hand did not open wide enough for available glasses or that the glass slipped. Two others, however, stated that the hand had a better grip and did not slip. Small opening and slippage were problems also reported with hooks. The general impression is that even children who rated a terminal device as satisfactory for holding a drinking glass were merely claiming they could hold a glass as a special feat, not as a commonly used skill (<b>Fig. 13</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Grasping a paper cup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Using silverware while eating</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   13</p> </td> <td> <p>   2</p> </td> <td> <p>   22</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   15</p> </td> <td> <p>   2</p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> <td> <p>   14</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   2</p> </td> <td> <p>   16</p> </td> <td> <p>   0</p> </td> </tr> </tbody></table> <p> Approximately a third of the children and half of the parents rated both hook and hand as satisfactory for holding silverware, while half of the children and a third of the parents indicated that neither device was used for the purpose. The slight differences favored the hand. With the exception of three bilateral arm amputees, the children who answered this question were left arm amputees. It appears likely that they used the terminal device only for holding a fork while cutting meat (<b>Fig. 14</b>), although one or two held a spoon in the terminal device also. Many children, even some who regarded a terminal device as satisfactory, reported that the parents usually cut their meat for them. Particular mention was made of problems of slippage, of difficulty of positioning, the better appearance of the hand performance, and the need for practice.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Holding a fork. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping large bulky objects, such as paste jars, books, balls, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   30</p> </td> <td> <p>   4</p> </td> <td> <p>   2</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   18</p> </td> <td> <p>   12</p> </td> <td> <p>   3</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   6</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Three fourths of the children rated the hook as satisfactory, but only half found the hand so. The same proportion of parents rated both hand and hook as satisfactory. </p> <p> The intention of the question was to determine whether the smaller opening provided by the hand was a disadvantage in actual use. The specifications of the No. 1 hand require that a minimum full opening of 2 in. be attainable with the thumb in the wide opening position, but most hands exceeded the specification to a maximum of approximately 2 3/8 in. However, there were indications that several children utilized the small, 1 1/2 in. opening only and did not bother to change the thumb position. A Dorrance 10X hook, by comparison, provided a 3 in. opening and the Dorrance 99X hook a 3 1/2 in. opening. </p> <p> A number of children and parents specifically mentioned holding baseball bats, balls, paste jars, books, boxes, dolls, and a see saw. Curtis: "With the hand, I can hold the bat better when I play ball." Glenda's mother: "Bats the ball using both hands now." Comments indicated that the hook was superior for throwing balls, but the hand was satisfactory for catching them in two handed fashion. In general, though, the children found it difficult to grasp balls with either the hook or the hand (<b>Fig. 15</b>). The hook was somewhat better for holding paste jars. Books, boxes, paper cups, and dolls (<b>Fig. 16</b>) were better held with the hook, but one boy said riding a see saw was easier with the hand. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Holding a large ball. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Holding a doll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping objects such as bicycle handles, swing chains or ropes, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   24</p> </td> <td> <p>   3</p> </td> <td> <p>   7</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   36</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   33</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p> Most children and parents rated the hook as suitable, but some children stated that the hand was unsatisfactory or not used for these activities. Confusion may have existed because of the separate uses; several of the children played on swings but did not ride a bicycle or tricycle. The hook was more often preferred for holding a swing chain, but preference was evenly divided for riding a bicycle (<b>Fig. 17</b>). Several parents felt that the hand grasp appeared more natural. There was concern about the danger of tearing the glove or breaking the thumb of the hand on a swing chain. Other activities mentioned under this heading were climbing monkey bars and holding a jump rope, a broom and a hoe, or a bow for archery. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Holding a bicycle handle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Putting on clothes, such as shirt, blouse, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   27</p> </td> <td> <p>   1</p> </td> <td> <p>   8</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   3</p> </td> <td> <p>   9</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   29</p> </td> <td> <p>   2</p> </td> <td> <p>   6</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   30</p> </td> <td> <p>   1</p> </td> <td> <p>   7</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p>Two-thirds of the children and parents rated the hook as satisfactory, but only half the children considered the hand as satisfactory for this purpose. Several children who considered both devices as satisfactory commented that they were usually dressed, or were assisted in dressing, by their mothers. There were more comments favoring the hook than the hand; the glove tended to stick to cloth and there was glove discoloration attributed to contact with clothing, particularly from red dyes.</p> <h5><i>Putting on shoes and socks</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   24</p> </td> <td> <p>   3</p> </td> <td> <p>   9</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> <td> <p>   11</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   29</p> </td> <td> <p>   3</p> </td> <td> <p>   6</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   3</p> </td> <td> <p>   7</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Two thirds of the children and the parents rated the hook as satisfactory, but less than half of the former considered the hand satisfactory (<b>Fig. 18</b>). A fourth of the children stated that they did not use either device to put on shoes and socks, and the number who did not tie shoelaces with prostheses was undoubtedly much higher. Timothy, for example, said that he did not know how to tie shoelaces and that his mother dressed him, but he and his mother rated both devices as suiTable for putting on shoes. Another reason given for parental assistance was that the child consumed too much time in dressing himself. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Putting on shoes and socks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Conclusions</h3> <p> In spite of the wide differences in the opinions expressed by the children and parents participating in the study, it was apparent that: </p> <ol> <li>The APRL Sierra No 1 hand was heavier and in most instances more difficult to operate than the previously worn hook, but for the majority of subjects in the sample these were not serious drawbacks. Those with shoulder disarticulation amputations and to a lesser extent some of the younger children and above elbow amputees were most likely to have difficulty with weight and operating forces. It is obvious, of course, that if the hand were lighter and had a more efficient operating ratio, it would be more accepTable to all.</li><li>The hand provided somewhat less pinch force than most of the hooks and a less precise grasp. The majority of children reported that they could perform more activities better with the hook; however, many could also specify a number of activities that were performed better with the hand. The latter was preferred somewhat more often for tasks such as picking up a pencil, grasping paper, and holding silverware for eating. The majority of the children and their parents considered the hand as "adequate" to "very satisfactory" for a wide range of activities.</li></ol> <h3>Acknowledgments</h3> <p> In Part I of this series of articles, grateful acknowledgments were made to the clinics participating in the Child Amputee Research Program and to a number of persons for valuable cooperation and assistance in the conduct of these studies and in the preparation of the report. We again express our sincere appreciation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "Kitty in the Kegs," a set of small plastic barrels, one inside the other. A picture of a kitten is in the innermost barre. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Drying Dishes </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Putting on clothes. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Loony Links." The child is asked to assemble a jointed doll and stand it on its feel, using a preassembled doll as a model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cutting and pasting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Eating ice cream. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, <i>Acceptability of a functional-cosmetic artificial hand for young children, </i>Child Prosthetic Studies, Research Division, College of Engineering, New York University, January 1964.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Actual pinch forces in the hooks worn by children in the study were not obtained. However, recommended forces for the age group are: below elbow, 3 1/2lb, above elbow, 3 lb. than the previously worn hook, the data must be questioned. Nevertheless, conservative interpretation of the available information does provide insight not only into hand usage but also into terminal device function in general.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York, N.Y. 10010.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St , New York, N.Y. 10010.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-07.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-08.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-09.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-10.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-11.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-12.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-13.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 Acceptability of Functional-Cosmetic Artificial Hand for Young Children, Part II Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Hector W. Kay, M.Ed. * 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.&nbsp;<a style="text-decoration: none;">*</a><br />Susan S. Lin, O.T.R.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>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"><b>Fig. 1</b></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"><b>Fig. 2</b></a>). Unfortunately, formal training for the aforementioned professionals provides very little, if any, information for the evaluation, assessment, and design of adaptive seating systems.</p> <strong><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.<br /></strong><br /> <h3>Development</h3> <p>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.</p> <p>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.</p> <h3>Education</h3> <p>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.</p> <p>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.</p> <h3>Information Collection</h3> <p>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.</p> <p>The following <i>In-take</i> 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"><b>Fig. 3</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-4.jpg"><b>Fig. 4</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-5.jpg"><b>Fig. 5</b></a>, and<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-6.jpg"> <b>Fig. 6</b></a>).</p> <h3>One Approach To Adaptive Equipment Provision</h3> <p>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.</p> <p>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.</p> <p>Prior to the first patient evaluation, the <i>In-take</i> 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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p><em><b>*Susan S. Lin, O.T.R. </b> 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.</em></p> <p><em><b>*Robert S. Lin, C.P.O. </b> Robert Lin is the Clinical Coordinator of Orthotics at Newington Children's Hospital, 181 East Cedar Street, Newington, Connecticut 06111.<br /><br /><br /></em></p> 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/181a62dbeea14fc8cb1883736bd6f417.pdf 090f8bf2b70b72c4c5b835bebc2ed0d7 https://staging.drfop.org/files/original/63ac87e98d222a1677b6e3631411fbe9.jpg 99dbf6e84f6a51a868181896f9e1847e https://staging.drfop.org/files/original/f51d49a6caadcd9ae0527929c1b793b2.jpg a5661d7829f929030e7b25e4be6e54ab https://staging.drfop.org/files/original/a9262bba31c61cb78e9c241a50d1da89.jpg 1bb3115c8ee83f1deee20edaf6dd73aa DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_02_004.pdf Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Adjustment to Misfortune-A Problem of Social-Psychological Rehabilitation</h2> <h5>Tamara Dembo, Ph.D., <a style="text-decoration:none;">*</a><br />Gloria Ladieu Leviton, Ph.D., <a style="text-decoration:none;">*</a><br />Beatrice A. Wright, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <blockquote><p><b>Dedicated to the memory of Kurt Lewin</b></p> </blockquote> <p>At particular times in the history of science, particular problems become ripe for investigation. A precipitating event brings them to the attention of a single person and sometimes to that of several at the same time. It is therefore understandable that during World War II the need was felt to investigate the problems of social psychological rehabilitation of the physically handicapped and that someone should look for a place and the means to set up a research project that would try to solve some of these problems. In pursuit of such a goal a research group was established at Stanford University on February 1, 1945. Conducted partially under a contract between Stanford University and the wartime Office of Scientific Research and Development (recommended by the Committee on Medical Research), partially under a contract between the University and the Army Medical Research and Development Board of the Office of the Surgeon General, War Department, the work continued until April 1, 1948. </p> <p> To investigate the personal and social problems of the physically handicapped, two groups of subjects were needed—people who were considered handicapped and people around them. Therefore, as subjects of the research both visibly injured and noninjured people were used. Interviews were employed as the primary method of investigation, the great majority of the 177 injured persons interviewed being servicemen or veterans of World War II. More than half the subjects had suffered amputations and almost one fourth facial disfigurements. The injured man was asked questions designed to elicit his expectations, experiences, and feelings in his dealings with people around him. Sixty five noninjured people also were interviewed in regard to their feelings toward the injured man. </p> <p> A first task in the research project was to determine the meaning of the relationship between the injured and the noninjured. Was it primarily that of the helper and the helped, of the curious onlooker and the one who is looked upon, of the independent and dependent person, the one who rejects and the one who is rejected, the person who pities and the one who is pitied? All these relationships exist between the injured and the noninjured. Some of them were described during the first period of the research program.<a></a> As the research proceeded, it was seen that one particular relationship between the injured and the noninjured was more "basic" than others—basic in the sense that it underlies and determines the character of other relationships. This underlying relationship is the one which exists when a person who regards himself as fortunate regards another as unfortunate. We learned that to understand this relationship one has to see "being unfortunate" as a value loss and, furthermore, that the adjustment of this relationship involves the problem of acceptance of loss—a case of value change. </p> <p> In current psychology, the problem of acceptance of loss is hardly investigated. Loss is usually seen as an end point of unsuccessful, goal directed behavior (failure) or else it is investigated in terms of the effect of failure on further goal directed behavior (such as on setting the next "level of aspiration"). But it is important to know what loss means to the person himself, how it affects the opinions and behavior of others toward him, and what acceptance of loss implies. Too often life is seen as a series of goal directed acts, whereas the <i>consumption of gains </i>and the <i>acceptance </i>(or nonacceptance) of losses which result from those acts are disregarded. </p> <p> Almost all people are at some time faced with the necessity of adjusting to loss. In investigating the problems of injured people, therefore, we are dealing not only with special problems of a special group but with problems important to all. If we state that the injured need psychological rehabilitation or adjustment, this in no way implies that they are not "normal." The impact of loss which they experience produces suffering and difficulties. The overcoming of psychological suffering, whether or not it threatens mental illness, is a problem of adjustment. </p> <p> This monograph is written as a scientific paper and no attempts at popularization are made. Popularization of our findings is a special task—a task which, if skillfully done, would indeed be useful for the information and education of the general public. Those who are not specially concerned with methodological and theoretical considerations may still find the less technical chapters (Chapters V through VII) of interest. The first four chapters and the last one will be of greater interest to the theoretical psychologist. </p> <p> Part I introduces the general field of social emotional relationships. It deals with our approach and viewpoints regarding problems, data, theory, and measurement. We tried to examine the appropriateness of scientific beliefs and attitudes for the new area investigated. Part II deals with the investigation of the visibly injured, a group which, in our culture, is frequently considered unfortunate. Chapter IV presents the procedures used and their rationale. Chapter V discusses devaluation, by the noninjured, of the injured as people who have experienced a misfortune a value loss. Chapter VI is concerned with the reactions of the noninjured to the suffering aspect of misfortune rather than to its value loss aspect. The structure or nature of the genuine, positive feelings of sympathy is outlined. Chapter VII deals with the problem of overcoming suffering through acceptance of loss. In Chapter VIII we attempt to point out the direction which future research may take. The appendices include sample interviews with injured and noninjured subjects and a brief summary of methods other than interviews that were tried out in our study.<a style="text-decoration:none;">*</a> </p> <p> Three years in a new and relatively unexplored field has to be considered a pilot period. After exploration the field is seen to be fruitful, both for the growth of ideas on the specific topics and also for the development of more general theoretical problems in psychology. But only a beginning has been made, and the material here presented is therefore properly viewed only in the light of its pioneer character. </p> <p> Many of our findings may from the theoretical standpoint be seen as more precise statements of problems awaiting further investigation. From the practical standpoint, the study may be useful to those who critically examine the findings, not with the orientation of translating them into rules of behavior but so that their understanding of the problems involved in loss may be broadened. The injured, we hope, will find this type of investigation promising in its attempts to lead people to feel that it is not the AMPUTATED LIMB and John Doe but John Doe, the person, who really exists. </p> <h3>Part I: Methodological and Theoretical Considerations Concerning Social Emotional Relationships </h3> <h4> Chapter I: Some Characteristics of Social Emotional Relationships </h4> <p> We shall present a list of pairs of words designating social emotional relationships. We ask you, the reader, to think about the feelings connoted. Specific points to consider may be seen in the first example, the idea of "abandonment." How does the abandoner feel? How does the abandoned feel? How do they feel toward each other? How do you, as a person not involved in the interaction, evaluate abandonment? As you proceed down the list, you should ask yourself these and any other questions you think of which bring out the emotional meanings of the interaction concerned. We ask you to work hard because in so doing we think that you will see the problems of the psychology of emotions in a very different way from the orientation given them traditionally. You will see this field not only as unexplored but also as full of psychological resources available to those who are ready to dig. Here is the list: </p> <ul> <li>To abandon — to be abandoned. </li> <li>To abhor — to be abhorred. </li> <li>To feel that someone is able — to feel that another considers you able.</li> <li>To consider someone abnormal — to be considered abnormal. </li> <li>To be abrupt — to be exposed to abruptness</li> <li>To consider someone absurd — to be considered absurd. </li> <li>To abuse — to be abused</li> <li>To accept another person — to be accepted. </li> <li>To feel in accord with someone — to feel that another person is in accord with you.</li> <li>To accuse — to be accused. </li> <li>To become accustomed to someone — to have someone become accustomed to you.</li> <li>To consider someone as an acquaintance — to be considered an acquaintance. </li> <li>To acquit someone — to be acquitted. </li> <li>To act in a given way, without actually feeling that way — to feel that someone is just acting. </li> <li>To adapt yourself to someone — to feel that another person is adapting himself to you. </li> <li>To help someone become adjusted — to have someone try to adjust you. </li> <li> To admire — to be admired. </li> <li> To admit to someone — to get an admission. </li> <li> To adopt — to be adopted. </li> <li> To adore — to be adored. </li> <li> To advise — to be advised. </li> <li> To feel affable — to feel that another person is affable. </li> <li> To give affection — to get affection. </li> <li> To affront — to be affronted. </li> <li> To be against someone — to feel that another person is against you. </li> <li> To aggravate someone — to be aggravated by someone. </li> <li> To be aggressive toward someone — to feel that another person is aggressive toward you. </li> <li> To agree with someone — to feel that another person agrees with you. </li> <li> To aid someone — to be aided. </li> <li> To alarm someone — to be alarmed by someone. </li> <li> To give an alibi — to get an alibi. </li> <li> To consider someone an alien — to be considered an alien. </li> <li> To allow someone — to do something to be allowed. </li> </ul> <p> Only a few of the diverse emotions or feelings are mentioned above. They were selected from the first 20 pages of <i>The Pocket Oxford Dictionary </i>(New York, 1927), which has 1010 pages. The list might have impressed you with the tremendous number of unexplored problems in the area of emotions. You might have wanted to take stock of the actual concern shown them in textbooks and courses and in current research in the field of emotions. The psychological structure and the functions of the majority of emotional relationships are unknown. Yet these problems practically do not exist as topics of systematic investigation. At the 1947 meeting of the American Psychological Association, only four of some 200 papers fell under the program headed <i>Emotions. </i>The program on <i>Emotions </i>was sponsored by the Division of Physiological and Comparative Psychology. </p> <p> We do not wish to imply that emotional problems are completely disregarded by psychologists. The psychology of personality, social psychology, and abnormal psychology <i>do </i>take them into account, but within these divisions other problems, particularly problems of needs and goal directed behavior, have been in the center of attention. </p> <h4>Evaluation by the Outsider </h4> <p> When you were asked to evaluate the emotional relationships given in the list, you may have felt uncomfortable because of a vague feeling indoctrinated into all of us that in science one should be nonevaluative. Whether a psychologist should or can be nonevaluative is not our present topic. Rather, we are concerned with emotional relationships which are considered by people at large, with or without the permission of the scientist, as desirable or undesirable, good or bad. It is simply an undeniable psychological phenomenon that evaluations are made, and as phenomena they cannot be disregarded. In fact, these evaluations, as shall be seen, are important for the understanding of the dynamics of emotional interpersonal relationships and the problem of adjustment of these relationships. </p> <p> If one considers the relationships in the list, it is noticed that, even though no specification is given of the conditions under which they exist, some of them connote undesirable feelings and states, others more desirable ones. Examples which fall into the negatively evaluated group are "to abuse," "to abhor," "to accuse," "to affront." Examples which fall into the positively evaluated group are "to accommodate," "to admire," "to allow." There are others which seem less definitely to belong to the negative or positive group. For example, "to get accustomed," "to admit." Such abstract evaluations are not made specifically in terms of the meaning of the relationship to either of the partners. They are given by a person who psychologically takes the position of an outsider. </p> <p> Evaluations of outsiders very often show a high level of agreement, as is easily demonstrated by a simple experiment. The list of words can be presented rapidly to a group of subjects who are asked to evaluate the relationship as positive or negative from the standpoint of an outsider to the relationship. In only a few instances will there be disagreement, and these disagreements will be due largely to what amounts to a violation of the instructions: for instance, the subject may "take sides" with one of the partners, or the subject may base his reply on the circumstances of particular situations. </p> <p> Evaluations of outsiders might be considered standards of cultural judgment. It may be the high agreement in the evaluations of outsiders which make them appear to have the role of common cultural standards. It might be interesting to investigate whether some of them are not, in fact, intercultural. The common cultural standards play a not unimportant role in the life of human beings. For example, they strongly determine reputations and the jury's verdict of life or death. </p> <h4>Evaluations by Donor and Recipient </h4> <p> In any relationship, the person who bestows the emotion may be called the "donor," and the person upon whom the emotion is bestowed may be called the "recipient." The difference in the meaning of the relationship for the donor and the recipient is frequently very great. To give an appreciation of this difference, the list was arranged in pairs. You were asked to feel the way the donor in the relationship might feel and the way the recipient might feel. "To abuse or to be abused, to accept or to be accepted" are emotionally far apart. Sometimes both donor and recipient will evaluate a given relationship in the same way. But since the meaning which the relationship has for one partner is not the same as that given to it by the other, their evaluations often differ, and this difference may produce difficulties in the relationship. Help, for example, is almost always seen as positive for the recipient as judged by the donor, but as judged by the recipient it often has both positive and negative aspects. It is important for adjustment of relationships to know the conditions under which the donor and the recipient give the same evaluations and, when they do not, to find ways of producing a change which will lead to agreement in evaluation. </p> <p> The donor and recipient not infrequently attempt to overcome the difficulties resulting from their different evaluations by urging each other to "be objective." But objectivity, in the sense of assuming the position of an outsider and giving abstract evaluations, is not what is really desired. What each <i>really </i>wants is that the partner should "understand" him, <i>i.e., </i>should understand the meanings the relationship has for him. He wants the other to take his (the first's) position and from this standpoint to think, evaluate, and act. </p> <h4>Scope of Meanings and Structure of Relationship </h4> <p> It is seen from the list that a great variety of social emotional relationships exist and that each is characterized not merely by pleasantness or unpleasantness but by a diversity of qualitative connotations. It might be agreed, for example, that one feels lost and hurt when abandoned or that one may feel free and at the same time guilty when abandoning someone. It may also be agreed that one will feel aversion for, and a desire to escape from, one abhorred and that one would feel rejected and resentful if a person abhorred him. Each connotation will be referred to as a "meaning" of an emotional relationship. The diverse, sometimes apparently contradictory meanings which an emotional relationship can have for different people under different circumstances build the "scope of meanings of a social emotional relationship." </p> <p> As an illustration, we present some of the meanings which "being helped" has for the injured: it means that a goal is made accessible; it means that another person is courteous and polite; it means that the injured person is in a position of lower status; it means dependence, burden, etc.<a></a>. We assume that these meanings are not merely a congeries of separate entities attached to the same word. Instead, we believe analysis will show that many of them hang together, that they may be integrated within one or more coherent structures.<a style="text-decoration:none;">*</a> When the structure of a relationship has been determined, it is sometimes found that some of the meanings which subjects give to the word do not belong to the relationship in question but to a different one. For instance, in the case of the sympathy relationship, the structure of which is described in Chapter VI (page 27), some of the subjects gave meanings which belong to the relationship of "pity," a relationship which has a different structure. </p> <p> The determination of the scope of meanings seems to us an essential problem because it is the first step toward determining structures of relationships. The structure is a better description of the social emotional relationship than is the scope of meanings. Even before the development of the structure of a relationship, however, the determination of the scope of meanings has practical value. It permits realization of possibly disturbing connotations and encourages precautions and safeguards against them. </p> <h4> Chapter II: Qualitative versus Quantitative Approaches in a New Field </h4> <p> In a new field, the formulation of meaningful problems is a task in itself—a task which often takes much time and effort. It is easy within an hour or two to state a hundred questions, in a few days to state many more. Yet only a few of these will prove to be fruitful. The selection of problems which are scientifically promising is an extensive qualitative research job. </p> <p> Essential questions are those which promise to become an integral part of an interrelated group of problems and to lead to the development of corresponding systems of concepts. In a new field neither the problems nor the systems are known. They have to be discovered by giving a "qualifying examination" to the problems and preconcepts which occur to us, since these include both promising and unpromising ones.<a style="text-decoration:none;">*</a> The qualifying examination consists of a test which shows whether a particular problem and preconcept with other "candidates" promise to form an interdependent team. When they not only develop but also add to the development of the emerging system, they acquire the position of fruitful essential problems and preconcepts. </p> <p> Consider an example of a problem which does not seem promising, in the sense that it is likely to remain an isolated problem. It is noted that some of the items in the list connote what may more frequently be called feelings <i>(e.g., </i>"to abhor," "admire," "adore"). Others have the character of emotional acts <i>(e.g., </i>"to accuse," "advise," "acquiesce," "admit"). Still others reflect social distance <i>(e.g., </i>"to consider someone an acquaintance or an alien"). These categorizations seem, however, not to lead to further understanding. They simply fix the different relationships into more or less neat cubbyholes, which are, as far as we can see at the present time, blind alleys. In this example, categories rather than preconcepts are relied upon to "order" the facts. Only an orderly catalog instead of a system of interrelated dynamic concepts can be built up in such a way. </p> <p> An example of a problem which we consider promising is the determination of value structures held by those people who are undergoing difficulties and by those who have overcome these difficulties. This, we believe, is one of the first steps in conceptualizing adjustive change (Chapters V, VII, VIII). </p> <p> Another example of what might be considered promising for future investigation relates to the "mutual" relationship. When discussing the relationships in the previous chapter, all of our examples were of "onesided relationships." Each involved one donor and one recipient. But partners may abuse each other, accept each other, or admire each other. Each may be in the position of donor and recipient at the same time. Mutual and one sided relationships are not merely convenient methods of classification. They bring into focus a number of questions important dynamically. </p> <p> It frequently happens that when a one sided relationship is unpleasant for the recipient, he will try to change it to a mutual one. For example, if he is being abused he may begin to abuse the other. What effect does this change produce? The question will be sharpened if we consider the following hypothetical statement: </p> <p> <i>R_p^rd </i>= <i>R_p^r </i>+ <i>R_P^d,</i> </p> <p> where <i>R_p </i>indicates the person <i>p</i>'s relationships, and <i>d </i>and <i>r </i>indicate the donor and recipient positions, respectively. In this statement, <i>p's </i>mutual relationship is a simple summation of his relationships as donor and recipient. Can this actually be the case? Are the <i>meanings </i>for <i>p </i>in the mutual relationships <i>(R_p^rd) </i>equal to the sum of meanings which the one sided relationship has for him when he is only a recipient <i>(R_p^r) </i>plus the meanings it has for him when he is a donor <i>(R_p^d)? </i>This question is important, for if the addition of the new meanings of the donor relationship does not change the old meanings of the recipient relationship, then the addition will not diminish the previously existing conflicts or difficulties.<a style="text-decoration:none;">*</a>Actually, the "adding" of new meanings may not be an addition at all but rather a re structurization of the first one sided relationship <i>(i.e., </i>a change in some of the meanings which the relationship originally had for the person). In the latter case we would have to study the type of change produced by the restructurization and the circumstances under which the change is adjustive. </p> <p> At different stages of research, the "candidate problems" must be subjected to further test. For a time they might drop out from the "team," and then later their participation may again become fruitful. Within this process they may change their character and gain a new role. </p> <p> The "candidate problems" are thoughts of the investigator, fed by qualitative observations and checked by them. For this type of work, an armchair and a pencil are more appropriate than a straight chair and a calculating machine. It might require self control on the part of the investigator to go on with conceptualization and qualitative analysis of data when he is constantly lured by more easily quantifiable, nonsystematic, isolated problems. </p> <h4>The Position of Measurement in Psychological Research </h4> <p> The attitude, "Investigate what you can measure," is not infrequently found in psychological research practice. But there is such a thing as primitive quantification. Quantification of data on systematically unimportant questions is primitive. And there is also such a thing as premature quantification. That quantification which is done before the laborious task of qualitative description of problems and concepts is sufficiently advanced is premature.<a style="text-decoration:none;">*</a></p> <p>The determination of statistically significant differences between two sets of data does not ensure that these data are important either practically or for further theoretical advance. Instead of regarding the statistical fact as an observation which needs anchoring in an explanatory system before its import can be judged, all too frequently such observations, by sheer virtue of their statistical nature, are held up as contributions in themselves. We do not declare that measurement should not be done without a well developed theoretical framework. But we do assert that such measurement often produces statistically significant differences on inessential details. And we further assert that where problems well grounded in theory have not as yet been formulated, data analyzed qualitatively may contribute far more to the understanding of important problems. </p> <p>Where there is a well defined theoretical system, however, measurement has a very important and different position. Measurement in this case, as we see it, means measurement of conceptually defined constructs and the determination of interrelationships among those constructs. Preliminary to such measurements, one has to determine whether the constructs used permit metrization or whether nonmetrical mathematical (topological) statements should be made. The particular problems involved in this type of mathematical determination in psychology were first realized by Kurt Lewin<a></a> in regard to problems of goal directed behavior. Such mathematical determination will have to be made in the field of emotions as in any other field, though it may take years before it is possible. In the meantime, sound investigation, systematic in nature, will have to be primarily qualitative.</p> <p>There also may be considerable practical value in qualitative investigation before quantification is possible. The knowledge of <i>what </i>affects a given social emotional relationship, even if we are unable to indicate the strength of that factor, is of value. For example, we may not be able to state the extent to which sympathy reminds an injured person of the negative implications of his injury. The fact that sympathy <i>may </i>remind, however, immediately calls for caution in conveying compassion to the injured.</p> <h4>Concerning Frequency Counts </h4> <p>At any stage in theoretical development, one may tally the number of times a given observation occurs in the sample studied. But the meaning of such frequencies needs to be examined. The sheer number of occurrences does not indicate the relative importance of the event. We do not consider more important the fact that a person dealt honestly with us ten times than that he once cheated us. Nor can we say, without further proof, that there is a one to one relation between the strength of a factor and the frequency of its occurrence. </p> <p> One function of frequency counts is to permit a more accurate prediction of the number of occurrences of like events in like populations. This function, however, is often limited by failure to define the research population in terms of systematically important factors. </p> <h4>Some Problems of Sampling </h4> <p> To "select" a population for research in a new field which lacks systematization is harmless but also meaningless and therefore to be rejected as impractical. The traditional parameters of age, IQ, socioeconomic status, and geographic location should not be thought of as automatic principles of selection. Their usefulness for the particular research has to be determined in each case. It may be, for example, that in research on the injured it would be more appropriate to define the sample in terms of preinjury attitudes toward the handicapped, relative evaluation of beauty and physical prowess as compared with other personality characteristics, and sensitivity to status position. A group which is homogeneous with regard to some arbitrarily selected factors will actually be heterogeneous with regard to those factors which prove to be of systematic importance. </p> <p> Heterogeneity is, however, not a disadvantage. In an unstructured, new field, where the first task is to determine fruitful problems and the concepts to be used in their solution, the danger lies in overlooking diversities which should be taken into account. Heterogeneous groups which yield a wide range of differences in behavior are therefore welcomed. To narrow down the range of subjects is permissible only for a good reason. This reason has to be specified. In the beginning stages of our research on the social emotional relationships between visibly injured and noninjured persons, it was legitimate to include a variety of subjects. To have limited the investigation to, say, leg amputation cases, for the sole reason that in the interests of homogeneity the type of disability should be uniform, would have been groundless. </p> <p> In later stages of research, the original sample might legitimately be narrowed down or enlarged, depending on the particular problem being pursued. For example, we have indications that a person's status values affect his attitudes toward such social emotional interactions as sympathy, help, curiosity, and so on. This suggested systematic relationship could be tested by narrowing down the sample so that but two groups would be included, one strongly status minded and the other not, according to certain criteria. Whether the expected differences are to be found could then be determined. As an example where an even more heterogeneous sample than the original one is indicated, we can present again an instance from our research. The understanding of problems of loss became clearer to us when the concept of misfortune was introduced. In light of this theoretical orientation, it undoubtedly would be fruitful for further research to enlarge the sample to include, in addition to the injured, other persons regarded as being in an unfortunate situation. In short, throughout research, the sample taken for study should be determined by the requirements of the problem being studied and not by applying sampling procedures which are either extraneous to the purpose of the research or else actually interfere with it. </p> <h4> Chapter III: The Interview as a Tool for Investigating Emotional Contents </h4> <p> The interview as an experimental tool is in disrepute with many present day investigators. Some investigators will go as far as to withdraw the honorable title of "real scientific endeavor" from a study which uses "just interviews" because interviews do not deal with how the person "actually behaves." In this chapter we shall examine the validity of this argument. </p> <h4>Reflection Units and Interaction Units </h4> <p> Consider this example: A young girl gets an invitation to a ball. She is full of anticipation perhaps she will be the belle. Perhaps a certain young man will dance often with her. She decides what gown she will wear and how to arrange her hair. She plans imaginary conversations with gallant partners. But she is anxious too. Maybe she will be a wallflower; maybe the young man will not even notice her. Finally, after a succession of alternating moods, the ball arrives. The social interaction which has occasioned so much thought and feeling actually takes place. </p> <p> If, in the investigation of social emotional relationships, only interaction units were studied, a large part of the course of events would be neglected. Periods of reflection which include planning, expectations, evaluations, struggle with one's feelings and moods, would be excluded from study. Similarly, if in the investigation of personal emotional events only action units were studied, periods of reflection would be overlooked. The interactions or actions themselves might not be fully understood without the consideration of reflection units. </p> <p> The high status position of interaction data as compared with the data of reflection units seems in part to be based upon a vague feeling that only interactions are "real facts." But the types of reflection units enumerated above are all <i>real in the sense that they exist as psychological phenomena. </i>Even if reflection units had a segregated existence and did not influence interaction units, they would still have to be studied as real psychological phenomena within the life of the person. The reflections themselves may produce pain and consequently require adjustment; for instance, a man with a scarred face believed that "no woman in her right mind could possibly accept me now." </p> <p> Is it meaningful to ask whether interaction units are <i>scientifically more real </i>than reflection units? The frequently stated criterion of scientific reality, "What is real is what has effects," concerns not observable facts but the reality of descriptive, explanatory concepts. The reality of the effects is not under discussion in the criterion; nothing is implied about them but their virtue of being available for observation. Scientifically, reflection units and interaction units are both legitimate observable facts. It is true that in the case of reflection units the content must be communicated to the interviewer. But this mediation should be no more disturbing than that of other instruments. The criterion cited does not specify that the observable facts must be observed directly.<a style="text-decoration:none;">*</a> </p> <p> What conclusions can be drawn as to the relative merits of the two types of units for study? Both interactions and reflections are real phenomena and legitimate observable facts; psychological difficulties requiring adjustment may exist in either case. They differ in that interactions can be observed directly, whereas the content of reflections must be communicated to the investigator by the subject. For an investigator, the difference between them is simply one of kind and not of value. </p> <h4> Interviews Versus Behavior Observations </h4> <p> We submit that the richness of emotional life can be more fully realized through the use of the interview than through observation of behavior. It is true that we can infer something about underlying emotions from behavioral observations, but the understanding gained in this way is usually more limited. If we could have observed the girl smiling over the invitation, taking from her wardrobe first one gown and then another, being absent minded about her everyday tasks, and so on, we might have been able to infer something about her feelings. But the complexity of her feelings, the content of her hopes and fears, remains largely unappreciated. On the other hand, for particular problems observation of behavior would be required, for example in order to study the effects of reflections on behavior, such as how fear of failure affects performance, or whether verbal attitudes correspond to behavior.<a style="text-decoration:none;">*</a> Only when a particular problem is specified may one method be judged better or worse than another. </p> <h4> Validity of Interviews Versus Validity of Behavior Observations </h4> <p> It is frequently stated that the subject willfully or otherwise does not tell the interviewer what he actually feels. But one cannot claim superiority for behavioral observations on these grounds. Hiding emotional contents is not limited to interviews. One can cover up one's real feelings with actions just as easily as with words. One can smile when he is sad just as easily as he can say he is well when he feels bad. Friendly acts may be due to bad intentions. They may be performed to cover up the real feelings behind them. One covers up if there is a <i>need </i>for it. </p> <p> The need to hide during an interview, it might be argued, may frequently be less strong than in interaction units. It might be considered whether hiding of feelings from a person with whom they are connected is not frequently more necessary than when discussing or reflecting about these feelings with a third person. It is likely that feelings of guilt or shame will be less strong in regard to statements than to acts. Especially if the third person takes a nonjudgmental position or the position of an ally will the true feelings as far as they are recognized by the subject be expressed more openly than in interaction units. Of course the need to hide particular emotions will exist during interviews, but the interaction units cannot be turned to as the better ones in this respect. </p> <h4> Knowledge of the Subject About His Own Emotions </h4> <p> Interviews are sometimes held in disrepute on grounds that people do not know their own feelings. Has not depth psychology taught that people fool themselves? Does not the subject need first to be analyzed and to be an experienced psychiatrist or to have special training in psychological matters in order to be able to make pertinent statements? Fortunately, people do not learn to cognize feelings in college only. Much of what one feels when someone nags him, for example, or helps him, or when he is jealous, can be perceived without special psychological training.<a style="text-decoration:none;">*</a> If the objection is raised that the conscious meanings which feelings have for the subject are less important and more superficial than those of which he is not aware, we would say that such a statement is premature. Explicit criteria of importance have first to be given. </p> <p> If important feelings are those which affect a person's behavior, we say that those consciously given share the same honors as the hidden. And if it is asserted that unconscious feelings are more important because they explain <i>more </i>of a person's behavior, one is called upon to compare counts. This has never been done, nor does it make sense to do so. For immediately the question arises as to what weights to assign to the individual behavior units. Are they more important because they are resisted? Then what is the rationale for considering the resisted more important? We suspect that all too often the hidden is identified with the important by sheer virtue of the fact of its covertness. Clearly missing is a link which must be supplied before such an evaluation can have scientific merit. </p> <p> As far as we can see, it is scientifically meaningless to argue about the importance or superficiality of perceived meanings of feelings before the criteria of such judgments are made clear. One criterion does exist. If important problems are those which are essential in the sense discussed on page 8, <i>i.e., </i>problems which attempt to relate observable facts to systems of concepts, then there is nothing which leads us to exclude feelings as perceived by the subject as "candidates." Criticisms regarding essentiality of problems are applicable to overt and covert meanings alike. </p> <h4> Feeling Level Versus Intellectual Level of Discussion </h4> <p> Emotional topics can be discussed with almost anyone who is willing to participate in an interview. The discussion, however, may take place on an intellectual level or on a feeling level. One can "just talk about" feelings, in an abstract, impersonal way (intellectual level), or one can analyze one's feelings in terms of the particular intimate meanings they have for the individual (feeling level). Psychotherapy, whether directive or non directive, strives for such a feeling analysis by the patient. It has been commonly recognized that, in order for feeling analysis to take place, the person must have a need to examine his feelings, and he must expect the interviewer to be tactful, understanding, trustworthy, etc. In the study of the meanings which social emotional relations have for the donor and for the recipient, however, a further important condition must be realized. To approach such meanings on the feeling level, the subject must <i>actually feel </i>the position of a partner in the relationship. He must feel something of the hurt involved in being stared at, for example; or in the case of the donor position, something of the curiosity. It is more advantageous to select subjects who in actual life are donors or recipients in the relationship investigated. Otherwise the subject tends to discuss on the intellectual level or evaluate as an outsider, and in neither case can he convey the emotional impact which the relationship has for a partner. </p> <h4>Analysis of Data in the Area of Emotions </h4> <p> The principles which guided us in choosing methods of collecting data apply no less to its handling after it has been gathered. The whole flavor of the emotional meanings which one was at such pains to obtain can be lost if the approach to the data is unwisely rigid. The investigator is forced to perceive and to feel emotional relationships from the point of view of the donor and recipient before he can understand the meanings and evaluations ascribed to them. Not being involved in the particular relationship, the investigator has to find equivalent relationships in his own experience. Frequently in our research we had to feel through relationships from our own personal histories in order to be able emotionally to understand the subject's comments. Though the occasion at which sympathy, for instance, was given to us differed from the occasion leading to sympathy relationships in our subjects, the tool of self analysis was useful. There is an obvious danger of analyzing superficially similar relationships instead of equivalent ones. Self analysis, therefore, should be used for the purpose of getting "hunches" which can be applied to the data obtained from the subjects. Such an approach leads to aspects of data which an investigator, viewing the data as an outsider, will overlook or misinterpret. </p> <p> There is nothing unscientific about being a subject and an investigator at the same time. In perception psychology, for example, the investigator frequently takes this double role. He can perceive and then cognize what he is perceiving. In the area of emotional problems, the investigator should try to feel the emotional situations being studied and then to examine what he is feeling. Physical, physiological, and psychological laws which hold for the object of the investigation hold for the investigator also. In investigating emotional relationships, to feel is at least as essential as to think. </p> <p> If we state that one has to do not only a thorough job of thinking but also of feeling we make a realistic statement concerning the method of studying emotional relationships. Our view on the necessity of emotional understanding is not as radical as it may seem. Frequently in psychology statements are made that we have to investigate contents as they "exist for the subject," "what it means to the subject," "to see with the eyes of the subject." The need for feeling "like the subject feels" was long felt by therapists. The requirement of psychoanalysis that they themselves be analyzed is partially for the purpose of facilitating emotional understanding. </p> <p> In attempting to find aspects under which the data may be fruitfully seen, complete freedom should be given to the investigator. He cannot be free enough and "wild" enough in looking for interpretations and possible implications of the raw data which might lead to hunches, hypotheses, and conceptual formulations. Hunches are freedom loving birds which do not hatch in supervised, restricted areas. This does not mean that the data will be distorted or that the results will be "only speculation" and not "facts." The test is whether, when a category has been well defined, independent observers will agree that given items of the raw data fit the category. If they do agree, then this aspect is indeed "an observable fact." If we are too "wild" in our interpretations, then we shall be caught by another observer. But if we are unwisely rigid we shall not be able to make a step in the direction of theoretical progress. </p> <h3><b>Part II: Study on the Visibly Injured</b> - A Group Considered Unfortunate</h3> <h4>Chapter IV: Research Procedures </h4> <p> Our approach to the problems of the social emotional relationships of the visibly injured was based on the theoretical and methodological considerations discussed in Part I. Because the task was that of determining essential problems in the new field of social emotional relationships, qualitative methods were chosen as the appropriate ones. Measurements at this time would have been premature. Frequencies of observations and statistical analysis are therefore not presented, since they would only be misleading. </p> <h4> Subjects </h4> <p> Heterogeneity of subjects, as has been seen, is an asset for such a study. The subjects (177 visibly injured and 65 noninjured persons) varied as to age, race, intelligence, socioeconomic background, occupational interests, marital status, and so on. The injuries varied. The relationship of the noninjured to the injured persons varied. To have narrowed the groups for the sole reason that they should be homogeneous would have given us a more limited picture of the emotional meanings of the relationships existing between the injured and the noninjured. </p> <p> If, at the beginning of our investigation rather than at the end of it, we had known that the relationship of misfortune was especially important to the understanding of the problems studied, we would have considered it profitable to have included persons who experienced misfortunes other than injuries. But our research was an outgrowth of interest in the problems of the injured, and thus misfortunes other than visible injuries were not studied. Orthopedic cases and cases involving plastic surgery were chosen because the visibility of the injury is important in relationships with noninjured who are not close to the injured. Blind and deaf persons were excluded as subjects since it was felt at the time that the specific additional problem of communication between them and the noninjured would have in the beginning of the research unnecessarily complicated the data. </p> <p> The ages of the injured subjects ranged from 19 to 58 years, the duration of their disabilities from two months to <i>33 </i>years. Of the 177 injured subjects, 121 were hospitalized servicemen of World War II and four were women. (<b>Table 1</b>) presents the distribution of the subjects according to type of disability; (<b>Table 2</b>) gives the distribution of the non injured according to relationship with injured persons. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Interview Procedures </h4> <p> After having tried out several techniques of investigation, a summary of which is given in Appendix I, we found that the scope of meanings of social emotional relationships could most adequately be determined by interviews. Prior to the interview much work was done on the selection and formulation of questions, the purpose being not to set up a questionnaire for the interviewer to follow rigidly but rather to prepare him for the interview. We wish first to point out why we think it unnecessary and often disadvantageous to follow a rigid order and formulation of questions; then we would like to explain what we mean by "preparing the interviewer for the interview." </p> <p> It was observed that, for at least three reasons, the actual course of events in an interview might require deviations from a prearranged interview. In the first place, identity of questions and order does not ensure that the psychological situation will be the same for different subjects. In many instances, a question will have the same meaning for each subject only when it is put in a different form. Thus, in our study, as well as in many investigations where comparisons among the subjects are made, rigid interview procedure is con traindicated. That we deny the necessity of maintaining a rigid formulation and order of questions does not imply that we disregard the influence of preceding events upon a given question. Rather, we assert that this kind of influence can be validly determined only when the analysis of data is made. A rigid order gives an "appearance" of the same conditions and illegitimately relieves the experimenter from investigating the effects of the actual psychological conditions upon the responses of the subject. </p> <p> Secondly, a rigid interview leads in many cases to a more superficial intellectual discussion than is the case when the interviewer follows the natural course of the discussion. If a subject is developing a topic in a given direction and the interviewer goes on to the next question on the list, the interruption might be emotionally disturbing. Such interruptions promote the feeling that the interviewer is not really interested in what the subject is saying but just has to complete the task of getting answers to "twenty questions." </p> <p> Finally, in a nonrigid interview the subject may introduce new topics which, in the exploratory stage of research, are often worthy of consideration. </p> <p> To "prepare" or train the interviewer, the design and redesign of questions that might be asked in the interview is of extreme value. First, the process of developing questions sharpens the sensitivity of the interviewer to the scope of meanings which may be implied in a question and in possible answers to it. It prepares him to listen for the shades of meanings which the subject may bring out. Secondly, the interviewer, when later analyzing the interviews, will also be more sensitive to the shades of meanings implied in the subjects' statements. Third, the attention given in the training to the problem of the logic of transitions from one question to another and to the possible negative effects implied in some transitions is also important. The interviewer is then better able, when the subject waits for him to take the lead, to introduce a new topic without disrupting the relationship. And finally, the training on design of questions makes the interviewer realize what questions may be seriously disturbing to the subjects, a matter especially important with the injured subjects and their sharers for whom the injury is a vital problem not limited to the interview situation. </p> <p> The design of questions to be used as guides for interviews in a new area is a serious and laborious task. During the research, changes in the original questions were made; some were dropped, others added. In successive interviews, the improved interview form served to suggest the areas to be brought up for discussion, but when and how they were to be introduced was left to the judgment of the trained interviewer. We present below one of the prearranged lists of questions which was developed during the training period and used as a guide in some interviews with injured subjects: </p> <ol> <li>How do people act? <ul> <li>How should they treat you?</li> </ul> </li><li>How about their asking questions? </li><li>How about help?</li><li>Do you think that noninjured people are uncomfortable when they are with you for instance are they at a loss for words? <ul> <li>Do you think they are afraid of hurting your feelings?</li> <li>Do you try to put them at ease? </li> </ul> </li><li>Do you think it wise for the uninjured to make light of the injury? <ul> <li>Do you think a person who is not injured should kid the man about the injury?</li> <li>Is it good for them to tell an injured man about all the things that another injured man can do? </li> <li>Is it good for them to tell a man that his injury is not noticeable? </li> </ul> </li><li>Do you like to hear it said that the injured man is courageous? </li><li>What do you think comes into a person's mind when he sees someone with an amputation? <ul> <li>Do you think many people would feel sorry for him?</li> <li>Would many people feel respect for him?</li> <li>Is the opposite ever true? Would anybody look down on him? </li> </ul> </li><li>Do other people react any differently from what you expected at first? </li><li>What percentage of people do you think act very well and really badly? How many in between? </li><li>How would you check whether a person has the right feeling toward injured people? Do you do anything like that? </li><li>Did you ever know anybody who was injured, before you were hurt? 11a. How did you feel about him? <ul> <li>Do you feel differently about them now? </li> </ul> </li><li>What would you be careful of now when you're with another injured person? </li><li>Do you ever feel sorry for anyone around here? </li><li>Is there a bad kind of sympathy and a good kind? <ul> <li>Is there a kind you can't help? </li> </ul> </li><li>Is pity different from feeling sorry? </li><li>Quite a number of things may be important for other people who are injured to know about the stages one goes through. It would help them to know they are not the only ones who have these feelings in the beginning. How was it at the beginning? What are the stages one has to go through and the things you have to get used to? </li><li>Do you think a person should try not to think about his injury? </li><li>Is it better if he thinks and talks about his injury in a matter of fact way, whenever there is any reason to think or talk about it? </li><li>What would you do if you saw a fellow patient who was feeling sorry for himself? </li><li>What kind of person will let his injury lick him, or get him down? </li><li>Do you think you would have been able to take it if it had been worse? </li><li>Does it help to know that another person was injured worse than you? <ul> <li>Is it because the other person is in a worse condition, or because even though he is in a worse condition he can still take it? </li> </ul> </li><li>What things have you learned to do since you were wounded? <ul> <li>What things do you still have to learn? </li> </ul> </li><li>Which is more important, the looks, or the things you can't do? <ul> <li>Does it matter much how it looks, either to other people, or to you? Do you have to get used to it? </li> </ul> </li><li>Is an injury easier to take for a woman or a man? 25a. Would you object to marrying an injured woman? </li><li>Do the men feel that their injuries will make a difference in their getting married? <ul> <li>Let's say that about 70 out of 100 men are married in the general population. What would you expect about wounded people, would there be more of them married, or less, or about the same? </li> </ul> </li><li>Are you satisfied with your stump? <ul> <li>Some people say that they get mad at the stump and try to hurt it. What do you think the reason might be? </li> <li>Have you ever felt that way? </li> </ul> </li><li>Are there some words you object to? <ul> <li>How about the word, stump? </li> </ul> </li><li>Do you think that after an injury a man gets more interested in new things that didn't interest him before that he looks on life differently or that things that were important before don't seem important now while new things do? <ul> <li>Do you have any new plans for a job? </li> <li>Do the same kind of people interest you? </li> </ul> </li><li>There are a good many things we haven't talked about that might be very important, and we'd be glad to have your suggestions. Is there anything else that occurs to you that would be good for us to talk about? <ul> <li>Anything you think the wounded man ought to know? </li> <li>Anything the public ought to know? </li> </ul> </li></ol> <p> The interview usually lasted about an hour and a half. In a few instances, there were repeated interviews with the same subject. About half of the interviews were recorded by the interviewer himself as verbatim as possible, the others by a stenographer or a trained recorder. A sample interview with a noninjured subject is given in Appendix II. Sample interviews with three injured subjects are given in Appendix III. </p> <p> The cooperation of the injured subjects was obtained by telling them that the purpose of the study was to determine difficulties existing in the relationships between injured and noninjured people and how these difficulties could be overcome. The subjects were asked to help in finding out "how people act" and "how they should act." The injured considered the endeavor a worthy one. Many of them challenged the usefulness of current magazine articles, and some felt that correct information might improve matters. The social emotional relationships discussed had a high potency for them. Many of the subjects were recently injured, but all of them had had contacts with the noninjured—contacts in which they were the recipients of help, of curiosity, of sympathy, of being considered an unfortunate person. For them, such relationships were real and vital. Because they mattered to them they discussed problems not only intellectually but also on the feeling level. </p> <p> In the interview the injured subjects were first asked "how the noninjured behave and how they should behave." This confirmed the feeling which we had attempted to convey when we first approached them that we valued their opinions and knowledge as they "are the ones who really know." This openended question was also a precaution against feelings in the subject of intrusion into his privacy. Later in the interview, when the subjects became involved and felt secure and free with the experimenter, they frequently shifted to their own personal feelings and were even willing to discuss private matters brought up by the interviewer. </p> <p>Since particularly during the war the feeling that something should be done to help the injured was strong, cooperation was also readily secured with the noninjured subjects when the purpose of the study was explained to them. At the beginning of the interview, however, it was a difficult task to achieve real emotional involvement on the part of those noninjured who were not close to injured persons. Noninjured persons who are in the position of sharers, wives and mothers of the injured for example, do feel that relationships between the injured and noninjured really concern them. But for other noninjured, the area of problems is not a vital one. Some time was therefore spent with subjects of this group at the beginning of the interview in discussion of injured persons they knew and how they felt about them in an attempt to bring the discussion to a more basic feeling level. In order to keep the subject on the feeling level, the interviewer also attempted to bring out the conflict in the noninjured between ethical demands and emotional feelings. Because it is considered "good" by the noninjured to believe that the injury does not matter to them, they may try to convince the interviewer and themselves that they do not have any "special feelings toward an injured person." When the interviewer responded to the underlying emotional feelings rather than to the overt ideological statements, the noninjured not infrequently became aware that the relationships involved important meanings for them and not merely intellectual or ideological ones. Discussion on the feeling level could then take place. </p> <h4>Analysis of Data</h4> <p> The analysis of data in a new field, where the aim is to discover essential problems, requires a great flexibility on the part of the investigator. Because the search is for "hunches" and connections among them and not for frequencies of occurrences, an attitude of a single subject in its ramifications requires much thought and understanding. For those who will work further in this field, we wish to mention some points which are well to keep in mind when analyzing interview material. </p> <p> The understanding of the emotional meanings implied in the statements of the subject requires taking into account the context of the discussion. It is important to consider the interplay between the responses of the subject and those of the interviewer. Sometimes contradictory statements made by the subject in different portions of the interview lead to understanding of basic feelings. Always it is necessary to try to put oneself in the position of the subject and to feel with him. Often, in order to appreciate the subject's subtle feelings, it helps to examine one's own feelings in situations similar to those evaluated by the subject. Frequently the impact of the subject's own feelings is further enhanced if the investigator assumes the position of the other partner in the relationship he was talking about. In our work this was especially true in analyzing the noninjured records. The covert meanings appeared most clearly if we tried to see the implications which a superficially innocuous statement might have if an injured person were to read it. </p> <p> A rigid scheme of analysis of interview material may lead to superficial conclusions; since in such a case one is obliged to cover the material in a technical, automatic way, the many meaningfulness of the single answer of the subjects is apt to be overlooked. Thus, for our purpose, the interview material was more fruitfully analyzed by developing categories as the analysis proceeded rather than by following a predetermined scheme. This meant categorizing, recategorizing, and again re categorizing. When a new category was added it sometimes required a re examination of parts of interviews in the light of the new insight gained. Not all of our theoretical statements, however, are based on category analysis of all the interviews. Sometimes the attitudes expressed in single cases gave us hunches which led to the development of hypotheses and theoretical understanding. In these ways we tried to determine the scopes of meanings and structures of social emotional relationships. </p> <h3> Chapter V: Misfortune </h3> <p>Many kinds of social-emotional relationships exist between injured and noninjured people. Which should be investigated as more essential? We began with those which were frequently pointed out by the injured themselves, namely, "to help—to be helped," "to question—to be questioned," "to stare—to be stared at," "to sympathize—to be sympathized with," "to accept—to be accepted."<a style="text-decoration:none;">*</a> During the analysis of data, a different relationship emerged as more basic for understanding the social psychological problems of the injured the relationship "to consider someone unfortunate to be considered unfortunate." This relationship enables us to tie together many of the phenomena observed and indicates the direction which further research should take. The finding and description of this essential relationship is a <i>result </i>rather than the historical beginning of our investigation. </p> <h4> An Experiment for the Reader </h4> <p> The line below represents a scale. The letter <i>F </i>designates the position of the most fortunate person and <i>U </i>the position of the most <i>un</i>fortunate. The sign in the middle of the scale designates the average position. Before reading the text further, quickly and going simply by feeling rather than on the basis of intellectual consideration indicate your own position on the line. (<b>Fig. 1</b>) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Figure 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> This experiment was performed with a group of 30 students at Stanford University but not in the context of a discussion about the injured. Only one of the group placed himself in the average position, none below this point. In a variation of the experiment with 10 other subjects, the instructions were changed so that the middle of the scale represented the average position for members of the subject's own social group. The "fortune phenomenon" still held in this case.<a style="text-decoration:none;">*</a> </p> <p> We expect that you too will have put yourself somewhere above the average position. It would seem that there must be a "terrible misfortune," and even this may not suffice, to lead one to put himself below the average. One feels also that should somebody judge him to be unfortunate and place him low on the scale he would resist accepting such a judgment. Yet very easily does the noninjured make such a judgment regarding the injured. </p> <p> It is our task to specify further the feelings of the person who considers himself fortunate toward the one whom he considers unfortunate and also the feelings of the person who is considered unfortunate when he knows that he is so considered. Though the relationship as it concerns the injured is in the focus of our attention, the discussion has implications for anyone who is judged unfortunate. </p> <h4> Misfortune As An Event </h4> <p> A painful event which does not have far reaching consequences may be called "a mishap." If the event produces prolonged and more inclusive suffering, if it affects a large part of the life space of the person, it is called "a misfortune." Other people will tend to shift the position of the sufferer downward on the fortune scale. The circumstances surrounding the event may themselves be important. They may affect the feelings of the person himself and the relationship between him and others. But this is a special problem, and fruitful investigation of it presupposes knowledge of the nature of the misfortune relationship. We shall, therefore, in this first study of misfortune, disregard such differences as whether an arm was lost in a car accident or because of shrapnel wounds. </p> <p> For an investigation of the effect of the circumstances surrounding the event upon the feelings of the person himself, simple grouping into war and accident casualties, for example, would be too superficial. The groupings have rather to be made in terms of the intimate psychological meanings which the circumstances have for the person. For example, in the case of the war wounded: I volunteered and therefore I caused my injury; I was not careful enough I handled explosives too automatically; I got shot when I went out to help my friend it just came; I wanted to be wounded in order to return to the mainland. Moreover, one would have to know whether after his injury the person believes that his loss was for a worthy cause, or whether he became disillusioned, and so on. Similarly, psychologically meaningful subgroups would have to be distinguished for the investigation of the effect of the circumstances upon the evaluation of the donor. We shall emphasize not the nature of the event which produced the change in position on the fortune scale but the consequences of the persisting difference in position between those who are considered fortunate and those who are considered unfortunate. </p> <h4> Misfortune and Suffering </h4> <p> That an unfortunate person suffers is the fact which is outstanding from the point of view of common sense observation. It is also the suffering aspect of misfortune to which people who are close to the sufferer and who share his difficulties predominantly react. We can then ask, "Is the judgment that a person is in an unfortunate position only a statement that he suffers and nothing more?" Are "unfortunate" and "suffering" equivalent? We shall see that there are instances in which the judgment of unfortunate is made in spite of the fact that the person does not suffer, at least not directly from the event itself, and that there are other instances in which suffering occurs and yet the judgment of unfortunate is withheld. </p> <p> Let us first consider the fact that when suffering is not perceived the person may still be considered unfortunate. This is true, for instance, in the case of a person having a facial disfigurement. It may be objected that, even if the suffering is not perceived, people "realize" that he suffers, and this may have something to do with considering him unfortunate. But, we ask in a provoking way, may it not be this "realization," the opinion of others that he is unfortunate, which makes him suffer, rather than anything independent of these opinions? </p> <p> It is also puzzling that not all people who experience suffering are considered unfortunate. Boxers, pioneers, members of an arctic expedition are not considered unfortunate. The argument that in such cases the suffering is of short duration does not always hold; the hardships of the pioneers lasted a lifetime. Nor does it help to point out that these sufferings are self imposed and are therefore not misfortunes. It is not strictly true that they are self imposed, especially when they are necessary to gain a livelihood. Moreover, someone who imposes an injury upon himself in attempting to commit suicide is still judged by many to be an unfortunate person. </p> <p> It should be clear from the foregoing that the statement, "One considers somebody unfortunate when one perceives that he suffers," is unprecise. We shall see in a subsequent section (p. 21) that a statement which is almost the reverse will, paradoxical as it seems, lead us further: "When one considers somebody unfortunate, one will not only expect him to suffer but may even feel that he <i>ought </i>to suffer!" </p> <h4> Misfortune As a Value Loss </h4> <p> In order to understand many of the social emotional relationships arising between the fortunate and the unfortunate we must make explicit one important aspect of misfortune: a misfortune involves, in the eyes of the judge, a loss or absence of something valuable. But the word "misfortune" is sometimes used when the person has experienced no unfortunate event, for example when the injury is congenital. In this case, the absence of a value may be felt psychologically as a loss. </p> <p> The judgment of misfortune is an expression of personal and social values which the donor holds high. In our culture, most persons do not consider an amputation, a facial scar, or other injuries simply neutral variations, like color of eyes or length of hair. Instead, these variations of "body whole," "body competent," and "body beautiful" are <i>considered </i>disfigurements and handicaps. That is, they are judged to be misfortunes value losses. </p> <h4> The Requirement of Mourning </h4> <p>Since a misfortune is, in the eyes of the judge, a loss of something valuable, the person who experiences a misfortune is generally expected to suffer and mourn his loss. An injured man described the expectations of his visitors in the hospital as follows: "They expected to see me in a worse mental state. I was pretty cheerful and cheered <i>them </i>up." Sometimes these expectations may even have the character of a judgment as to what is proper: it is <i>natural </i>and <i>normal </i>to mourn one's loss when struck by misfortune. It may therefore be disturbing and uncanny to the noninjured to find an injured person who is not distressed, who does not feel and act like an unfortunate person. The noninjured will tend to suspect that the injured person is putting on a good act, or they may conclude that he does not yet realize what has happened to him but "will in time." </p> <p> We venture to say that these feelings of the donor do not arise solely from the possible intellectual consideration that emotional acceptance of a loss is inconceivable. It is likely that they stem also from the need on the part of the fortunate to keep high those personal and social values which he possesses or cherishes. He therefore objects to the apparent disrespect shown these values as implied in the nonacceptance of the unfortunate position by the person who is deprived of them. When the recipient does not show that he feels unfortunate, the implication is that the loss is not so great, and therefore the donor requires that the recipient mourn. We are now ready to state the following hypothesis: When the fortunate person has a need to safeguard his values, he will either <i>(a) </i>insist that the person he considers unfortunate is suffering (even when he seems not to be suffering) and that he ought to suffer or <i>(b) </i>devaluate the unfortunate person because he ought to suffer and does not. </p> <p> We expect that the noninjured will resist the implications of this hypothesis. It implies that they <i>want </i>the unfortunate to suffer, which is in direct conflict with prevailing ethical codes. An analysis of several examples will, however, make the hypothesis more convincing. </p> <p> Consider a woman to whom "position is everything in life." She must consider as unfortunate those who are omitted from the social register. If she does not it would mean that her position is not so valuable after all. If they do not accept the fact that they are unfortunate, she must consider them either too stupid to know better, or insensitive, or shamming; otherwise her own position is threatened. </p> <p> Or take the attitude of a married woman toward her spinster sister. Perhaps the duties of a wife and mother make up her whole life. If these are not important, then what is she? Nothing. It would be an intolerable state. She must consider single women unfortunate and require that they recognize this position. Otherwise how can she escape insecurity, anxieties, conflicts, and the necessity for revaluation which might increase the importance of other value scales on which she has a low position? </p> <p> To one who is proud of her beauty, whose sole stock in trade it is, the ugly duckling who flirts and seems happy would be disturbing. The beauty may laugh at the plain one and comment on her appearance so that she will "know her place." If she accepts this place, then she supports and does not challenge the values of the beauty. </p> <p> For like reasons, it is considered scandalous if a widower remarries too soon. He should have observed a "decent" period of mourning. He is heartless and disrespectful. He threatens the value of strong interpersonal ties. He undermines the value of dependence upon each other in close relationships. </p> <p> The feelings of the judge which are implicit in the requirement of mourning will tend to be expressed, however, only in covert ways because of the conflict between these feelings and ethical demands. Thus in the following example, though the demand for suffering is not overt, the noninjured subject makes it clear that an injury is devaluating and that the injured should be ashamed of and hide the injury: </p> <blockquote><p> The last place I worked there was a girl there who had been born without an arm. It was about to here [indicates above elbow). And she had fingers on it. She didn't care. She used it to hold bobbie pins, etc. ... I didn't think it was very nice. Right in front of the other girls she would uncover it. Would you think that was all right? [Interviewer: What did you feel about it?] It was repulsive. If it had been an amputation it would have seemed cleaner. I thought at the time that I would have gone into the dressing room and do that and not be where so many people could see it. </p> </blockquote> <h4>Misfortune and Devaluation </h4> <p>It has been seen that if a person does not mourn his loss when the donor believes that he ought to he will be devaluated. Mourning his loss does not, however, insure the unfortunate against devaluation. He may be devaluated whether he mourns or not. There remains then the task of determining other conditions under which a person who experienced a misfortune is devaluated. </p> <p>Devaluation of a person implies comparison. The comparison may be made between two persons in respect to particular characteristics, or between the current state and a previously existing or predicted future state of the same person, or a person may be compared with some abstract norm. The standard of comparison has a position which is evaluated positively and below which any position is negative. Thus, when there is devaluation, the comparisons are not made in neutral terms indicating likeness or difference. Instead, there is always a judgment of better or worse. The position of the person being judged and the standard against which he is compared may be represented on a value scale. </p> <p> Summarizing, we may say that devaluation presupposes comparison on a value scale on which a person is judged to be in position <i>x, </i>the standard occupying position <i>y, </i>which is higher on the scale. Close consideration of this statement, which sounds so self evident, will show the problems actually involved. Several terms used require further specification. These specifications will help in the task of determining the conditions which lead to devaluation. The terms are "value," "person," "position of the person," and "standard." </p> <h4> <i>Value</i> </h4> <p> We raise the question: Does devaluation occur when a person has lost or lacks <i>any </i>value, or does it occur only when particular values are involved? It would seem that even when something is evaluated highly, the nonpossessor is not necessarily devaluated. Two kinds of values which preclude devaluation can be distinguished—possession values and asset values. </p> <p> <i>Possession Values. </i>If a value is seen only as a possession of a person and not as a personal characteristic, devaluation of the person cannot take place. Thus beautiful pictures may be evaluated highly, yet those whose homes do not boast of even one old master are not devaluated. Though this seems clear, the terms "personal characteristic" and "possession" are in themselves problematic. Psychologists are uncomfortable when they have to draw a boundary between the person and the environment. Whether something is seen as a part or characteristic of a person or as a possession seems to depend upon the judge. The person who has lost someone dear to him may feel that he has lost part of himself. Clothes may be thought of as a material possession and "being well dressed" as a personal characteristic. Where some judges would perceive a "man who owns a house," others would perceive a "home owner," a substantial and responsible member of the community. Even a part of the body may be thought of simply as a possession rather than as a characteristic of the person, as the following statement of an injured man would seem to imply: </p> <blockquote> <p>In other words, I kind of think now that the hands and legs are just merely tools. Where if you haven't got the right tool there are some jobs you cannot do. It is not the handicap that holds a man down. It is his head. In the beginning one does not see it— that they are tools. </p> </blockquote> <p> The general problem will have to be solved: What are the conditions under which a value will be seen as a personal characteristic or simply as a possession? </p> <p> <i>Asset Values. </i>Even when a value is seen as a personal characteristic, the nonpossessor is not devaluated if the value is regarded as an asset value. When asset values are involved, the person does not base his evaluation upon comparison with any standard. He may, for example, simply enjoy the musical performance of his acquaintance without comparing it with the performance of anyone else. Should the judge not be talented in this regard, he is not disturbed because he is inferior to another. Musical ability in others and himself is seen as an asset value. More generally, the existing state of a person may be felt to be satisfying (or disturbing) without comparing it with a standard. A woman, for example, who is forced because of family and children to give up a vocation which until then had made up a large part of her life will not feel inferior if a vocation represents to her an asset value which is a "fine thing to have" if circumstances permit. </p> <p> From the above, it is clear that it is not inherent in a value to be considered an asset value. Among other things, the needs of the judge will determine whether or not he is in a comparison frame of reference. Thus, though musical ability may be an asset value under certain circumstances, when the judge is in a comparison frame of reference because he has to select members of an orchestra it is not. In the latter case, we may speak of musical ability as a comparative value, a value used in making comparisons for the purpose of evaluating the person. </p> <p> We wish to make a sharp distinction between comparative values and the possibility of making comparisons when asset values are in question. In the latter case, comparisons which might be made are intellectual ones which do not affect the evaluation of the person. In the former case, the comparison is the main aspect; whether or not the person is meeting the standard with all its consequences is most important. </p> <h4><i>Person</i> </h4> <p>We have to distinguish between what we call "total person" and "characteristics of a person." By "total person" we mean all the characteristics which are taken into account by the judge at a given time whether they are clearly or only vaguely perceived. Devaluation can exist in regard to single characteristics and not in regard to others. If the characteristics on which the person is devaluated are "decisive" for the judgment of the total person, total devaluation will take place. But if these characteristics are seen as unimportant, then the person is not devaluated as a total person though he is devaluated on single scales. Moreover, when the single characteristics on which the person is devaluated are the only ones that enter the evaluation of the judge, then "total person" is equivalent to these characteristics and total devaluation takes place. </p> <p> Consider the example of the noninjured girl who said: </p> <blockquote> <p>He's correct in not proposing if he couldn't earn a living because of his handicap. </p> </blockquote> <p> This subject evaluated the injured person as a husband in terms of a single characteristic or scale on which she feels he has an inferior position. Because other characteristics of a good husband are not taken into account, he is necessarily devaluated as a husband. If other characteristics which are felt to be the decisive ones are considered, such as affection and understanding, he may be judged equal to whatever is taken as the standard. He will be devaluated only if the girl feels that earning a living is of primary importance. </p> <p> Examine similarly the self devaluation of an amputee who says: </p> <blockquote> <p>You feel like a heel lots of times when kids are playing on the street with their sleds. Other fathers can play with their kids.</p> </blockquote> <p>The subject devaluates himself because other characteristics which may be considered more important for a good father than those on which he falls short are not considered at the moment. </p> <p> Devaluation of the injured is not limited to bodily values only. When the injured person is devaluated because of physical performance, appearance, or aptitude for particular roles, a jump is not infrequently made so that he is also devaluated in regard to assumed mental characteristics. Some people directly indicate that abnormality of the body means abnormality of the psychological make up. Thus we have the following statements made by noninjured subjects: </p> <blockquote><p>You'd be very conscious of your own deformity; it would hurt you psychologically.</p> <p> Some have a disposition to arrogance. "You are going to accept me whether you like it or not" like a midget, you know, inferiority complex. Some overdo the matter of being congenial. [Note that even positive traits are seen as negative]</p> <p>After she [girl with short bowed legs] had been with us for a short while, we accepted her as normal, except for that handicap. [This implies that at first they didn't accept her as normal.] </p> </blockquote> <p> We should like also to point out that devaluation of the total person does not always occur by way of single characteristics. Sometimes there seems to be a direct, all inclusive judgment of devaluation of the total person. It seems that the broader the meaning of the word "person" the less clearly does the judge perceive how the single scales determine his evaluation of the person. He has a vague feeling, for example, that a "cripple" is somehow "an inferior person." </p> <p> In speaking about devaluation of a person, then, we must ask two questions. Is his devaluation limited to particular characteristics or is he devaluated as a total person? Is he devaluated because only those scales on which he has a low position are taken into account or because these scales are given considerable weight when the scope of values is enlarged to include other characteristics of the person. </p> <h4> <i>Position of the Person</i> </h4> <p> To a judge, the permanence of a person's position with respect to the standard is important in his evaluation of the person. We may expect that devaluation will be less severe if, when taking the "time perspective" into account, the position of the person is seen to shift in the direction of the standard.<a style="text-decoration:none;">*</a> The judge may expect the shift for different reasons. In some cases, he may feel that the loss can be replaced in whole or in part. Thus, even a person who considers "home owner" as a characteristic of the person, and a minimum requirement for the role of a responsible community member, may not devaluate someone who suffers the misfortune of having his house destroyed. The judge may expect that he will again be able to establish a home and thereby to regain his former position. The loss is only temporary. </p> <p> In other cases, the person may be expected to adjust to his loss even though the lost value cannot be regained. The position of the person, then, is felt to shift so that he can meet the standards in regard to such values as, for example, adequate personality, social usefulness, and the like. For problems of injuries, the shift due to perception of adjustability is of particular importance. Even in those instances in which physical improvement can be limited only, the recognition that one can adjust to the injured state will minimize de valuative feelings. A noninjured woman says: </p> <blockquote><p>When I thought of the courage it took to ignore those handicaps, I felt humble. I felt that anyone who overcomes a handicap like that wins an added amount of respect from everyone.</p> </blockquote> <p> For this subject, the fact that the injured men were able to adjust to their handicaps led her to evaluate them not as inferior but, on the contrary, as persons meriting respect. </p> <p> We believe further that the judgment of adjustability will depend upon the adjustment of the judge. A person who feels in essence "What a terrible misfortune to be injured, I could never stand it. I would rather die," we consider maladjusted with respect to injuries. The following comments were made by noninjured people: </p> <blockquote><p> It wouldn't be worth while to live. I'd develop a complex and go off in my little hole. I'd go into hiding and not show my face for the rest of my life.</p> </blockquote> <p>To such people it will seem impossible that one can adjust to injuries. </p> <h4> <i>Standard</i> </h4> <p> In connection with the term "standard," we have previously noted that the standard may be another person, the same person at a different time, or some abstract norm. Frequently the abstract norm has the character of the minimum requirement for a certain role. If the person does not meet the minimum requirement, he will be judged as an unacceptable candidate for whatever role is in question (for example, that of husband, employee, team member, etc.) or he will be devaluated as unfit to continue in the role. This is illustrated by the noninjured girl who said: </p> <blockquote><p> He's correct in not proposing if he couldn't earn a living because of his handicap. </p> </blockquote> <p> In the extreme case of devaluation of the total person, the person will be thought of as an outcast. He does not meet the minimum requirements on a value scale which, in the opinion of the judge, everyone "ought to possess" in order to be a normal human being. Though such extreme devaluation is not often directly expressed, we do find, in the records of the noninjured, statements such as the following when severe handicaps are being discussed: </p> <blockquote><p> If you have no limbs you are not a person really. With both arms and legs gone the person isn't of any use, a detriment to society. </p> </blockquote> <p> When a person is above the level of minimum requirements or "ought standard" (either for a particular role or for a "normal" human being), he may still be devaluated as inferior, for example in comparison with some other person, but the devaluation will not be as severe. </p> <p> There are individual differences in regard to where the ought standard is set. For some it is simply undeniable that a man ought to be able to support his family entirely by his own efforts. If he is disabled so that his wife must work, or if state assistance is required, he will be seen to fall short of this minimum requirement and will be judged unworthy to have a family. Some people may not see this as an ought standard at all; others may apply it to themselves and yet not require anyone else to meet it. </p> <p> We can now state that the most severe type of devaluation (devaluation as unworthy or unacceptable) will occur when the person, in the eyes of the judge, falls below the ought standard on a value scale. </p> <h4> <i>Conclusion</i> </h4> <p> It is obvious by now that the value structure of the judge is of utmost importance. Devaluation will depend upon whether the judge regards the values in question as possessions or as personal characteristics. It will depend upon whether the judge considers the values as comparative values or as asset values. It will depend upon whether the judge regards the person only in terms of single value scales on which he has a low position; whether the judge regards these values as decisive in the context of other characteristics of the person, that is, when the scope of values is enlarged; or whether in this context they are felt to be nonessential. It will depend upon whether or not the judge regards the state of the person as an unadjustable one. It is up to the judge how high the standards will be set, whether he considers a particular standard an ought standard for <i>his </i>concept of the role of husband, father, etc., or of a "normal" person, and whether the standards are flexible or rigid. It is not the objective loss but the values of the judge which determine devaluation. A remedy, therefore, is a change in the value system of the judge. The judge may be another person, or the person himself who experiences the loss. In the first case we speak of the devaluation of someone else, in the second case of self devaluation. </p> <h4> Conflict in the Noninjured </h4> <p> Devaluation of the injured, like the requirement of mourning, conflicts with ethical prescripts as well as with spontaneous, positive feelings toward the injured. The noninjured person does not want to hurt the injured. He tries to be tactful. He will not address the injured with an emotionally loaded word like "cripple." He will be reluctant to say that the injured man is inferior, to be pitied, etc. He will not point to the injured part of the body. He will hesitate to mention handicaps in the presence of the handicapped person. He might sometimes dare to mention handicapped people who "get along amazingly well" (almost as good as a noninjured person) or who, like Roosevelt, are as good as the best noninjured. He might dare to say that he "would never have noticed it" or that someone else has not noticed it. He might feel a strong positive tie with the injured person and feel genuinely sympathetic toward him. </p> <p> Because negative, devaluating attitudes conflict with positive feelings toward the injured which are ethically prompted or which are spontaneous and genuine, we can expect that devaluation will seldom be manifested simply and directly but will tend, instead, to be covered up. For example, a noninjured subject who showed concern and warmth toward the injured could not admit his attitude that a handicapped person is less acceptable. But this status discriminatory attitude is covertly expressed when he says: </p> <blockquote><p>I can readily understand how they [people with less severe handicaps] might resent being classed with those who are totally handicapped.</p> </blockquote> <p>Another subject is able to express his de valuative feelings when speaking about himself if he were injured: </p> <blockquote><p>Without doubt I would be tremendously depressed [if I had an arm or a leg off] at the thought that your usefulness is over now and that you will be nothing but a burden from now on. </p> </blockquote> <p> But he is unable to leave the discussion on this negative level. He hastens to right the situation, to pay deference to the other side of the conflict, and adds:</p> <blockquote><p>But I presume that that would pass and with a little bit of expert help one could return to a normal life.</p> </blockquote> <p> It is also often difficult to disentangle just when the favorable, verbalized attitudes correspond to the underlying feelings and when they do not. When our subjects speak of the courage of the injured, their cheerfulness, perseverance, etc., they are expressing attitudes which overtly are favorable. Sometimes these attitudes seem to be prompted by ethical demands and sometimes they seem to reflect genuine feelings. One suspects that the positive feelings expressed by the following subject are glib and superficial: </p> <blockquote><p> I have met one woman in particular with both legs gone and she had artificial limbs and she got along beautifully. She lost her legs about a year before I met her. And she was very happy. I have more sympathy, and I thought she was very brave.</p> </blockquote> <p>On the other hand, in the following account a noninjured subject reveals a feeling of warmth and respect for the injured: </p> <blockquote><p> I went to a dinner party the other night for the wounded Japanese soldiers at —— Hospital. There were about a dozen of them one completely blind, two with partial sight, another with a leg off, another without an arm. When I first arrived I thought, "I can't bear this. I have never been able to look at suffering." I wanted to go away. I stayed. I got acquainted with these boys. They not only had the physical handicap. They had the racial handicap which is a serious one in this country. I stayed until midnight. I felt each one could have been a friend of my son. They were so courageous, so gay, so sympathetic and generous with the blind boy. They helped him so unobtrusively. I felt I had learned a great deal. I felt there was nothing we could do for them. They were doing for us ... . The way I felt about those boys I felt inferior. </p> </blockquote> <p> The conflict in the noninjured may be evaded or diminished in different ways. We should like to mention two phenomena which might be less obvious than simple avoidance of the injured as a means of escaping the conflict. These phenomena are aversion and spread emotional reactions which make it easier for the noninjured to avoid the injured Aversions have the useful quality of enabling the non injured person to feel that he does not voluntarily avoid the injured but that he does so for reasons beyond his control.<a style="text-decoration:none;">*</a> Spread, or the exaggeration of negative effects of an injury, may provide the noninjured with an excellent reason for excluding the injured from participation in activities which might, for example, be somewhat strenuous. And if one exaggerates the injured person's sensitiveness and withdrawing tendencies, ethical demands will not be obviously violated, since one can assert that the injured person would feel uncomfortable in the group or decline the invitation anyway. </p> <p> In the following chapter we discuss in detail one type of genuine and spontaneous positive feeling toward the injured—that of sympathy. </p> <h3> Chapter VI: Sympathy </h3> <p> Sympathy is brought about in the donor by the suffering aspect of misfortune rather than by the value loss aspect. As stated on page 8, our approach to the study of the sympathy relationship was to consider the total scope of meanings assigned to the word "sympathy" and then to extract those which were tied together by a coherent underlying structure. Pity and other devaluative meanings which the subjects sometimes give to the word "sympathy" do not belong to the same structure. </p> <h4> Primacy of Needs and Emotions </h4> <p> In the older treatises, sympathy was considered an instinctive, or at least an immediate, response to the perception of emotion in another; the perception of pain would bring about discomfort in the observer, the perception of joy would give him satisfaction. We would have no great objection to such a "theory" as far as it goes, but there are difficulties in its incompleteness. For example, we would be reluctant to term "sympathetic" one who, because of his discomfort on perceiving the distress of another, tries to escape the situation. </p> <p> It is essential for the sympathy relationship that the donor set aside his own needs and feelings in favor of those of the suffering member. The recipient will then feel that his needs and emotions are given primacy, and only then will he feel that the donor is sympathetic. The conditions leading to the existence of primacy of needs and emotions of the other are not known to us and require further study. Most frequently it arises in what we call "we groups." The partners in a we group feel bound together by strong ties of friendship, family, etc. They like each other, enjoy being together, need each other. But relative contributions are not measured; comparison of values possessed is not in order; what is important is "we" rather than "you as compared with me." The group is characterized by the sharing of the feelings of one member by the other. The partner is pleased with the joy of the recipient; he is made sorry by the recipient's sorrow. As an injured man says: </p> <blockquote><p> Love for a certain person, that is why you feel sorry. I know my mother feels awfully sorry that I lost my arm. Every time something happened to me my father too felt awfully sorry for me. It was just that he loved me. You just can't get away from it I guess. </p> </blockquote> <p> Instead of putting one's own needs always first, primacy is given to those of the other when they are felt to be more urgent. Exceptional stress and exceptional happiness of the other take precedence over the everyday level of feelings of the donor. He sets them aside and participates in the intense joys and sorrows of the partner. </p> <p> Primacy of needs and emotions, however, does not arise in we groups only. It may exist between people who have no lasting relationship with each other, whose relationships are as tenuous as being fellow Americans in a foreign country or even passers by. What the forces are which keep the donor in the negative distress situation in these instances are not known. </p> <p> What primacy of needs and emotions implies in the sympathy relationship may be described under the headings <i>Congruence, Understanding, </i>and <i>Readiness to Help.</i><a style="text-decoration:none;">*</a> </p> <h4> <i>Congruence</i> </h4> <p> The injured sometimes slate that no one can ever really know what it is like to be injured unless he is himself injured. Those who would urge this against the possibility of real sympathy would probably subscribe to the "identity theory" of sympathy. This as usually stated is "seeing and feeling the distress as the other person sees and feels it." An injured person who rejects sympathy gave this as a reason: </p> <blockquote><p> It's very easy for a person to sympathize who hasn't had the experience himself. It would be a very shallow thing. It wouldn't mean anything to me ... . How can you sympathize with me if you haven't lost your father and I have? You wouldn't know what it is like. How can a fellow sympathize with you if he hasn't lost the leg or the arm? I don't think he could do it. </p> </blockquote> <p> It should be clear that primacy of needs and emotions does not imply identity of feeling. We doubt that the feelings of the donor and recipient can be identical. Nor would identity have advantages. The donor cannot <i>see </i>the situation as the recipient sees it. He cannot know all the emotional ramifications of being injured. And even if he were to understand much of what it means to be injured, he would not feel the suffering in the same way as the injured person does. He does not suffer the actual social deprivation nor the self devaluative feelings of the recipient. The recipient is distressed over the loss itself, the donor because the recipient suffers. The <i>content </i>of their distress is therefore different. Even in the case of a sharer (e.g., a wife or mother) who may himself experience loss, the content is still different. </p> <p> The donor need not approach the <i>mood </i>of the recipient in intensity, nor is it necessary that his mood be the same qualitatively, as long as it is not incongruous. If someone is depressed, a sympathizer need not also become depressed. There are other manifestations of concern sufficiently in harmony with the mood of the recipient to be considered sympathy. On the other hand, gay attempts to divert him will seem incongruous and may be considered an indication that the donor does not give primacy to the needs and emotions of the recipient. </p> <p> Moreover, were the donor to feel precisely the same way as the recipient, it is questionable whether any <i>action </i>he could take would be effective in diminishing the distress. The anxiety and fearfulness of the recipient, for example, would prevent him from realistically evaluating his situation. A similar anxiety and fearfulness in the donor would also act as a barrier to adjustive effort. </p> <p> Thus the donor and the recipient <i>perceive </i>differently, <i>feel </i>differently, and <i>act </i>differently. Congruence rather than identity is required in each of these instances. What makes for congruence is an important problem meriting special investigation. </p> <h4> <i>Understanding</i> </h4> <p> In a distress situation there are in the recipient two conflicting needs that must be taken into account by the donor. On the one hand the recipient wishes to remain in the area of preoccupation with his loss because of attachment to the object of loss, desire for clarification, etc. On the other hand, he wishes to leave the area because of the negative character of the situation (the unpleasantness of the state of depression, a feeling of unproductiveness, etc.). A clear example of both tendencies is found in a bereavement situation in which, in spite of the negative characteristics of grief, one wishes to continue to mourn as an expression of devotion to the person he loves. The first thing the donor must understand, then, is this conflict in the recipient. He must not only be concerned about the emotional state of the recipient in the sense of wishing to help him leave the negative area; he must also give sufficient weight or respect to the reasons which produced the distress and which keep the recipient in the area of preoccupation with the loss. When either of these attitudes is felt to be lacking, the recipient feels that he is not understood. For example, a mother may be genuinely concerned over the unhappiness of her adolescent daughter, but if she tries to soothe her by saying, "It's only puppy love. You'll soon forget all about him," the daughter, even when recognizing her mother's concern, will feel that she doesn't understand and thus that she is not really sympathetic. Similarly, if someone tries to "cheer up" an injured friend by saying, "Oh, you'll soon get a new leg," he may be felt to take lightly the feeling of loss which the injured man experiences. It is equivalent to saying to someone bereaved, "You'll soon get a new wife"! In the following instance an injured man defines sympathy entirely in terms of giving sufficient weight to the reasons for distress: </p> <blockquote><p> Sympathy is appreciating the difficulties you might have.</p> </blockquote> <p>The wish for respect to the cause of distress is seen in the following statements made by injured subjects:</p> <blockquote><p>[People say] "Now before long you'll be as good as new." That's a bunch of posies all for naught .... They don't know what they're talking about .... Though people say, "Oh you'll forget it in a few years," they're always the people who aren't injured. </p> <p> People would come in and tell me how lucky I was. It was just that they were trying to put a whole new set of values on my misfortune. If there is anything you feel about it, it is that it was not lucky. </p> </blockquote> <p>The sympathizer cannot take lightly any features of the situation which are of great moment to the injured even though, in his efforts to bring about emotional relief, he may try to emphasize certain positive aspects. </p> <p> It is important to point out that the word "understanding" is misleading when it is taken to imply only a conscious intellectual appreciation of the diverse meanings which the loss has for the injured. When the injured speak of a person who understands, they sometimes speak in these terms: </p> <blockquote><p> Probably that girl could not answer your questions but she just knew. Some people are like that. . . . There is a person that just has an instinctive good taste and quality in her.</p> </blockquote> <p>It seems as though there is such a thing as emotional understanding that is, grasping the emotions of the other person directly on the emotional level without the intermediate step of intellectual realization of these emotions. The distinction between intellectual and emotional understanding is clearly brought out in the following statement of a noninjured woman: </p> <blockquote><p> Every mother thinks about the possibility of her son coming back wounded or disabled. ... I don't know just how I would react. . . . You would have to feel your way along and learn every day. But if you really love and understand them, you would learn very quickly, by experimentation, and I think you would have to give it a great deal of deep thought, and you would have to have a lot of wisdom, but wisdom comes in an emergency of that sort. [Interviewer: When you said wisdom, that implied intellectual knowledge.] Not necessarily. I would say more a wisdom of the heart. </p> </blockquote> <p> There is nothing mystical in the fact that one may react before having time to understand intellectually. We spontaneously catch a ball suddenly thrown to us without intellectually deciding on a course of action. Similarly, in the case of emotional relationships we frequently react in an appropriate way which is called "intuitive." It seems necessary to assume that the speed of emotional processes is greater than the speed of intellectual ones and that, in communication, emotional grasping of the feelings of another person is faster than intellectual grasping.<a style="text-decoration:none;">*</a> Intellectual understanding may, however, enhance the relationship in which emotional understanding already exists. It may increase the effectiveness of the help offered because intellectual understanding may lead to useful suggestions which the recipient may be ready to accept. </p> <h4> <i>Readiness to Help</i> </h4> <p> It is not by chance that expressions of sympathy are usually followed by some such statement as, "If there is anything I can do, let me know." Such readiness to help should be considered as much a part of the structure of sympathy as congruence of feelings and understanding. This is demonstrated when the injured inveigh against the "so called sympathy which is nothing but words." For example: </p> <blockquote><p> The good kind you try to do what you can for them to help them out. The bad kind they just say they feel sorry and let it go at that. </p> <p>Oh, absolutely [there is a good and bad kind of sympathy]. But it can be expressed through actions rather than through words fidelity, sticking by you through thick and thin. </p> </blockquote> <p> The kind of physical help which is acceptable is elaborated elsewhere<a></a>. In the sympathy relationship, we are especially concerned with emotional help in overcoming feelings of distress. Whether or not this type of help will be acceptable will depend upon whether the donor continues to be guided by the recipient's wishes and also upon his knowlesdge of the relative strength of the momentary tendencies toward and away from the distress area. The donor should be passive or active depending on these wishes and tendencies. </p> <p> When the tendency to stay in the area of concern with loss is very strong, the recipient may want nothing more than assurance of concern, an understanding listener, or the comfort of bodily contact with a person with whom strong ties exist. The word "passive" should be taken very seriously. Expressions of concern which are uncontrolled and immoderate may be very disturbing. A few subjects give hints as to why demonstrative manifestations of sympathy are disturbing: </p> <ol> <li>The injured person may be so keyed up emotionally in regard to the whole injury situation that additional emotionality is difficult to bear: <em>Sympathy is disagreeable to the man because of the state of emotion he is already in.</em> </li><li>Any strong emotional expression may make the man feel that his situation is even more unfortunate than he thought it to be. It can easily lead to a feeling of futility of his attempts to adjust: <em>I don't want them to cry. It makes me feel sick I can do anything anybody else can but when they do that I would have to feel that I would have to give up trying to do things.</em> </li><li>The man does not know how to act when strong emotionality is shown. The situation tends to become unstructured. Embarrassment results: <em>Sometimes a motherly old gal embarrasses you with how sorry she feels for you.</em> </li><li>Strong emotionality may arouse feelings of guilt in the man at having caused so much distress: <em>I don't want anybody to feel sorry for me Sorrow isn't a thing to share.</em> </li></ol> <p> Further, there are other important reasons why the injured objects to excessive emotionality. The injured may doubt the sincerity of the feeling, and any demonstration may convey to the injured that the donor is trying to make sure that his "goodness" is appreciated by the injured (page 31). We wish especially to stress the fact that excessive emotionality has also the danger of making the donor imperceptive to the shifts in feelings and changes in needs of the sufferer. It is important to note that in the opinion of the injured a deep positive feeling on the part of the sympathizer can be conveyed to them without any emotional display. They object to shallow sympathy, but shallow sympathy is not, of course, equivalent to sympathy that is manifested simply and without elaboration. <i>Active </i>help requires that the donor be alert in watching for an occasion when he can strengthen the forces in the recipient in the direction of leaving the distress area without provoking resistance from the recipient. One injured subject identifies this as encouragement rather than sympathy, but the idea is essentially the same: </p> <blockquote><p> You can always take encouragement. More than sympathy, it is the cheerful look, not a sorrowful look a feeling of raring to go that kind of infects you not the idea that the world has gone wrong. </p> </blockquote> <p> Yet sudden or too strong or persistent urgings in the direction of leaving the area reflects on the genuineness of the donor's appreciation of the cause of distress. At the first sign that he has proceeded beyond the ability of the recipient to follow him, the donor must be ready to abandon any benevolent attempts. Because the emotions of the donor are not identical with those of the recipient, because he is not so depressed, he is already a step ahead in the struggle to overcome the distress. It is this discrepancy in feeling which gives the donor the possibility of shifting the recipient in positive directions. But the emotional change required of the recipient cannot be too great. Only small steps can be taken, the size of the allowable step being not infrequently smaller than the donor wishes would be possible. </p> <p> The meaning of size of step may be grasped more fully if we consider the parallel case in the intellectual realm. A teacher may explain too quickly or may omit necessary intermediate points. The student is then unable to follow because the size of the steps taken by the teacher has been too great. In the emotional realm, we may take the case of a noninjured person who, wishing to overcome the brooding of his injured friend, suggests a joyful interlude. Though the injured friend <i>also </i>wishes to overcome his brooding, merrymaking requires too great an emotional change for him. It is interesting that when someone is deeply distressed a sympathetic person may suggest a cup of tea. This may represent not only concern for needs which the sufferer himself might neglect; it is also a shift from preoccupation with loss to an activity which is neutral enough not to seem incongruous. It will also not be seen as too great an emotional step if the donor gradually aligns himself with and strengthens those positive aspects which the recipient might express, for example that he has the fortitude or stamina required, or the hope of an eventually successful outcome. </p> <h4> Spontaneous and Ethically Dictated Sympathy Sincerity </h4> <p> In the absence of spontaneous sympathetic feeling, there may still be strong social pressure to play the appropriate role. Thus, besides sympathy based on genuine primacy of need of another person there is simulated sympathy— sympathy for the purpose of adhering to the ethical ideal that one <i>ought </i>to be a good person, which sometimes implies self aggrandizement. Most people will be able to recall being at one time or another donors of both kinds of sympathy—that which is "ought inspired" and that which is prompted by genuine concern In some instances the former will be difficult to admit to oneself. </p> <p> It is important that the dynamics of interrelationship between the donor and recipient is different in the two cases. If the sympathy is ought inspired, the donor will do as much for the recipient as is required by the donor's need to be "good." We cannot help but suspect that he will be guided much more by what <i>he considers </i>good for the other than by the needs and wishes of the person he is sympathizing with. The recipient distinguishes between spontaneous and ought inspired feelings of sympathy in the donor and speaks of them as "sincere" or "insincere." This does not mean that he always correctly detects them. But when the underlying feelings are seen as spontaneous and genuine they will be evaluated as positive, even though the recipient may not for other reasons welcome the overt expression of sympathy <i>(e.g., </i>because of lack of knowledge or sensitivity in the donor or because of some conflict in himself; see page 32). Positive evaluations of the genuine feelings are expressed in these terms: </p> <blockquote><p> I don't mind [if old friends say they are sorry]. Being a friend I felt that his word was sincere, coming from the heart. <br /> Sincerity means a lot.</p> <p>Yes [there is a good kind of sympathy and a bad kind]. You can always tell the person who does actually have a feeling for you and is sincere. </p> </blockquote> <p> Ought inspired sympathy can be evaluated as proper when seen as a formal expression of politeness. The donor thereby conveys only a recognition of the seriousness of the event and his intention not to intrude further into the privacy of the recipient. A limited interaction of this sort is accepted, but it must be brief and does not bear repetition. The injured say: </p> <blockquote><p> I think it is all right [for someone to say he is sorry on first meeting]. I think I would say the same thing. If he would let it go with saying he was sorry and not rave on about it. </p> <p>I don't mind anybody saying that. It's just like a person saying, "I'm sorry you are sick." Not if he just said it once. It's the same if you have lost a wife or relative or something; people offer their condolences. That is the same thing. It is all right if you don't overdo it. That is just common politeness. </p> </blockquote> <p> While this type of sympathy is less valuable to the recipient than is genuine sympathy, it bears no great dangers. Perhaps the only additional caution required is that overt expression of this sort of feeling should emphasize the event and not the man. To say, "I'm sorry it happened," conveys what is needed. "I'm sorry for you," may connote devaluation: </p> <blockquote><p> A person can say he is sorry it happened, but I don't want him to say he's sorry for me. . . . It's in the time element. Sorry it happened refers to the past and it doesn't mean he keeps right on feeling sorry . . . and pity and being sorry <i>for </i>a person suggests looking down. </p> </blockquote> <p> Though interactions of this kind are accepted, they are by no means considered necessary by the injured. But the injured know also that their acquaintances may feel embarrassed if they make no comment on first meeting the man after the injury. Hence, in addition to the evaluation of "proper," the same behavior may be regarded as <i>neutral or unimportant:</i> </p> <blockquote><p> They don't really need to say it, but it's all right. If they say [casually], "It was hard luck," it's all right. I'd just as soon they wouldn't say it. If it's a friend of yours, you know anyway. </p> </blockquote> <p>The evaluations become negative when the basis for the expression of sympathy is felt entirely to be a matter of obligation:</p> <blockquote> <p>Some people who are not so close to you feel they <i>should </i>give sympathy and say they're sorry you lost your leg. </p> <p>This sentimental stuff. It seems to be partly an act. Old people seem to think they are obligated. </p> </blockquote> <p>The simulated sympathy which is feigned for self aggrandizement or to satisfy some other need of the donor is rejected: </p> <blockquote><p>Well, there's the crocodile type [of sympathizer]. . . . Cries, you know, like the crocodile. Then . . . the he man type. He comes up and claps you on the back. All the time patting himself on the back. </p> </blockquote> <p> Ought inspired sympathy, when mistaken by the recipient for genuine feelings, provokes positive feelings toward the donor in return. When the recipient does reciprocate and later finds no real concern for his needs, he feels cheated or fooled first because he was under false pretenses drawn into serving as a means of satisfaction of the needs of the other; second because he was ready to accept emotionally this person whom he now rejects as unworthy; and third because, believing himself secure with this person, he permitted himself to expose his private and sensitive feelings. Insincerity in such a case is therefore threatening; it is rejected and avoided. </p> <h4> Desire To Be Noninjured </h4> <p> Sympathy may be unwelcome not only because of some failing of the donor but because of the recipient's own attitude toward his injury. To welcome sympathy means that the injured man must admit that the injury has made a difference to him, even if it is only in particular and confined ways. He must not only see himself in the sympathetic situation as an injured person but must also be willing to have the sympathizer see him as such. This is not easy to do if the man has negative emotional feelings toward being considered an injured man. The resistance against being regarded as an injured person may be seen in the man's resentment of sympathy when he says: </p> <blockquote><p> Servicemen don't want their family to feel sorry for them. . . . Some people feel sorry but not around Utah. They see a lot of it. They treat you just as if you were another man. </p> </blockquote> <p> The persistent demand by the injured to be treated like anyone else may be indicative of healthy attitudes when it reflects their resistance to being devaluated. But when it is a sign that the injured person doesn't want to share injury connected matters because he is ashamed of them, that he wishes above all else to be considered a noninjured person, then he must of necessity remain troubled. When he reaches the point where he can face the fact of his injury, then he becomes able to receive the comfort which sympathy may bring. </p> <h4> Sympathy and Adjustment </h4> <p> The desire of the sympathizer is to help the sufferer to reach a happier state, to help him to adjust. The recipient, too, may wish sympathy not only because of the immediate comfort that it may give him but also because he hopes that the other will help him overcome emotional difficulties. But is there anything in the nature of the sympathy relationship as such which will assure better adjustment? Does it imply that the sympathizer will be better able to recognize intellectually or emotionally what leads to adjustment? Just as the recipient himself, the donor may err as to what is adjustive. He may lead in nonadjustive directions. One can say only that the sympathy relationship provides a favorable atmosphere for influencing the recipient, whether for better or for worse. </p> <p> There is, however, another point to be considered, namely, whether sympathy, as an expression of we group feelings, does not always have some adjustive value. Sympathy, as an expression of we group feelings, gives assurance that one is of worth to another person. We shall see that adjustment may imply the overcoming of the feeling of worthlessness of oneself and meaninglessness of the world around. </p> <h3> Chapter VII: Acceptance of Loss </h3> <p> In the preceding two chapters we spoke about the meaning which misfortune has for the noninjured and about his feelings toward the injured. We indicated that these feelings lead to difficulties <i>(Misfortune, </i>Chapter V) and to attempts on the part of the noninjured to lessen the suffering of the injured <i>(Sympathy, </i>Chapter VI). In his social relationship with the noninjured, the injured has to find a manner of living most satisfactory for him. He has also to overcome certain individual difficulties in addition to those produced by social relationships. He has to accept both personal loss and social loss. </p> <p> The content of personal loss as felt by the injured may be conveyed by the following statement ascribed by us to a leg amputee: </p> <blockquote><p> The leg which was a part of me and like the other is now detached from me. With it I felt free to move, to jump, to run, to play. I could move it, move with it; it moved me. I will be hampered. I will not be able to climb a mountain (even though I never climbed one before). I won't be able to dance or fight as well as before. I won't be able to take a job that requires standing for hours. The prosthesis can fail. I can slip and fall. I have to take care of the stump. When I look in a mirror I won't see a whole man; I will have to get used to seeing myself this way. I can't bound out of bed in an emergency. When I move I will think, "Is it worth the inconvenience and effort of getting up?" So much that I will do would have been so much easier; in a shorter time I could have done so much more. I will always be less able than I would have been. I was a better man when I had my leg and amounted to much more than now. I will never be what I wish I were, and ought to be had I the leg. </p> </blockquote> <p> In suffering from social loss, the individual suffers as a member of a group. He feels that he is not accepted as equally worthy. Other values which the group can offer, such as companionship, are made inaccessible. </p> <p> The content of social loss as felt by the injured may be conveyed by the following statement ascribed by us to a leg amputee: </p> <blockquote><p> I will be considered inferior by others. They feel that I can't contribute my fair share. I will be regarded as a burden. They won't want to associate with me. They might stand my presence but not accept me as they would a noninjured man. Girls won't want to go out with me. People will be repulsed by the sight of me. </p> </blockquote> <p> One could consider each of these difficulties and see how each in turn could be overcome. This obviously is an endless task, for one could continue to enumerate specific sufferings involved in personal and social loss. Instead, it is more meaningful to try to see whether there are not some conditions common to diverse difficulties. Understanding of these conditions is actually a first step toward solving problems of adjustment, for only when they are clearly specified can we tell what it is that must be changed, and only then are we able to get some insight regarding the state to which it would be desirable to change and how to produce the change. </p> <p> The desired state which we call "acceptance of loss" does not mean becoming reconciled to one's unfortunate situation. Instead, acceptance of loss is a process of value change. Before discussing value changes, however, we wish to describe those attempts at adjustment which seem promising to the injured, yet not only fail basically to overcome the difficulties but even create new ones. </p> <h4> Maintaining the Noninjured Standard </h4> <p> The way in which the injured person tries to overcome difficulties is determined by the fact that his values are those of a noninjured person. A blow which damages a part of his body does not at the same time lead to changes within his value system.<a style="text-decoration:none;">*</a> He may continue to maintain the noninjured position as <i>the </i>standard of comparison and direct his efforts toward reaching it. He may cling to the belief that the way to overcome his difficulties is to be, in his own eyes and in the eyes of others, a noninjured person. To achieve the end of being considered noninjured, he uses all means available, both realistic and unrealistic ones. </p> <h4> <i>Realistic Attempts to Achieve the Noninjured Standard</i> </h4> <p> The realistic means used by the injured to be like the noninjured are strenuous efforts to perform certain tasks independently and to equal or surpass the success of the noninjured in certain roles. These attempts can be considered realistic because in certain limited ways they are successful. The injured can equal or surpass the noninjured performance on particular scales or in particular roles. But <i>if the sheer fact of being an injured person is a difference which makes a difference to the injured man, that is, if the noninjured remains the wished for ideal, no matter how often he does as well or better than the noninjured he will still devaluate himself as an imperfect noninjured person.</i> </p> <p> In their efforts to be noninjured, the injured impose upon themselves unnecessary strain, Whereas the noninjured person often readily accepts help when it is more convenient to do so than to perform a task alone, the injured person tends to be reluctant to accept help if the help is not absolutely necessary<a></a>. Thus an injured man says: </p> <blockquote><p> I wouldn't accept help except where absolutely necessary. Offers of help get me down unless I were in a real jam. [Interviewer: What do you mean by absolutely necessary?] Oh, something like an earthquake out here where I couldn't get my hands on my crutches in time. </p> </blockquote> <p> <b>And another says: </b></p> <blockquote><p> You'd like to be a lot more independent than you were before. If somebody opened the door before, you never paid attention to it, but they do it now and you notice it. </p> </blockquote> <p> In order to explain why the injured, in striving to be and behave like a noninjured person, is led to impose greater hardships upon himself, we must take into account that "help is necessary" has a double connotation. It means "Without help I will not reach a desired goal," and "I am not able." The latter implies comparison of one's own ability with that of another. "You cannot do it, but I can," is, in our ability minded society, a most unwelcome comparison. For the injured person who wishes to be noninjured, the ability comparison aspect of help has a greater weight than for the noninjured, and he wishes to deny that he <i>needs </i>to be helped. The necessity of the goal, therefore, has to be greater for the injured in order to overcome the resistance against being helped. This, we suspect, could be shown by a simple experiment. </p> <p> A scale of the necessity of help is constructed. One end indicates "help is a pure matter of convenience" <i>{i.e., </i>no great effort needed to perform the activity alone, but someone willing to share the effort), the other "help is absolutely necessary" <i>{i.e., </i>an important goal completely inaccessible without the assistance of another). We can then determine the points at which help will be welcomed by injured and noninjured persons. Judging from the data we have, we would expect that the point of acceptance of help by those of the injured who wish to be as much like the non injured as possible will not in general coincide with that chosen by the average of the non injured subjects but will be nearer to the point of "help is absolutely necessary." Thus, when the injured person in speaking about help says, "Treat me like anyone else," he may not mean "Give me as much help as you would a non injured person for whom a task is inconvenient." Instead, he may mean "Do not help me; a noninjured person would not require help in this situation." </p> <h4> <i>Unrealistic Attempts to Achieve the Noninjured Standard</i> </h4> <p> The unrealistic means toward being considered noninjured are the attempts to deny that an injury makes any difference whatsoever, either to the person himself or to anyone else. The injured man should forget and others should forget; if both would forget there would be no difficulties: </p> <blockquote><p> [Interviewer: How should a person go about adjusting?] <br /> I think he should forget about it. People should just forget what happened. If he doesn't think of it, it won't bother him. </p> </blockquote> <p> Two reasons seem to support the belief in this literal kind of forgetting. First of all, in the highly emotional striving for adjustment, the aim and the means are not sharply distinguished. "I wish my injury would be forgotten," and "It can be done by actual forgetting," merge together in an emotional state which leads to primitivization in thinking. </p> <p> Secondly, the injured man does many things without feeling like an injured person. When he is in a bar, reading the comics, discussing political affairs, and so on, the thought that he is an injured person may not enter. In such situations he escapes the painful devaluative feelings associated with his loss. Temporary forgetting which the injured man does experience may make him believe that he can forget the injury most of the time. </p> <p> Temporary forgetting may not be altogether valueless in the process of adjustment. It may provide much needed emotional relief before one can again become involved with the problems brought about by other adjustment attempts. Consideration of problems connected with the injury goes on at the emotional level with such intensity that temporary escape may be welcomed as a psychological rest from too much strain on the organism.<a style="text-decoration:none;">*</a>But the injured person realizes in time that it is not only hard to forget what exists but that also so much happens which may "remind." Thus an injured man who said, "You can forget you are hurt if everybody ignores it," a few sentences later complained, "If you go out you can hardly go through a day without people asking you about it." And reminding is not due only to the incorrigibility of the non injured. A person who wears a prosthesis, for example, has to put it on and take it off. The injured often has to enter situations in which other people are handicapped, and again he is reminded. Thus even if one could willfully forget, one would constantly be reminded by new occurrences. The wish and the impossibility of forgetting are brought out clearly in this statement: </p> <blockquote><p> More or less forget about it is the best thing, but how are you going to forget when everybody keeps reminding you of it? I guess in time to come they won't be half as curious and will accept it. ... I don't think about it unless someone speaks about it, or if I think about something I want to do and then I think, "Hell, I can't do that." You shouldn't worry about it, but you can't forget that one moment when you got hit. But it's about the future that you think. </p> </blockquote> <p> The belief in the possibility of literal forgetting gives way, therefore, to the feeling that the injured and noninjured should behave toward each other <i>as if </i>the injury did not exist: </p> <blockquote> <p>I'd just act normal, as if nothing had happened. <br /> The happy and perfect thing is to have it ignored completely. <br /> [Forgetting?] That's hardly possible but we can all make believe. </p> </blockquote> <p> It is evident that such behavior does not really mean that the man will be considered noninjured. On the contrary, it is implicit in acting "as if" that he actually is not noninjured. </p> <p> As in the case of temporary forgetting, which has some positive aspects, so also "as if" behavior has its assets, though they be limited. The injury may be considered a personal matter, and "as if" behavior serves the purpose of keeping others from intrusion into privacy. Thus, under certain circumstances, "as if" behavior may be appropriate, especially where strangers are involved. But "as if" behavior, again as in the case of the attempt to forget, brings about difficulties in the relationships between the injured and the noninjured. When the participants in a relationship are closely associated, persistent role play has negative effects. First, if each feels that he can never relax his guard there will be a constant strain. But worse than that. It is characteristic of close relationships for the partners to share their feelings. If the formal surface behavior which is appropriate to stranger relationships persists, they will begin to feel like strangers to each other. Closeness, which is built upon easy communication, sharing of feelings, the warmth of sympathetic interactions, gives way to estrangement. Basic understanding between the persons cannot be reached. The injured person will continue to feel that he is not understood and cannot be understood.<a></a> Again, as in the case of help (page 34), the injured deviates from the actual behavior of the noninjured, for the noninjured does not ordinarily impose such restraint upon himself and does not in time of stress deprive himself of the comfort of sympathy. </p> <h4>Some Value Changes Involved in Acceptance of Loss </h4> <p> Denial that a difference exists, as we have seen, not only does not overcome difficulties; it may actually create new ones. But above all it hinders basic adjustment, for admission that a difference exists is a prerequisite for the further step of accepting the difference as non devaluating. Most important for the process which we have called "acceptance of loss" is a process of revaluation. Although this process is too complicated to permit us at present to make more than a few statements regarding either observed changes or possible ones, we can present, as an incentive to further study, the advances we have thus far made in understanding it. </p> <p> The first problem is why revaluation should be so difficult for the injured. Why, in the face of persistent difficulties, do they cling so strongly to those evaluations which hurt them? Two reasons may be mentioned. First, the injured seem to feel that, since abnormality of the body connotes psychological deviation or even mental abnormality to some people, they will only strengthen this impression should they maintain values which differ from the noninjured's viewpoints and ideals. Second, and most important, is the fact that to produce value changes on the emotional level is at least as difficult as to change the needs of the person. Though one may easily convince a person intellectually of the advantage of adhering to different values, their actual integration within the value system of the person is bound to meet resistance. This is understandable if we consider that single values are not independent from other values of the person, so that one change in the value system necessitates making changes in other values or giving them up. </p> <p> Some of the value changes which we believe would do much to overcome suffering from loss may be examined in the light of certain considerations brought out in the discussion of devaluating misfortune. First, devaluation will be diminished to the extent that the values lost are felt to be nonessential for the evaluation of the person when the scope of values is enlarged to include other personal characteristics. Second, devaluation will be overcome when the values lost are regarded as asset values rather than as comparative values. A third possibility, viewing the value lost as a possession value rather than as a personal characteristic (page 22), doubtless has ad justive significance, but this will not be further elaborated here. </p> <h4> <i>Enlargement of Scope of Values</i> </h4> <p> We may describe two examples in which enlargement of scope of values takes place.</p> <p><i>The State of All-Inclusive Suffering. </i></p> <p>For the injured person to see the lost values in a larger setting of other values is of special importance in the case where he feels he has nothing more for which to live. The problem then is to bring about the emotional realization of the existence of other values. Some injured subjects have admitted that in the initial stages their suffering was so acute, the experience of loss (of both personal and social values) so overpowering, that the idea of suicide presented itself. In such a state the loss seems to pervade all areas of the person's life. Whatever he thinks about, whatever he does, he is troubled, pained, and distressed. There is no differentiation between areas of the person which are and are not injury connected. All that matters are the values affected by the injury, and they are lost. No other values in life are important or even exist. </p> <p> There are two characteristics of such a state which make the thought of suicide likely. First, the perception of only a single area which is characterized by suffering means complete devaluation of one's life. Moreover, the suffering seems to be boundless, not only in extent but also in time. If no other area is seen, then there is nothing to which one can hope to change. The only hope of escaping suffering is to leave life altogether.<a style="text-decoration:none;">*</a> </p> <p> Fortunately, such black depression and despair does not persist in most of the injured who experience it. There is a gap in our knowledge as to just how it is overcome, but what is necessary is the perception of something besides suffering in life. It may be that, when the decision to commit suicide is made and when only execution of the plan remains, the injured may look back at what will be given up: suffering <i>and life. </i>When fighting against living further is no longer necessary, as it is before the decision is reached, life itself may be seen as a value. At such a moment this sudden experience of something else than suffering may be sufficient to give the first hold and with it the feeling of hope and strength which we have called the "stamina experience," so distinctive and easy to recognize when encountered, although difficult to convey, that it was named long before its place in problems of value change was seen. </p> <p> Those who have had the stamina experience know that life is worth living again. They feel that'' they have been all the way down to the last door and come back," that no other enemy will ever be so formidable. The realization that the essential value of life is regained means that the unbearability of the situation has been overcome. It means that the person is able to attend to what life holds for him, to begin to appreciate the fullness of meaning of having what he does have. As one very severely injured man put it: </p> <blockquote><p> You gradually see that there is more to life than you thought possible. . . . They all think at the beginning that they are no good. Why there was a fellow here the other night who had a couple of fingers missing, and you would think there was nothing worse under the sun. And I said to him, "Well, son, you still have a pair of arms, a good pair of legs, a good pair of eyes. Why just think of it! I would be glad to have a good pair of anything." </p> </blockquote> <p> Another injured man stated: </p> <blockquote><p> I have a sharper appreciation of things I valued before health, happiness, comfort, friendship. I am a hedonist. I feel lucky for just being here.</p> </blockquote> <p>And still another calls it a "conversion to life": </p> <blockquote><p> Before, when I would try to analyze myself, I would come against a blank wall. F'or seven months I don't think half the time I knew what was going on. . . . Some things have become more important that before seemed so unimportant, and consequently less important the other things that seemed so important before. ... I never had a clear conception of what it meant to live. In other words, I have come to the conclusion that most people go through life and never accomplish anything. They just live. They eat and sleep. . . .Cows I call them . . .They just grow and disintegrate. ... I feel that if I don't make a contribution what's the use of having come back alive. I don't want to waste my life now. . . . [Interviewer: It's almost a religious experience.] Well, it's a complete change. . . a conversion to life. Religion is another thing. . . . You have got to dance, to laugh, and have your fun, but also you can put your aims on a higher plane. </p> </blockquote> <p> The injured frequently maintain that "It is up to the man himself," to overcome the depression in the acute suffering stage. In other words, perception by an outsider that something other than suffering exists is felt to be unconvincing to one who is within the area which seems all pervading. Some injured therefore state that the depressed one should be left alone. Others, however, try to overcome what they call "self pity" in a friend by scolding and ridicule: </p> <blockquote><p> That's all within the man himself. I have seen them when they haven't anything to live for after the injury. [One guy] wasn't eating, feeling so sorry for himself. I called him everything but a gentleman. I called him everything I could think of. After that he started eating. </p> </blockquote> <p> The fact that the friend is hurt and feels these insults to his manliness means that he discovers at least pride as a remaining value. As different as the overcoming of depression by oneself or with this sort of "help" may be, they have in common the finding of a value at a time when every value is lost. </p> <p> The method of hurting the injured man during depression should not be given as a recommendation to the noninjured. Such behavior on the part of the noninjured would simply intensify the feeling of being devaluated. When the injured use this method it means "He is not devaluating me for being injured but for being unmanly." At the same time, the injured friend is there as an example that one can be injured without feeling that everything has been shattered. </p> <p> What the conditions are which give the values of manliness, of pride, the power to restructure the meaning of the lost values so that they no longer dominate the person's life needs further investigation. Though the lost values may retain their importance, the stamina experience brings with it the strength and hope which make the injured person feel that he is ready to live further <i>in spile </i>of difficulties. An important condition toward overcoming devaluation is thereby realized. The injured state is no longer regarded as an unadjustable one. At least in the sense of being able to make a go of it in spite of difficulties, the person feels he can adjust (page 24). But though the worst consequences of loss may be avoided through enlargement of scope of values, it does not mean that all suffering is overcome. It does mean, however, that the person has been faced with the necessity for revaluation. He has had to see the place of the lost values in his whole value system. In this way he is a step ahead, for adjustment, when the person is not in a depressed state, also entails value changes. </p> <p> <i>The Problem of Appearance. </i>A person may be bothered by his appearance because he feels that it discounts his attractiveness to others. The injured person may believe, for example, that when someone looks at him his scar is seen and nothing else matters. We propose that devaluation due to damaged appearance will be diminished to the extent that surface appearance is felt to be nonessential for the evaluation of the person when the scope of values is enlarged so that surface appearance is included within personality appearance. Actually, the perception of the appearance itself may then change so that it is seen in light of the personality. Thus, whatever the objective condition of the surface appearance may be, when one reacts positively to the person the appearance may be felt to be attractive. Of appearance, a man who was undergoing plastic surgery had this to say: </p> <blockquote><p> Some people who you can look at their picture and say that they are extremely homely and yet the people who know them will swear that they are good looking. I heard that people used to think that Lincoln was very handsome. A man could not grow an awful lot homelier than Lincoln. . . . There are certain things in a man's face that are an indication of his character, and if those things are what you like they make him good looking despite the fact that his features are a little irregular. </p> </blockquote> <p> In this case the attractiveness of a person is determined not primarily by a smooth, unblemished surface appearance but more decisively by his personality, from which scars may not detract. </p> <p> Many people quite naturally judge a person's attractiveness in terms of his personality. Under certain circumstances it seems that the influence of personality recedes to the background while that of surface appearance becomes the focus of attention. In the case of the injured, primacy of surface appearance leads to devaluation, so that the integration of surface appearance within the context of personality should diminish suffering. The conditions which determine the primacy of personality or surface appearance is a problem requiring special investigation. </p> <p> We present below an excerpt from an interview with a person who has a severe facial injury. During the interview, the evaluation of the appearance or attractiveness of a person is seen to change from surface appearance to personality appearance: </p> <blockquote><p> <i>Subject: </i>Undoubtedly at first it is a great shock to a person's family their loved ones when they see him with his features changed from what he was before. It is a great shock at first. They have to be around him for a while before they realize that fundamentally he is not changed. <br /> <i>Interviewer: </i>Do you think, actually, it is a big shock? I don't think so. I am speaking from my own experience, I am asking you, what do <i>you </i>see in a person you meet a new person what do <i>you </i>see? <br /> <i>Subject: </i>The first thing you see is his appearance. <br /> <i>Interviewer: </i>Why do you say that? The first person you saw here was John Hall. When he came in, what did you see? <br /> <i>Subject: </i>A fine looking young man a gentleman. <br /> <i>Interviewer: </i>Now, has gentleman anything to do with a scar? <br /> <i>Subject: </i>No. <br /> <i>Interviewer: </i>Now let us say there is a new doctor on the ward. He comes in. What do you see? <br /> <i>Subject: </i>It is hard to say. If he has a strong personality, the first thing you see is his personality. Is he capable? How he approaches you. <br /> <i>Interviewer: </i>That is it. Myself, I think is it a nice person? Do you see? It is the kind of person. What kind of a nose? Do you remember the kind of nose John Hall has? What kind of mouth he has? <br /> <i>Subject: </i>Not distinctly. But if there had been something outstanding, for instance a bad scar, you would remember, wouldn't you? <br /> <i>Interviewer: </i>Now, for instance, when you look at the patients in the hospital, what do you notice about them? <br /> <i>Subject: </i>The boys, when you first see them, you notice first their scars. <br /> <i>Interviewer: </i>The first moment? <br /> <i>Subject: </i>The first moment. That is the hard part. <br /> <i>Interviewer: </i>How long? <br /> <i>Subject: </i>Until he says something. Then you start getting an idea about his personality, and once you start thinking of him as he really is, you don't think of his scars. You don't remember them. <br /> <i>Interviewer: </i>You can see the nose of a person, but when you speak to a person you don't notice the nose. You notice the personality, because you see you looked at John Hall, and you only saw the personality. <br /> <i>Subject: </i>The way I was impressed that is the way I was impressed. That is new. I hadn't thought of that before. </p> </blockquote> <p> In the above example, the attractiveness of a person is seen primarily in terms of the more inclusive personality appearance rather than in terms of surface appearance. If this is a lasting change, then we can expect that for this subject devaluation of the injured due to damaged surface appearance will be diminished. </p> <h4> <i>Change from Comparative Values to Asset Values</i> </h4> <p> Two situations involving a change from comparative to asset values may be described. </p> <p> <i>The Problem of Mourning. </i>A person may mourn his loss because the personal satisfactions which the object of loss gave him in the past are now denied him. For example, the injured man may feel, "With the old leg I was free to move, to jump, to run, to play. I could move it, move with it; it moved me." Overcoming of mourning does not require a lowering of the level of aspiration (being satisfied with less), nor does it require depreciating the object of loss. What seems to be necessary to overcome mourning is a change in relationship to the object of loss. </p> <p> In the case of loss of a person, the one bereaved must recognize that, although further <i>interactions </i>with the person are impossible, a <i>relationship </i>nevertheless can still persist. Some of the values which they had formerly shared, and which, in his first grief, he may have seen as dependent upon the presence of the lost one, can be kept. He can do what the loved one would have done and wanted him to do. He can bring up his children to observe the traditions which his wife had begun. Then he can look back upon the past with tenderness rather than rejecting any painful reminders of it. </p> <p> Some similarities may be found in the change of relationship to the lost object which is necessary in the case of the injured. An amputee, for example, has to feel that the most essential functions which the limb had formerly enabled him to perform can be carried on by the stump and the prosthesis. He has to feel that he is still an intact organism, a whole man. A change of feeling has to take place from that expressed by one subject: </p> <blockquote><p>What does she see when she comes in? Half a man lying on the bed. . . .</p> </blockquote> <p>to that expressed by another:</p> <blockquote><p>I am a long way from worthless. I am still a good man without the leg.</p> </blockquote> <p> Such a viewpoint implies that one turns to the satisfactions existing in the present and does not derive essential satisfactions or dissatisfactions from comparison with the noninjured state in the past. It means that a leg as a value has changed from a comparative value (without which one is inferior) to an asset value (a good thing when it is present). If such a change takes place on the emotional level, the past can be remembered without pain but with tenderness with that tenderness which old people not infrequently feel toward the reminiscences of their youth. The two states of the person before and after the change can be described as, first, "I am nothing but an incomplete noninjured person who has always to mourn his loss," and, second, "I am as I am, and though I don't have all the possible values which can be <i>imagined, </i>my life is full." </p> <p> <i>The Problem of Disability. </i>The change from comparative to asset values is indicated not only when the person suffers because of personal loss as described above but also when he suffers because of loss which is socially evaluated. As an example, we shall consider the disability aspect of the injury. </p> <p> To call someone disabled implies that <i>performance </i>determines the evaluation of the person. In our society, people are frequently compared with each other on the basis of their achievements. Schools, for example, are predominantly influenced by the achievement or product ideology. High grades are given not to the one who worked hardest but to the one who performed best. Under certain circumstances, of two who reached the same performance level, the one who did so with greater ease is considered the better. He is seen as potentially a better producer than the one who had to work harder. Thus, effort is not always considered as a positive value but, paradoxically, sometimes as a liability. </p> <p> If one would follow the maxim which also exists in our society to the effect that, "All that is expected of you is that you do your best," it would mean that the person would not be compared with others in regard to ability; it would mean that his own state matters and thus that it does not matter whether he lost or lacks ability. Actually, one wishes to say, a person does not lack ability; he can only <i>have </i>it. In everyday life we do evaluate as equally good citizens those who pay taxes according to their financial state. The injured who applies himself with effort contributes the most that he can as a <i>person. </i>Though the unsatisfactory physical tools of his body may have limited his production, his personal contributions are at the maximum. As a <i>person </i>he is not different from the noninjured. </p> <p> Effort as a basis for evaluation is observed in the injured. A bilateral amputee stated: </p> <blockquote><p> Sorry is for someone who does his damnedest but still he is physically unable to accomplish what he does in the best way. Pity is for someone you feel like he isn't putting everything into it. Not up to standard, up to what you judge by. Maybe I am wrong but that's the way I think of it. </p> </blockquote> <p> This man expresses the thought that, in addition to the scale of achievement ("accomplishing what one does in the best way"), there is another scale, that of effort ("doing one's damnedest," "putting everything into it"), and that devaluation ("pity") should be reserved for those who are lower on the effort scale. Only those who do not put forth sufficient effort should be judged as "not up to standard." </p> <p> Why bring up the change from one comparative value (the product achievement value) to what appears to be just another comparative value (effort) when we are discussing the change of comparative values to asset values? It is true that effort, in this case, is seen as a comparative value, but when effort becomes the yardstick by which a person judges himself, then the <i>values lost </i>are changed from comparative to asset values. Greater ability or achievement becomes a good thing when it exists, but not a loss, or a lack, or a disturbance when it is absent. Such a change is but one among others that are required for the person to perceive his existing state as valuable rather than as a crippled, noninjured state. </p> <p> These differing evaluations of one's existing state have important consequences. The particular problem which we should like to discuss as an example is the effect of the two evaluations on the readiness of the person to improve wherever realistic improvements are possible and on his persistence in bettering his state. </p> <p> It would seem at first glance that maintaining the noninjured state as the standard would have the advantage of leading the injured to increase his efforts, for example in dealing with the physical environment. The injured would desire the best prosthesis, try to improve in using it, and learn as many skills as he could in order to be able to perform the physical tasks which the noninjured can perform. But the desire to be able to handle the physical world does not stem only from the wish to be as much like the noninjured as possible. We even doubt that the desire to be as good as the noninjured is helpful. The injured person who emotionally desires to be noninjured will see even objective improvement over previous performance as still falling short of the goal and hence failure. The same objective improvement can be seen as success (in comparison with recent performance) or failure (in comparison with the noninjured). The following two examples illustrate the different feelings resulting from the different evaluations of one's present state. In the first, "always wondering whether I could have done better" indicates feeling of failure, in the second, "enjoying learning over again" a feeling of success: </p> <blockquote><p> We'll be satisfied with less but there'll always be a little bit of doubt as to whether we could have done a little bit better without it. Maybe I'll be able again to play a good game of golf, but I'll always wonder whether I could have done better. ... In some part of your mind you just have to check off the fact that vou're missing something extremely valuable. </p> <p> The more you learn to use it the less it bothers you. If it's just hanging it will. . . . The more I learned the better off I was. ... I figured it was gone so I might as well see what to do about it. ... I enjoy learning to do things over again. It offers a challenge to you. I think, "What's the best way?" before I start fooling around. </p> </blockquote> <p> It seems reasonable to expect that, if a subject feels he is improving, he will hopefully continue. If he is constantly frustrated by unsuccessful attempts, forces away from the unreachable goal and disruptive emotional effects will appear.<a></a> </p> <p> Our discussion is of value for an important practical problem of the amputee. In trying out a new, technically improved prosthesis, some of the injured feel that it is an improvement and others do not. Besides the question of the physical fitness of the prosthesis for the individual, psychological conditions leading to the different reactions are important. It would be promising to study whether those injured who are dominated by the noninjured standard are more easily dissatisfied with the new prosthesis than are those who consider their postinjury state as valuable. We predict that the former group will more easily be disappointed because, in comparison with the noninjured standard, the results obtained with the prosthesis can be seen only as a failure. The latter group, however, will recognize any actual improvement and consequently will be encouraged to continue using the prosthesis. Those who maintain the noninjured as their standard require psychological adjustment before they will be able to accept an objective improvement as such rather than as a new indication of the unreachability of the noninjured state. We venture to say that only if the postinjury state is taken by the subject as a basis for comparison can he make valid judgments as to the advantages of the technically improved prosthesis.<a style="text-decoration:none;">*</a> </p> <h4> <i>Conclusion</i> </h4> <p> Acceptance of loss is seen as involving changes in the value structure of the person. We have pointed out only some of the changes which may lead to acceptance of loss. Clearly there are others. Our statements have to be taken as suggestions for further research rather than at their face value. We discussed four kinds of situations: <i>a, </i>overcoming all inclusive suffering; <i>b, </i>overcoming mourning; <i>c, </i>overcoming devaluation produced by damage to appearance; and <i>d, </i>overcoming devaluation produced by physical disability. </p> <p> The kinds of value changes that may alleviate the suffering in these situations are closely connected with those value preconstructs discussed under <i>Misfortune and Devaluation </i>(page 22). The value change involved in <i>a </i>and <i>c </i>can be seen as one in which enlargement of the scope of values takes place. In the case of all inclusive suffering, enlargement of the scope of values is the first step toward the possibility of acceptance of loss, since the main problem here is to regain, psychologically, values other than those lost. In the case of devaluating appearance, enlargement as such is not in itself an advantage unless with the enlarged scope of values the values lost are seen as relatively nonessential. In both cases, the person will maintain the noninjured standard and regard the values lost as comparative values. Thus, the person may still devaluate himself, for instance when a particular situation arises in which enlargement is made difficult. </p> <p> The value change involved in <i>b </i>and <i>d </i>can be seen as one in which the values lost are regarded as asset values rather than comparative values. In this case, the person feels that his own state is a worthy one. When, instead of selecting unreachable states as a standard, he turns to what he has and can reach, life can be seen to offer more than he can possibly avail himself of. He frees himself from devaluating comparisons with a ghost ideal of a different but actually not better person, the noninjured. Thus, acceptance of loss seems to be more fully realized through the second type of value change. </p> <h4> Acceptance of Personal Loss and Reaction to Social Loss </h4> <p> The injured person who has accepted his personal loss will feel one way about the discriminatory attitudes of the noninjured. He who has not accepted his loss feels another. The social loss of the injured person his feelings of nonacceptance as a group member has a basis in reality. Whether or not the person has adjusted to his loss, therefore, he will experience difficulties in his relationships with noninjured people. But the reaction in the two cases will be quite different. </p> <p> Where the person devaluates himself because of his loss, he will feel that his nonacceptance by others is largely justified. He will agree with the other group members that a noninjured person is more valuable, more likeable, more worthy. He will suffer keenly that he happens to be on the short end of this relationship, but he will see it as an unavoidable and natural fact, to be supported as morally valid. He will feel that no one can change this state of affairs that one can perhaps try to behave "as if" he were non injured but that emotional devaluation of him must prevail. </p> <p> If, however, the injured person has accepted his loss, he will not devaluate himself. He will consider himself an equally worthy member of the group and thus feel that he should be fully accepted by the group and have access to the values which the group can offer. He will see that it is the maladjustment of the noninjured toward injuries which leads them to devaluate and reject him, a fact which hinders him from having access to the values of the group. He will see that the locus of the difficulties is not in the injured who adjusted to his personal loss, not in the natural, lawfulness of devaluation of the injured, but in the noninjured. </p> <p> A considerable part of the suffering due to nonacceptance by others is thereby removed. Because the negative evaluations of others are seen as unwarranted, because the injured person does not blame himself, they hurt less. Instead, the person who holds them may in turn be devaluated and seen as ignorant or prejudiced. This counterdevaluation also may serve to diminish suffering from social loss.<a style="text-decoration:none;">*</a> </p> <p> Whereas the maladjusted injured person wishes to be accepted by the noninjured though he feels he ought not be accepted, the adjusted injured person will care less to associate with those whose values he does not share or respect. The adjusted injured person gains a considerable degree of emotional independence and freedom from the noninjured. This does not mean that the injured person does not and need not care about how the noninjured receive him. Even though he may not care to associate with a given person, he does wish to maintain close relationships with others. Moreover, in a world dominated by the noninjured, it is often the noninjured who determine whether the injured person can have access to important values such as jobs and group memberships of many kinds. Thus it is of vital interest to the injured that the noninjured become adjusted to injuries. </p> <h4> Acceptance of Loss By the Noninjured</h4> <p> Acceptance of loss is of great importance not only to the injured. Persons close to the injured (that is, those who are in the position of sharers), as well as the large number of non injured who have little to do with injured people, have much to gain from healthy attitudes toward injuries. The sharer suffers not only because the injured person suffers (sympathy) but also because he too experiences a loss (personal and social loss). A wife may feel the loss of her husband's leg just as personally, just as deeply, as the husband himself. The sharer has, therefore, to accept the loss just as does the injured person before suffering may be overcome. It is of extraordinary practical importance for an injured man to realize that his closest sharers his wife, mother, and so on cannot be expected to accept the loss immediately. Just as he has to go through the struggle to accept the loss, so does the sharer. </p> <p> For the nonsharer, adjusted attitudes toward injuries do much to free him from anxieties regarding bodily harm. He still will continue to regard body whole as a value, but as an asset value and not as a comparative value. The loss, then, is regarded as an adjustable state and not as a catastrophe. Consequently, in threatening situations, he would not become careless about his safety, but the anxiety would be reduced to realistic fear. </p> <p> Since acceptance of loss has adjustive significance for all persons, the question arises as to how the noninjured may be brought to face it as a problem. The need to attempt to accept the loss exists in noninjured sharers, for they also experience a loss. But what about nonsharers? In general, they do not feel the necessity of imposing upon themselves the problem of adjusting to injuries. They may feel uncomfortable in the presence of an injured person, they may devaluate the injured or wish to diminish his suffering, but they do not see the suffering as <i>their </i>problem. Not only do they feel that real acceptance of this kind of loss is extremely difficult; what is more important, they do not feel that they should try to accept it. The general attitude may be described as, "Problems of visible injuries are special problems. They do not actually concern me." </p> <p> At least two groups of people not in the position of sharing a loss with an injured person may consider more closely their feelings toward injuries. First, there are people who are bothered by social justice. When considering injured people, they may question their own attitudes, since negative feelings toward a suffering part of humanity are regarded as unjust and intolerable. As they puzzle, they may discover their own basic nonacceptance of injuries and struggle to see the loss as an adjustable and acceptable state. The second group consists of those people who have a general need for self adjustment in whatever area anxiety is felt. Just as a person who is frightened when climbing a mountain may wish to ascend again in order to overcome the fear, so may a person who feels uneasy about body welfare wish to meet the problem of non acceptance of loss. </p> <h3> Chapter VIII: Direction of Further Research </h3> <p> The study of adjustment of any kind, including acceptance of loss, requires the investigation of, first, the conditions C₁ and C₂underlying the nonadjusted and adjusted states, respectively, and, second, the conditions leading to change of condition C₁ to condition C₂, expressed as ch(C₁ --&gt; C₂). That is, two distinct tasks are involved: first, there must be determined <i>what </i>has to be changed to <i>what </i>and, second, <i>how </i>the change takes place. The study reported here deals only with the first task, that is, with the determination of conditions of nonacceptance (C₁) and acceptance (C₂) of loss. </p> <p> For the determination of what has to be changed to what, manifestations of the two conditions C₁ and C₂ have to be observed. These manifestations, or events, which in our case were the statements by injured persons concerning nonacceptance and acceptance of loss, were the raw data on the basis of which the underlying conditions C₁ and C₂ were specified. Conditions C₁ and C₂ are always specified in terms of constructs and their interrelationships; the underlying conditions in our case are value statements on the conceptual level. </p> <p> Once C₁ and C₂ have been determined, further research should take the direction of systematic search for and examination of the manifestations of ch(C₁ --&gt; C₂). As the result of our study, we know that conditions C₁ and C₂involve different value structures. The conditions of value change could then be studied by designing experiments which would promote value change and permit the observation of its manifestations. </p> <p> We will now suggest two examples of situations in which value change may be brought about. Both are designed to have the subject himself try to bring about the change. </p> <p> First example: The injured man is asked to try for one day to accept the role he usually resists taking, namely, the injured role. The injured role does not mean one of overde pendence and self pity. Rather, it means that the person does not go out of his way to appear noninjured. He is encouraged, for example, to take advantage of offers of special consideration by others which will make things easier for him. He may also be asked to discuss a personal matter related to his injury with someone to whom he feels close; this should be a matter which in the past he has refrained from bringing up. For that day he has to abandon the noninjured role as the ideal and accept the injured role as the one to strive for. He may succeed in changing, and report these changes, or he may fail and report the difficulties. In either case, a gateway is opened for analysis of the conditions of change. </p> <p> Second example: An injured man is asked to note events, situations, and interpersonal relationships occurring during the day which are and are not injury connected <i>(i.e., </i>whether the event included any aspect of the injury). He is asked to consider further whether the injury entered in a positive, negative, or neutral way. Finally, he is to examine, for alternative interpretations which give them a more positive character, those events which he characterized as negative. For example, the events noted may have included a lift on the way to work (injury connected, positive), staring by someone in the elevator (injury connected, negative), or dictating letters (not injury connected). Crucial for the study is the instruction given to the subject to search for a change in the character of the injury connected negative events. In the elevator example, the subject may come up with the statement that not all staring needs to be staring at an amputation; someone might stare when he is in deep thought about his own personal concerns. In searching for a substitute for the negative character of the event, the injured person thus restricts the all inclusive ness of the devaluating injury so that other values become available. As in the preceding hypothetical experiment, analysis of these attempts at changing values should lead us to the specifications of the general conditions of value change. </p> <p> In returning to our study here reported, we want to mention a number of value constructs related in pairs to C₁ and C₂. These are: comparative values <i>vs. </i>asset values, personal properties <i>vs. </i>posessions, and all inclusive value loss <i>vs. </i>partial value loss. The conditions of change from one member of a pair to the other, ch(C₁ --&gt;&gt; C₂), are yet to be determined. </p> <p> These changes, we believe, are only a few of the necessary changes involved in acceptance of loss. One can be sure that acceptance of loss does not imply only the value changes mentioned above, nor only value constructs. </p> <p> Although much further study of C₁ and C₂ is indicated, we feel enough is already known to encourage investigations of ch(C₁ <i> --&gt; </i>C₂). The knowledge to come from such investigations should provide a systematic basis for understanding and aiding the psychological adjustment of the injured. </p> <h3> Acknowledgments </h3> <p> The research project which gave rise to this article might never have started without the encouragement and advice of many people, and in particular of Gordon W. All port, Roger G. Barker, Karl M. Bowman, Albert A. Campbell, Dorwin Cartwright, Lawrence K. Frank, Kurt Lewin, Rensis Likert, Ronald Lippit, Jean W. Macfarlane, Donald G. Marquis, David Shakow, George D. Stoddard, and Donald Young. The active interest and hospitality of Roger G. Barker, Alvin C. Eurich, Paul R. Farnsworth, Ernest R. Hilgard, Quinn McNemar, Calvin P. Stone, Edward K. Strong, and Lewis M. Terman provided a home for the project at Stanford University. </p> <p> The Advisory Board included Ernest R. Hilgard (Chairman), Roger G. Barker, Paul R. Farnsworth, George S. Johnson, Donald E. King, Quinn McNemar, and Calvin P. Stone. Their interest and support helped us to complete this phase of the investigation. The research staff included Dan L. Adler, Tamara Dembo, Eugenia Hanfmann, Helen Jennings, Gloria Ladieu Leviton, Milton Rose, Ralph K. White, and Beatrice A. Wright. </p> <p> The findings are the result of a group endeavor. Some of the members were unable to continue for the whole period, however, and the three acknowledged authors take responsibility for whatever in this paper is subject to criticism. </p> <p> The investigation was furthered by the productive thinking and hard work of Donald Glad, Verda Heisler, Marguerite Q. McFate, and Alice Phillips Rose, all Research Assistants. The following students contributed not only their technical skills but also stimulating and fruitful ideas: Dorothy Groesbeck, Ruth Katz, J. Maurice Rogers, Heber C. Sharp, Nancy Starbuck, William L. Thompson, Helene Veltfort, George Gromeeko, and Marjorie Dwyer. Our secretaries, to whom we are much indebted, were Bertha Bull, Joan Glad, and Joyce James. </p> <p> We highly appreciate the cooperation of the staff and patients at Dibble and Bushnell General Hospitals. To all who served as subjects we are most grateful. </p> <p><b>References:</b></p> <ol> <li>Adler, D., G. Ladieu, and T. Dembo, Studies in adjustment to visible injuries: social acceptance of the injured, J. Soc. Issues, 4:55 (1948). </li> <li>Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 1953. </li> <li>Dembo, Tamara, Der Aerger als dynamisches Problem, Psychol. Forsch., 16:1 (1931). </li> <li>Frank, L. K., Time perspectives, J. Soc. Phil., 4:293 (1939). </li> <li>Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </li> <li>Lewin, Kurt, Richtungsbegriff in der Psychologie, Psychol. Forsch., 19:244 (1934). </li> <li>Lewin, Kurt, The conceptual representation and the measurement of psychological forces, Duke University Press, Durham, N. C, 1938. </li> <li>White, R. K., B. A. Wright, and T. Dembo, Studies in adjustment to visible injuries: evaluation of curiosity by the injured, J. Abnorm. and; Soc. Psychol., 43:13 (1948). </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">This is a good example of how changing a onesided relationship to a mutual one changes the meanings which the relationship originally had for the person (page 9). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A similar practical problem is raised in a much more general area. If ones own state is felt to be valuable, should not comparison with oneself in performing activities be a better incentive than comparison with others and, if so, should not this guide our educational procedures? </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Dembo, Tamara, Der Aerger als dynamisches Problem, Psychol. Forsch., 16:1 (1931). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In the present state of knowledge, we are not able to state whether those who consider or commit suicide after acquisition of a physical injury have had pronounced neurotic trends which prevent them from standing the additional stress of the unfortunate position or whether an otherwise stable individual but with an extreme evaluation of the fortunate position may consider or commit it Also, we may ask whether the extreme evaluation of body whole and bodybeautiful is not itself an expression of instability or strong neurotic trends. There was a time, not so long ago, when little attention was paid to the problems of the good, quiet child; only the boisterous child was considered a problem. Similarly, high self esteem and satisfaction with ones appearance or any other fortunate position is considered healthy and only lack of self esteem is felt to be a problem. We think that extreme self esteem on the basis of comparison with the unfortunate position of others may be an unhealthy and dangerous state of unpreparedness to meet situations of loss or misfortune. From the standpoint of mental health, little attention is paid to preparedness for psychological suffering. Attitudes toward misfortune, as is the case with any other emotional attitudes, need educational and sometimes therapeutic guidance.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">White, R. K., B. A. Wright, and T. Dembo, Studies in adjustment to visible injuries: evaluation of curiosity by the injured, J. Abnorm. and; Soc. Psychol., 43:13 (1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Activities which separate one sufficiently from emotionally intense conflicting and frustrating contents seem to give one the possibility of recuperation. To shift at will to less emotionally intense situations, i.e., temporary forgetting, is a blessing and sign of psychological well being or health. When one is under strain, he seems to need it more, but frequently the shift is more difficult. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The study of congenital cases, or those injured in early childhood, would be important for understanding problems of acceptance of loss. Do these people differ in their value systems from those who are injured later in life? It would also be important to study the value structure of those who experienced gain after loss, who changed from a handicapped to a nonhandicapped position (e.g., cured cardiac cases and cases of arrested tuberculosis).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The postulate that the speed of emotional processes is greater than the speed of intellectual ones leads us to further statements. First, in a unit of communication in which a single intellectual thought is conveyed, we can expect to find several emotional meanings. Second, the speed of emotional processes is greater than the speed of intellectual control of them (if we assume that intellectual realization is a prerequisite for intellectual control). Thus, in communication we sometimes convey more than we intend since intellectual control cannot keep pace with feelings. The phenomena of the piling up of emotional meanings (first statement) and of covert meanings (second statement) can be shown if a record of communication is made and if we have enough time to analyze each emotional connotation separately. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">This study deals with loss, and therefore with distress situations. Omitted in the rest of this chapter are the modifications and extensions which would be necessary to take account of joy and other emotions that could be shared.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">We do not imply that the reason for aversions is a need to escape the conflict. Nor is the reason something inherent in humans which makes it natural for them to be filled with aversion at the sight of deviations from the normal human form. The ideal of beauty, the Venus de Milo, is a bilateral amputee. The stunted feet of Chinese women were considered beautiful. The heavily padded shoulders of a few years ago exceeded the normal body form. Aversions are visual allergies, symptoms of more general psychological maladjustment and not only of conflict between positive and negative feelings toward the injured.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">For a discussion of time perspective, see Frank.4</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It would be worth while to study this phenomenon further and, in the search for those who might put themselves below the average, to take as subjects prisoners and different groups of mental patients. Interviews in connection with such experiments are indicated.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The findings concerning these relationships (except sympathy, which is discussed in the present monograph) have been reported by Ladieu, Hanfmann, and Dembo (5), by White, Wright, and Dembo (8), and by Adler, Ladieu, and Dembo (1).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In no way do we believe that the subjects conscious perceptions of their feelings are the only data worthy of study Many other clues during an interview give us indications of hidden meanings which broaden the understanding of the persons feelings.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">One would wish that instead of imputing a lower quality to interview data, instead of stressing that how a person thinks he will act does not always correspondto how he will act, attention would be given to the specific conditions under which intentions and attitudes, given an action test, either are or are not carried out.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The validity of the interview as an instrument is a separate problem. See next column.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Lewin, Kurt, Richtungsbegriff in der Psychologie, Psychol. Forsch., 19:244 (1934). </td></tr><tr><td class="clsTextSmall"><b> 7.</b> </td><td class="clsTextSmall">Lewin, Kurt, The conceptual representation and the measurement of psychological forces, Duke University Press, Durham, N. C, 1938. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Though it may increase them.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Thous it may increase them.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall"> By preconcept we mean a term which lacks either a rigid conceptual definition or a precise operational definition. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">By structure of a social emotional relationship we mean those characteristics which, when interrelated, are necessary and sufficient to describe the nature of the relationship. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">For other methods used in the area of adjustment to physical handicaps, see the critical review of the literature by Barker, Wright, Myerson, and Gonick.2</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adler, D., G. Ladieu, and T. Dembo, Studies in adjustment to visible injuries: social acceptance of the injured, J. Soc. Issues, 4:55 (1948). </td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">White, R. K., B. A. Wright, and T. Dembo, Studies in adjustment to visible injuries: evaluation of curiosity by the injured, J. Abnorm. and; Soc. Psychol., 43:13 (1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Beatrice A. Wright, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Research Fellow in Psychology, University of Kansas. Lawrence.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gloria Ladieu Leviton, Ph.D., </b></td></tr><tr><td class="clsTextSmall">Psychologist, LaGrange, Illinois</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Tamara Dembo, Ph.D., </b></td></tr><tr><td class="clsTextSmall">Associate Professor in Psychology, Clark University, Worcester, Massachusetts.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1956_02_004/1956-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1956_02_004/1956-Autumn-1b.jpg Figure 3 http://www.oandplibrary.org/al/images/1956_02_004/1956-Autumn-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 Adjustment to Misfortune-A Problem of Social-Psychological Rehabilitation Creator An entity primarily responsible for making the resource Tamara Dembo, Ph.D., * Gloria Ladieu Leviton, Ph.D., * Beatrice A. Wright, Ph.D. * https://staging.drfop.org/files/original/8697a8f963d8891708f7146a8800f1fa.pdf 49a4a04ffbca3021f555d7b987e35685 https://staging.drfop.org/files/original/4caa47c2d021f88d058ca6724b453a4c.jpg 87d9e4145cc6305c442954af03851d1a https://staging.drfop.org/files/original/db019b84f1068a9dd8b7a17c9f3c82f5.jpg 4b54d9acd0a32a50d47ca3a3315312b8 https://staging.drfop.org/files/original/daf8c596c8eb7e9d49656325de183a55.jpg abe05f2d30dae891020dbda823205d85 https://staging.drfop.org/files/original/2cf7234b28f3f375fd1f6ba2eb438cba.jpg 5007228a1cc68268e5171f413d39e00f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_001.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Aging and Amputation</h2> <h5>Harold W. Glattly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The loss of a part of a lower extremity due to peripheral vascular disease (PVD) incident to the effects of arteriosclerosis with or without the presence of diabetes is today the predominant type of amputation that is being performed in peacetime in the Western World; <i>i.e., </i>the United States and Europe. These ischemic amputations begin to make their appearance in the late forties of life and their incidence increases rapidly in succeeding decades. Lower-extremity PVD cases constituted 85 per cent of all amputations performed at the Massachusetts General Hospital during the period 1962-1964 and the average age of these patients was 70 years.</p> <p>This predominance of PVD lower-extremity cases in the field of amputation surgery is a development of quite recent origin. A survey of lower-extremity amputations by Doctor Jan Hansson in Sweden for the period 1947-1962 documents this fact. During this period, the incidence of lower-extremity amputations in individuals under 60 years of age remained constant at an annual rate of 4 to 5 per 100,000 population. In males over 60, the rate rose from 34 per 100,000 in 1947 to 129 in 1962. In females over 60 years of age, the amputation rate increased from 24 to 62 per 100,000 during this period. Doctor Hansson expressed the opinion that these rates would continue to rise over the coming years.</p> <p>One cannot but surmise that these rapidly increasing rates of lower-extremity amputations in individuals over 60 years of age are but a reflection of the change in the character of our older aged population that has occurred over the past four decades as a result of the dramatic advances that have been made in the prevention, care, and management of disease. Before the advent of insulin, it is doubtful that many diabetics lived long enough to develop gangrene of a lower extremity. Countless numbers of people are now reaching the age of 65 or older with medical conditions which, forty years ago, would have been fatal at a much earlier age.</p> <p>Ischemic amputations of the lower extremity formed an insignificant part of the workload of prosthetic facilities forty years ago. This is borne out by Doctor Hansson's Swedish study. In 1926, only 2 per cent of fitted lower-extremity cases were due to PVD amputations, whereas by 1955, they had increased to 57 per cent. Older prosthetists in the United States, whose professional experience dates back to the 1920's, have unanimously stated that this Swedish study accurately reflects their own experience in that forty years ago they rarely fitted a PVD amputee, whereas today these cases form the major part of their workload. The incidence of ischemic amputations was relatively low in 1926 and at that time the mortality rate for these operations was extremely high in view of the fact that no means were available to control infection. Furthermore, it appears that forty years ago very few of these cases were considered as candidates for prosthetic rehabilitation.</p> <p>Potentially, the Medicare Act for the Aged which became effective in July 1966 can relieve a serious national inequity that in the past has involved the older aged amputees in this country. Over the years federal and state programs have been available to provide financial assistance for needy amputees from birth until they reached the 60 to 65 year age period. The Children's Bureau and the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare have conducted these assistance programs through their support of corresponding state agencies. Until the Medicare Act, amputees and other handicapped individuals over 65 years of age who needed assistance, except for beneficiaries of the Veterans Administration, have been dependent upon local welfare programs that varied widely in their character throughout the country. The 1964 annual VRA report revealed that only 1.7 per cent of their rehabilitated cases for that year were over 65 years of age. Yet this older aged segment of our population is characterized by multiple disabilities and, as a group, does not have the financial resources to take advantage of the rehabilitation opportunities that are available in most sections of this country. A bulletin of the National Health Survey of the Public Health Service, Series 10, Number 32, reports that 50 per cent of citizens 65 years or older have incomes of less than $3,000 per year and that 50 per cent have disabilities that limit materially their daily activities.</p> <p><b>Table 1</b> compares, in terms of their ages, a study of 12,000 new, fitted amputees that were collected during the two-year period 1961-1963 in the United States with all new cases that were furnished prostheses in Great Britain in 1962. No unfitted or old amputee cases provided with a new replacement device are included in these two groups of amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The basis for this wide disparity between Great Britain and the United States with respect to the fitting of older aged amputees is economic. Any amputee in Great Britain, regardless of his age, can receive a prosthesis at government expense if he demonstrates that he has some useful prosthetic rehabilitation potential.</p> <p><b>Table 2</b> presents the sources of payment for prostheses of the 12,000 new, fitted cases cited in <b>Table 1</b> above. Cases assisted by welfare agencies are almost exclusively geriatric since the state programs subsidized by the Children's Bureau and VRA are available to younger amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The data presented in <b>Table 2</b> apply to the United States as a whole and vary widely between individual states. This is illustrated by <b>Table 3</b> that compares the percentage of new, fitted cases over 65 years of age in two states that have, roughly, the same numerical population. The relatively higher economic status of state A and its well-developed welfare programs, as compared with state B, form the basis for the very wide disparity in the fitting of older aged amputees in these two states. The Medicare Act is now available to provide the geriatric amputees in state B with the prosthetic rehabilitation services that have been denied them in the past.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Individuals with peripheral vascular disease of their lower extremities of a severity requiring amputation have, as a group, multiple disabilities that can abridge and even reduce to zero their prosthetic rehabilitation potential. The prosthetic evaluation of these cases, therefore, is critical. They have widely varying rehabilitation goals. Recent studies of these geriatric amputees indicate that, under present management concepts, only about 30 per cent will ever be able to obtain any use of their prostheses. This percentage could be significantly increased if the surgical community would adopt a conservative philosophy in its management of PVD amputations with respect to the original level of amputation and the indications for reamputation in cases of delayed wound healing.</p> <p>The study of PVD amputations at the Massachusetts General Hospital, referred to above, documents the fact that the preservation of the knee joint is all important in determining the rehabilitation potentials of these cases. Percentage-wise, twice as many below-knee cases will be able to use effectively a replacement device as those with above-knee amputations. That there are today widely divergent views concerning the level of amputation in PVD cases is indicated by the fact that, in one large metropolitan area, two-thirds of these cases were amputated above the knee and, in another large city, two-thirds were amputated below the knee. A study of all ischemic amputations performed in 1964 at 14 Veterans Administration hospitals reveals this same disparity in surgical philosophy as regards the level of amputation. The two extremes among these hospitals is shown in <b>Table 4</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The study of 12,000 new, fitted cases cited earlier reveals that the reamputation rate in successfully fitted, below-knee cases is almost zero. The reamputation of a BK is nearly always due to wound complications at the time of amputation. Pedersen and others have shown that a high percentage of these cases of delayed wound healing following amputation below the knee will successfully respond to conservative management and, because of the preservation of the knee joint, will become effective users of prostheses.</p> <p>The percentage of geriatric amputees that can achieve some useful degree of prosthetic rehabilitation would be increased by early fitting and ambulation. There is today an undue time lag between amputation and the fitting of these cases. A recent spot check revealed that this interval averages seven and one-half months. During this period, many of these older amputees will have developed contractures that may preclude prosthetic restoration, or they may become wedded to a wheelchair existence.</p> <p>It is hoped that orthopedic surgeons who are knowledgeable in the field of amputee rehabilitation will endeavor to inform the general surgeons in their respective communities with regard to modern concepts in the care and management of this form of disability.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Harold W. Glattly, M.D. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetic-Orthotic Education, Division of Medical Sciences, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-04.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 Aging and Amputation Creator An entity primarily responsible for making the resource Harold W. Glattly, M.D. * 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL www.americares.org Contact Name/Title HELP HOTLINE M-F: 9AM-5PM (EST) 1-203-658-9500 Address 88 Hamilton Ave. City Stamford State/Province Connecticut Countries Served USA, Latin America & the Caribbean, Africa & the Middle East, Asia & Eurasia Postal Code 06902 Phone 1-203-658-9500 Fax 203-972-0116 Email info@americares.org Organization Type Including ID and tax status Non-profit501 (C) (3) tax-exempt organization, and all donations are tax deductible to the extent provided by law Not-for-profit Type 501C-3 Services Provided Medical Equipment / Supplies, Funding, Medical / Surgical Care, Rehabilitation / Training Need I Financial Assistance Mission Americares supports local health centers, helping providers meet the needs of their patients and communities—in times of disaster and every day. Need II Americares accepts donations of medicine and medical supplies from manufacturers and distributors. Americares does not accept products donations from individuals. LinkedIN Page/Profile https://www.linkedin.com/company/americares Facebook Page https://www.facebook.com/americares/ 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 AmeriCares Description An account of the resource Americares is a health-focused relief and development organization that saves lives and improves health for people affected by poverty or disaster. https://staging.drfop.org/files/original/b4f40bca2c90d2cb7aaabe73acdc9755.pdf 93f307630ba83bd52f500cbae4929830 https://staging.drfop.org/files/original/6ade0b441b483cc9f3804c0eb907cef2.jpg 510989eb599f892c8b2e8c055704eb08 https://staging.drfop.org/files/original/f992d6f159add6551a5927ffdad104a4.jpg 2b3059782381c1b405945cc1df2a65e4 https://staging.drfop.org/files/original/97cfb5d939b20b09ce8eef3379376ff5.jpg 3159b4335f45fb7d187f4e230713fe30 https://staging.drfop.org/files/original/e71107f0f952e070fd0f18a250c50c5e.jpg 3187980e5eb0db54e1fd157d75985aef https://staging.drfop.org/files/original/9f5149248ae20c875ebc879851fc505d.jpg 7975ed4b11b397c330fbd73d34711061 https://staging.drfop.org/files/original/95f314b39e2ef9df0a3d3e113c78841d.jpg 20023369bfd507d6c8b1eaf7c139ccad https://staging.drfop.org/files/original/1e75d8d603b0a37b68c5d88f571954d8.jpg 06838a7e96d784457010a04ffb0d4939 https://staging.drfop.org/files/original/47657fbbbf25bb2870775a5111f1ae16.jpg c6bf99f27ce81525ce4a3c18d6a22984 https://staging.drfop.org/files/original/e2a1a8f0badea8e1360e71eacea7e5ae.jpg 1f9b134869c49e1a7594c8a28780e58c https://staging.drfop.org/files/original/62d143747db0eb1a6cec876a190f8120.jpg 85a7f0afcba88084e4cdc1a630c7606a https://staging.drfop.org/files/original/78e31cec1089a104b5192b24ccb1c522.jpg b7a478f3d3152aeafe4cbc46b503926f https://staging.drfop.org/files/original/a78e4e9e46e8d715eca8b5ddc28d10d1.jpg 63281a59efb08f181a317a6aae358edd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_001.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 1 - 12 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Amputations Below the Knee</h2> <h5>Ernest M. Burgess. M.D. <a style="text-decoration:none;">*</a><br />Joseph H. Zettl, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The elective amputation must be considered plastic and reconstructive in nature. The need to create a dynamic and sensory motor end-organ should be foremost in the surgeon's mind in planning an amputation, and is emphasized here once more. The below-knee stump no longer hangs suspended in an open-end socket. The variable degrees of pressure and weight-bearing over the entire stump surface afforded by the total-contact patellar-tendon-bearing prosthesis enhance the surgeon's opportunity to fashion a functional terminal end-organ. Stump strength created by surgical muscle stabilization; pliable, sensitive, but nontender skin and scar; adequate soft tissue coverage of bone ends and other pressure-sensitive areas; high ligation and division of nerves to remove neuromata from pressure zones; meticulous rounding and tailoring of bone surfaces; all contribute to an ideal organ for substitute limb application. The atrophic, wasted, bony, below-knee stump so commonly encountered in years past is no longer acceptable. Stump-muscle stabilization, <i>i.e., </i>the attachment of sectioned muscles under appropriate tension to bone (myodesis) and to opposing muscles (myoplasty), is a prime requisite for dynamic stump activity. Muscle stabilization is especially needed in the through-knee and the above-knee amputee. Our experience also justifies its routine use in below-knee amputation. Muscle-to-bone suture does add operative handling of tissues and encircling sutures carry the potential of local muscle constriction. For these reasons myodesis is not recommended for use in the below-knee amputation for vascular disease. The new technique developed by the Prosthetics Research Study utilizes the long posterior myofascial flap sewn anteriorly to anterolateral deep fascia and tibial periosteum and provides a reasonable degree of muscle fixation without risk of strangulation. Muscle-to-bone suture is reserved for the nonischemic patient.</p> <h3>Nonischemic Patients</h3> <p>The optimum level for a below-knee amputation in the presence of adequate blood supply is at the junction of the middle and lower third of the leg. However, the level of amputation will often be determined by the causal pathology, including infection, the degree of scarring of the tissues, and related factors. The surgeon should save all effective length down to optimum level, consistent with providing a comfortable, nontender stump.</p> <p>A cylindrical stump shape is desired. The surgeon should think in terms of producing a "foot-like" organ at the below-knee level. The total-contact socket is the "shoe on the foot." Just as plastic surgical techniques are required in operating on the hand and foot, the same techniques of gentleness in skin and other tissue handling are applicable to amputation surgery. When viewed in this light, the amputation becomes a surgical challenge instead of a distressing surgical exercise. Immediate postsurgical prosthetic fitting not only supports and augments the dynamic approach to rehabilitation, it offers certain physical advantages, <i>i.e., </i>immobilization, appropriate continuous pressure relationships, and comfort. These benefits further justify its incorporation into the over-all management of the below-knee amputee.</p> <h4>Amputation Technique For The Nonishemic Patient</h4> <p>The patient is prepared for surgery in the usual manner. A pneumatic tourniquet is used. Short, broad fishmouth skin flaps are outlined to provide a mediolateral closure. In the nonischemic patient the flaps are fashioned approximately equal in length. It is advisable to cut the flaps long, then trim them at the time of closure to provide correct skin tension without puckering or undue tension. Skin and fascia are reflected together.</p> <p>Scarring, infection, deformity, or other unusual circumstances may necessitate modification of the skin closure. Flaps can be outlined to permit closure in any plane or direction provided the resulting scar is nonadherent, nontender, and able to withstand properly and comfortably wearing of a total-contact socket. Anterior location of the scar, condemned in the past, actually is well tolerated even in elderly patients. The application of principles of plastic surgery in skin management must prevail.</p> <p>In the average adult the tibia is transected 2 1/2 to 3 in. above the distal level of the skin incision. The fibula is divided 3/8 to 1/2<i> </i>in. higher. A reciprocating power saw facilitates clean bone section. The tibial periosteum is elevated about 3/4 in. above the cut end of the tibia and the an-teromedial angle beveled to provide a larger radius on the anteromedial aspect. Careful <i>rounding </i>of the edges with a sharp, fine-tooth file is now done. Bone surfaces must be smooth so as to eliminate the possibility of high unit pressures.</p> <p>When the muscles are to be reattached to bone, a procedure recommended where it is physiologically feasible, 4 to 6 holes not more than 7/64 in. in diameter are drilled through the lateral and posterior periphery of the tibia about 3/8 in. proximal to the distal end. Muscles are sectioned long, the gastrocnemius-soleus is left as a myofascial flap sufficiently long to bring it around the end of the tibia to the anterior surface, and nerves and blood vessels are ligated and divided, the former well above amputation level, the latter at the level of tibial section. The nerves are ligated high, as indicated, but are not pulled down so forcibly that traction-avulsion injury results proximal to ligation.</p> <p>Muscles are now sutured to the bone through the drill holes with medium braided polyester suture and tying the knots within the medullary cavity of the tibia. The loop sutures pass through the body of the major muscle groups and through deep fascia. They should be attached under moderate tension, slightly greater than rest length and therefore capable of providing maximum function. Muscle groups are now sectioned just beyond the end of the tibia except for the gastrocnemius-soleus flap which is left long, beveled, and brought over the end of the tibia as a thinned myofascial flap and sutured to anterior deep fascia and anterior periosteum. Good muscle stability and stump contour are provided by this technique. The moderately bulbous stump will rapidly contour to an ideal cylindrical shape in the rigid postsurgical dressing.</p> <p>The skin flaps are trimmed and closed with interrupted fine polyester sutures in such a manner that no tension is present, yet a firm stump without redundant tissue is provided (<b>Fig. 1</b>). Drainage of the stump is optional. We prefer a through-and-through Penrose drain; however, suction drainage is convenient and some wounds will not require any drainage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Below-knee stump of nonischemic patient immediately after closure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Rigid Dressing</h4> <p>The wound is covered with a saline-dampened nonadherent silk or nylon dressing and a small amount of fluffed gauze (2 to 3) is placed over the distal stump end. A sterile three-ply Orion Lycra stump sock is rolled carefully over the stump to avoid damage to the suture lines. The superior portion of the stump sock is held firmly suspended anteriorly and in a proximal direction by an assistant. A simple adjustable shoulder-suspension harness which is interchangeable for right and left can be substituted to achieve the same result.</p> <p>Relief pads of felt or polyurethane are glued to appropriate locations on the stump sock to provide relief for bony prominences. Prefabricated pads are available in a standard size, right and left, but must be trimmed, skived, and beveled in appropriate areas to suit individual requirements. The pads are designed and located to provide relief of pressures over the patella, the tibial tubercle including the tibial crest, and the distal-anterior (bevel) aspect of the tibia. Dow Corning medical adhesive is used to secure the felt relief pads in place while the polyurethane relief pads are provided with an adhesive backing. A sterile reticulated polyurethane distal pad of the proper size is selected and applied to the distal stump end over the tibial relief pads (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Application of distal polyurethane pad. Other relief pads are already in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the initial part of the rigid dressing, elastic plaster bandage is used because, when pulled within limits of its elasticity, this bandage provides safe and beneficial compression to the stump while conforming well to its contours, providing a smooth, effective, rigid dressing.</p> <p>Before the wrap is started, the tibial relief and distal relief pads are secured in place with one-and-three-quarter turns of elastic plaster bandage (<b>Fig. 3</b>). Firm tension is applied to the distal portion of the stump from a posterior-to-anterior direction, while the plaster bandage is pulled almost to the limit of its elasticity. By supporting the posterior skin flap, tension on the suture line is reduced and the soft tissues are immobilized. The wrap is then started on the distal end and carried prox-imally to a level slightly past mid-thigh while tension is maintained in the bandage. A minimum of two layers is required. Circumferential wrapping is carried out from the lateral to the medial aspect, when viewed from the front, in order to avoid anterior displacement of the gastrocnemius (<b>Fig. 4</b>). Tension in the wrap decreases progressively as the application proceeds proximally to the level of the knee joint where it is simply rolled on up to slightly past mid-thigh. It is important to apply the dressing with firm tension to the distal portion of the stump and to avoid proximal constriction to blood flow. The knee is held in 5 to 15 deg. of flexion controlled by longitudinal tension applied to the stump sock from the proximal end. Owing to the inherent structural weakness of elastic plaster bandage, the initial wrap must be reinforced with conventional plaster bandage and splints. Two splints are applied over the distal portion of the rigid dressing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Beginning the rigid dressing by securing the tibial relief and distal relief pads in place with elastic plaster bandage. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Application of the first layers of the rigid dressing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A minimum of two layers of conventional plaster bandage is applied starting at the distal third and wrapping proximally with even, overlapping circular wraps (<b>Fig. 5</b>). At the proximal border of the cast a suspension strap is incorporated anteriorly. For an obese patient with excessive soft tissue over the thigh, a second suspension strap is applied posterolaterally. With the plaster of Paris still wet, the cast is gently compressed with the base of each hand just proximal to the femoral condyles to provide an effective built-in suspension mechanism.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Completed rigid dressing. Note alignment reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the plaster has hardened sufficiently, the contoured waistbelt is applied to the patient and connected to the strap or straps of the rigid dressing. The prosthetic unit is located and attached to the cast with a roll of conventional plaster bandage (<b>Fig. 6</b>). The pylon is sized and cut to correspond to the length of the sound extremity. A window is cut out of the plaster over the patella to insure complete relief in this area (<b>Fig. 7</b>). The prosthetic unit is then disconnected from the cast socket before the patient is taken to the recovery room.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Attachment of upper portion of prosthetic unit to the rigid dressing. Note alignment reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Window in rigid dressing to provide complete relief over patella, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Postsurgical Care</h4> <p>As a rule, a minimum amount of pain is experienced by patients that have been provided with a rigid dressing. It is unusual for drugs stronger than mild opiates and sedatives to be required for relief. A slight degree of weight-bearing on the stump will usually tend to reduce any discomfort that might be present.</p> <p>The patient should be encouraged to stand up and bear some weight on the prosthesis as soon after the first 24-hour period postoperatively as is practicable.</p> <p>The time and extent of ambulation must be determined by the responsible surgeon. Walking training should be carried out only under the direction of a physical therapist or other qualified personnel. Activity should be increased daily as the patient's condition permits. Parallel bars, walkerettes, crutches, and canes are used as aids in ambulation. Two bathroom scales may be used to determine the degree of weight-bearing that is taken on the amputated side. These measurements provide a good guide to the clinic team concerning the progress being made by the patient. The patient should never be allowed to ambulate without supervision. Furthermore, ambulation should not be permitted without the prosthesis because in this case the effect of gravity tends to pull the socket away from the stump, thereby reducing the pressure between stump and socket.</p> <p>On the second postoperative day (48 hours after surgery) the drain is removed. If there does not appear to be any reason for removing the cast, such as elevated body temperature, extreme discomfort, or excessive looseness of fit, the cast is kept in place up to 14 days. If for any reason the cast is removed, whether intentionally or unintentionally, it is mandatory that, if a new cast is indicated, it be applied immediately. During the first two postoperative weeks edema will form rapidly upon removal of the cast and, unless a new cast is reapplied within a very short period, the patient will have to be treated in the conventional manner. The old cast should never be reapplied because of the trauma that is apt to result. When the socket is removed purposely, a cast cutter is used. Often the sutures can be taken out at the time of removal of the first cast, 10 to 14 days after surgery. Sometimes it is necessary to wait until removal of the second cast, 15 to 20 days postoperatively.</p> <p>In many instances the stump will be sufficiently mature and stable for use of a definitive prosthesis at the time the second cast is removed. When this is so, a cast of the stump is taken and appropriate measurements are recorded so that fabrication of a permanent prosthesis can proceed immediately. When the definitive prosthesis is delivered, a light plaster socket mobilizing the knee joint is provided for use when the definitive prosthesis is removed. Use of a plaster socket has proven to be superior to elastic bandages to prevent edema. If delays are anticipated in providing the patient with a definitive prosthesis, the prosthetic unit, pylon, and foot are applied to the short cast to continue ambulation activities.</p> <h3>The Ischemic Patient</h3> <p>Throughout the United States and Canada an estimated 80 per cent of all major, elective, civilian amputations result from ischemia. All but a relatively few involve the lower extremity. Significant advances in surgical and postsurgical management coupled with the use of improved prostheses now allow amputation below the knee in the great majority of these patients.</p> <p>It is difficult to overestimate the importance of the knee in amputee rehabilitation, especially in the older, classical ischemic patient. Debility, impaired vision, poor balance, neuropathy, compromised circulation and joint function in the remaining lower limb, and chronic systemic illness, all emphasize the critical need to save the knee. The older bilateral leg amputee, especially, needs his knees to approach the rehabilitation goal that permits a reasonable degree of ambulation and self-sufficiency. In a consecutive series of 128 unselected major lower-extremity amputations for peripheral vascular disease (1964 through 1968), we have been able to obtain primary healing at below-knee level in 86 per cent. Once healed, the stumps remain healed. With adequate prosthetic care, secondary breakdown will seldom occur. These patients were among the approximately 300 cases requiring amputation of the lower extremity that were used in studying and developing the techniques of fitting prostheses immediately after surgery. As a result of these experiences, separate surgical techniques have been developed for the ischemic patient and for the nonischemic patient.</p> <h4>Level Of Amputation</h4> <p>The great achievements in surgical reconstruction of the peripheral vascular system represent a leading chapter in medical progress during the past two decades. Continuing basic and clinical research throughout the world supports the hope that an even higher percentage of limb salvage can be expected in the years ahead. However, despite the practical effectiveness of modern vascular reconstructive surgery, statistics indicate that amputations for ischemia are increasing both relatively and absolutely in relation to population throughout the western world.</p> <p>When acute or chronic compromise of arterial blood supply reaches a level insufficient to support tissue viability and when reconstructive surgery and nonsurgical supportive measures fail, amputation will be required.</p> <p>Patients requiring amputation are entitled to comparable medical and surgical consideration, comparable team effort, and the same high-level rehabilitation management attending similar patients whose ischemic limbs are treated by vascular reconstruction. Too often, ablative surgery does not command this high estate.</p> <p>Decision to amputate may be simple and evident. Gross necrosis of tissue with demarcation, uncontrollable infection, pain, irreversible neuropathy, alone or in combination, and with results of specific tests to assay circulation, will establish the need to amputate. When all available information poses a serious question as to the possibility of limb salvage by reconstructive surgery rather than amputation, it has been common practice to attempt such surgery, even though extensive. Before questionable extensive reconstructive arterial surgery is carried out, the surgeon should consider critically the overriding probability of its failure with mandatory subsequent amputation. Will the proposed surgery compromise the level of amputation? Will amputee rehabilitation be additionally complicated by further deterioration of general health incident to the extensive surgical attempt at limb salvage? On a number of occasions, below-knee amputations have been performed in ischemic patients who were being considered for possible vascular surgical treatment but in whom, after review of all available information, such surgery might well have damaged the existing blood supply to a degree that an above-knee amputation would then have been required. It is important that the responsible surgeon understand the great rehabilitation value of the knee and weigh all facts relevant to the rehabilitation potential.</p> <p>There is no single test or combination of tests now available that will demonstrate specifically the lowest effective amputation level. Successful below-knee amputations have been obtained repeatedly in patients whose arteriograms indicated complete occlusion of the superficial femoral artery.</p> <p>A careful physical examination is the first requisite in determination of the level of amputation. Appearance of the soft tissues, temperature of the skin, the presence or absence of edema after elevation, growth of hair, level of sensation and acuity, together with palpation of pulses, are all important and cannot be supplanted by laboratory data. Arteriography, plethysmography, thermography, and a number of other objective techniques are useful. These include skin mapping with interar-terial fluorescein, the use of radioactive Xenon #133, and transcutaneous ultrasonic Doppler recordings. Each adds to the available information and assists in level determination. Old established guidelines for determining amputation level are not valid when weighed against recent experience.</p> <p>Unless it is <i>clearly evident </i>that a through-knee or above-knee amputation will be required, the surgeon should prepare the leg for both below-knee and above-knee amputation. Incisions through the skin and muscle preparatory to belowknee surgery can then be carried out quickly.</p> <p>Bleeding and tissue viability can be observed directly and the final decision can now be made as to the level of amputation. Only a few minutes are added to the operative time should one elect the above-knee or through-knee level.</p> <h4>Amputation Technique For The Ischemic Patient</h4> <p>No tourniquet is used. The leg is draped free with the patient supine. Open and infected areas are walled off and shielded by sterile adherent plastic drapes prior to skin preparation. The level of amputation is 3-1/2 to 5 in. below the knee, <i>i.e., </i>a short below-knee stump (<b>Fig. 8</b>). It has been recognized for many years that skin over the posterior leg has better blood supply than that anterior and anterolateral, and a long posterior and a short anterior skin flap are now used routinely. A long anterior flap, or even equal anterior and posterior flaps, should be avoided. The anterior scar resulting from use of a long posterior flap poses no problem in fitting the prosthesis. The modern total-contact below-knee prosthetic socket can accept a stump with scar placement in any position, provided it is nonadherent, well-healed, and nontender, and it is now standard policy in the Prosthetics Research Study to place the scar wherever it will heal most advantageously.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Left, stump of 33-year-old patient on 26th day after amputation because of infection owing to nonunion of the tibia. Right, permanent prosthesis provided same patient on 26th day postoperative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The anterior skin flap is fashioned approximately at the level of anticipated tibial section. The posterior flap must then be 5 to 6 in. longer to provide proper skin coverage without undue tension (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Outline of skin flaps for below-knee amputation on typical ischemic patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After outlining the skin flaps, dissection is carried down through the deep fascia to the tibia. The periosteum is incised and stripped proximally 1 in. The anterolateral muscles are divided down to the intermuscular septum; blood vessels and nerves are ligated appropriately and severed; and then the tibia and fibula are sectioned, preferably with a power saw. The fibula is cut no more than 3/8 to 1/2 in. above the level of the tibia. Soft tissues are dissected from the posterior aspect of the tibia and fibula down to the level of the posterior transverse division of skin. The leg is then separated and removed. The tibia is very carefully rounded with a short bevel over its anterior and medial aspects. It is important that no rough bone areas or ridges remain. A long bevel is specifically avoided. Nerves are pulled down and sectioned high with a sharp knife. They are not injected, crushed, or cauterized. The major nerves are ligated with a fine suture just above the site of division before the division is made. Encircling suture controls oozing from the blood supply that accompanies the nerve, and it also appears to localize neuroma formation and to lessen overgrowth and adherence to adjacent structures. The posterior muscle mass consisting of the gastrocnemius-soleus and deep flexor group is now beveled and tailored to permit the entire muscle flap to come forward and be sewn anteriorly to the deep fascia of the anterolateral muscle group and to the reflected periosteum over the anterior tibia. Contouring and trimming of the gastrocnemius medially and laterally gives a smooth musculofascial flap stabilized over the end of the bones. The skin is then brought up and closed without subcutaneous suture (<b>Fig. 10</b>). Medial and lateral "dog ears" are contoured moderately. They should not be taken back sufficiently to disturb skin circulation. The immediate postsurgical socket rapidly shapes the stump including moderate skin irregularity at the medial and lateral angles. The wound is drained deep to the muscle flap, <i>i.e., </i>to bone. Through-and-through drain or suction drainage may be used. An immediate postsurgical rigid dressing and prosthesis are then applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Below-knee stump of typical ischemic patient showing position of suture line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Postsurgical Care</h4> <p>Drains are removed 48 hours after surgery. If the patient's general condition permits, ambulation with guarded weight-bearing is begun 24 to 48 hours following surgery. The advantages of upright activity with limited stance and gait are obvious. However, only touch-down weight-bearing not exceeding 25 lb. is allowed until the initial cast is changed. Personnel in charge of the patient should be instructed carefully as to their responsibility in preventing the patient from bearing excessive weight or from falling.</p> <p>The postsurgical management with an immediate prosthesis has resulted in much less pain than previously encountered. Postoperative pain is generally of a diffuse aching type. Complaint of localized pain almost always indicates abnormal pressure and requires inspection of the stump and change of the socket. Unless complications develop, <i>i.e., </i>evidence of infection, excessive loosening of the socket, or severe pain, the initial rigid dressing should be left intact until the time of anticipated suture removal, usually two to two-and-one-half weeks following surgery. The cast is then removed, with the patient under sedation but not anesthesia, the wound is inspected, sutures are removed if indicated, and a new temporary prosthesis is applied. By this time the patient is usually ready for unsupported crutch ambulation and discharge from the hospital. A temporary prosthesis is worn continuously until a definitive limb is provided. Ordinarily the final limb can be fabricated, fitted, and worn four to five weeks following below-knee amputation. Typical ischemic patients are shown in <b>Fig. 11</b> and <b>Fig. 12</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. A 69-year-old, white male had multiple difficulties consisting of arteriosclerosis obliterans with complete right superficial femoral occlusion, diabetes mellitus, arteriosclerotic heart disease with mitral insufficiency, and coronary occlusion. No reconstructive vascular surgery was considered to be feasible. The preoperative condition of his foot is indicated on the left. Good stump healing was achieved by the 25th postoperative day, center. The definitive prosthesis was applied on the 28th postoperative day, right. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. A 73-year-old, white female with severe chronic peripheral vascular disease without diabetes. Two attempts at femoral popliteal bypass graft had been made in the three weeks prior to "breakdown" of the graft operative sites. Progressive gangrene of the foot had ensued with demarcation just above the ankle level. Figure in upper left shows the appearance of the leg prior to amputation. A short below-knee level of amputation was selected and a long posterior musculocutaneous flap developed, upper right. The appearance of the below-knee stump at 19 and 29 days following surgery is indicated in the lower figures. The definitive prosthesis was fitted on the 32nd postoperative day. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necrosis of skin flaps can result from either inadequate blood supply or undue pressure. If the level of amputation is so low that the blood supply is insufficient to support a below-knee amputation, it will be evident at the initial cast change. The decision then to amputate at a higher level should be made promptly. Re-amputation rate in the PRS series to through-knee or above-knee over the four-year period has been 9.4 per cent. As experience and techniques have improved, the re-amputation rate for below-knee cases with ischemia has continued to decrease. The surgeon, of course, likes to avoid all re-amputations. However, salvage of the knee is of such paramount importance that an occasional re-amputation may be required if we are to save all knee joints possible in view of our inadequate means for determining the best level for amputation.</p> <h3>Summary and Conclusions</h3> <p>Below-knee amputation is statistically by far the most important major amputation used today. The vast majority of major lower-extremity amputations performed for ischemia will heal primarily and remain healed at below-knee level. The below-knee amputation for ischemia is short in length, the posterior skin and myofascial flaps are fashioned long, and the technique is precise. The resulting stump is cylindrical in shape, well-padded, comfortable, and easily fitted with modern below-knee prostheses of the total-contact type. An immediate postsurgical prosthesis is an integral part of the over-all below-knee amputee management in both the ischemic and nonischemic patient. Restoration of function and rehabilitation of the below-knee amputee, both unilateral and bilateral, have improved in almost spectacular fashion when the guidelines and management which have been outlined are followed.</p> <p><b>References:</b></p> <ol> <li>Baddeley, R. M., and J. C. Fulford, <i>The use of arteriography in conservative amputations forlesions of the feet in diabetes mellitus</i>, Brit. J. Surg., 51:633-658, September 1964.</li> <li>Berlemont, M., <i>Notre experience de I'appareillageprecoce des amputes des membres inferieursaux Etablissements Helio-Marinsde Berck</i>, Ann. Med. Phys., Tome IV, No.4, October-November-December 1961.</li> <li>Berlemont, M., <i>L'appareillage des amputes des membres inferieurs sur la table d'operations,paper given at the International Congress of Physical Medicine</i>, Paris, 1964.</li> <li>Bickel, William H., <i>Amputations below the knee in occlusive arterial disease</i>, Surg. Clin. N. Amer., Mayo Clinic Number, August 1943.</li> <li>Bickel, William H., and R. K. Ghormley, <i>Amputations below the knee in occlusive arterial disease</i>, Proc. Mayo Clinic, 18:361, 1943.</li> <li>Block, M. S., and F. W. Whitehouse, <i>Below knee amputation in patients with diabetes mellitus</i>, Arch. Surg., 87:682-689, October 1963.</li> <li>Bradham, R. R., and R. D. Smoak, <i>Amputations of the lower extremity used for arteriosclerosis obliterans</i>, Arch. Surg., 90:60-64, January 1965.</li> <li>Burgess, Ernest M., <i>The below-knee amputation</i>, Inter-Clinic Inform. Bull., 8:4, January 1969.</li> <li>Burgess, E. M., and R. L. Romano, <i>The management of lower extremity amputees using immediate postsurgical prostheses</i>, Clin. Orthop., 57:137-146, 1968.</li> <li>Burgess, E. M., and R. L. Romano, <i>New day for leg amputees</i>, Rehab. Rec, July-August 1965.</li> <li>Burgess, E. M., and J. H. Zettl, <i>Immediate postsurgical prosthetics</i>, Orthop. Pros. Appl. J., June 1967.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A.Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, Prosthetic and Sensory AidsService, U.S. Veterans Administration, 1967.</li> <li>Compere, Clinton L., <i>Early fitting of prosthesis following amputation</i>, Surg. Clin. N. Amer., 48:1:215-226, 1968.</li> <li>Dederich, Rolf, <i>Die muskelplastische Stumpfkorrektur</i>, Zentralbl. Chir., 81:29:1194-1206, 1956.</li> <li>Dederich, Rolf, <i>Plastic treatment of the muscles and bone in amputation surgery</i>, J. Bone Joint Surg.,45B:l:60-66, February 1963.</li> <li>Eraklis, A., and W. Brownell, <i>Below knee amputations in patients with severe arterial insufficiency</i>, New Eng. J. Med., 269:938-942, October 1963.</li> <li>Ertl, Johann, <i>Uber Amputationsstumpfe</i>, Chirurg, 20:218-224, May 1949.</li> <li>Glattly, Harold W., <i>A preliminary report on the amputee census</i>, Artif. Limbs, 7:1:5-10, Spring 1963.</li> <li>Golbranson, F. L., Charles Asbelle, and Donald Strand, <i>Immediate postsurgical fitting and early ambulation</i>, Clin. Orthop., 56:119-131, 1968.</li> <li>Guthrie, G. J., <i>A treatise on gun-shot wounds</i>, Ed. 2, Burgess and Hill, London, 1820.</li> <li>Harris, P. D., S. I. Schwartz, and J. A. DeWeese, <i>Midcalf amputation for peripheral vascular disease</i>, Arch. Surg., 82:381-383, March 1961.</li> <li>Hey, William, <i>Practical observations in surgery</i>, Ed. 3, Cadell and Davies, London, 1814.</li> <li>Hoar, C. S., Jr., and J. Torres, <i>Evaluation of below-the-knee amputation in the treatment of diabetic gangrene</i>, New Eng. J. Med., 266: 440-443, March 1962.</li> <li>Jansen, Knud, <i>Amputation, a manual of principles and methods</i>, World Veterans Federation, Paris, 1965.</li> <li>Kelly, P. J., and J. M. Janes, <i>Criteria for determining the proper level of amputation in occlusive vascular disease: A review of 232 amputations</i>, J. Bone Joint Surg., 39A:833-891, July 1957.</li> <li>Kendrick, R. R., <i>Below knee amputation in arteriosclerotic gangrene</i>, Brit. J. Surg., 44:13-17, July 1956.</li> <li>Loon, Henry E., <i>Below-knee amputation surgery</i>, Artif. Limbs, 6:1:86-99, June 1962.</li> <li>Loon, Henry E., <i>Biological and biomechanical principles in amputation surgery</i>, Prosthetics International, Committee on Prostheses, Braces, and Technical Aids, International Society for the Welfare of Cripples,Copenhagen, 1960.</li> <li>Mondry, F., <i>Der Muskelkraftige Ober-und Unterschenkelstumpf</i>, Chirurg, 23:517-519, November 1952.</li> <li>Murphy, Eugene F., and A. Bennett Wilson, Jr., <i>Anatomical and physiological considerations in below-knee prosthetics</i>, Artif. Limbs, 6:2:4-15, 1962.</li> <li>Pedersen, Herbert E., <i>Lower extremity amputations for gangrene</i>, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 15:262, 1958.</li> <li>Pedersen, H. E., R. L. LaMont, and R. H. Ramsey, <i>Below-knee amputation for gangrene</i>, Southern Med. J., July 1964. Reprinted in Orthop. Pros. Appl. J., 18:281- 287, December 1964.</li> <li>Radcliffe, C. W., and James Foort, <i>The patellar tendon-bearing below-knee prosthesis</i>, Biomechanics Laboratory, University of California. Berkeley and San Francisco, 1961.</li> <li>Robb, H. J., L. F. Jacobsen, and B. Jordan, <i>Midcalf amputation in the ischemic extremity: Use of lateral and medial flap</i>, Arch. Surg., 91:506-508, September 1965.</li> <li>Rosenberg, N., <i>Midleg amputation in patients with necrotic leg muscles</i>, Arch. Surg., 81:614-617, October 1960.</li> <li>Silbert, Samuel, <i>Mid-leg amputations for gangrene in the diabetic</i>, Ann. Surg., 127:503, 1948.</li> <li>Slocum, D. B., <i>An atlas of amputations</i>, C. V. Mosby, St. Louis, 1959.</li> <li>Smith, B. C,<i> Amputation through lower third of leg for diabetic and arteriosclerotic gangrene</i>, Arch. Surg., 27:267, 1933.</li> <li>Tillgren, C., <i>Obliterative arterial disease of the lower limbs: A study of the course of the disease</i>, Acta Med. Scand., 178:103-119, July 1965.</li> <li><i>Manual of below-knee prosthetics</i>, University of California, San Francisco, Biomechanics Laboratory, November 1959.</li> <li>Weiss, Marian, personal communication and demonstration, Konstancin Rehabilitation Hospital, Poland, 1964.</li> <li>Weiss, Marian,<i> Neurological implications of fitting artificial limbs immediately after amputation surgery</i>. Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Weiss, Marian, <i>Myoplasty—immediate fitting—ambulation, paper presented at the Sessions of the World Commission on Research in Rehabilitation</i>, Tenth World Congress of the International Society, Wiesbaden, Germany, September, 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Joseph H. Zettl, C.P. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Research Study, Seattle, Wash.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ernest M. Burgess. M.D. </b></td></tr><tr><td class="clsTextSmall">Principal Investigator, Prosthetics Research Study, Seattle, Wash., and Director of Amputations and Congenital Defects Service, Children's Orthopedic Hospital, Seattle, Wash. This study was conducted under Contract V5261P-438 with the Veterans Administration.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_001/spring69-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_001/spring69-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_001/spring69-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_001/spring69-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_001/spring69-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_001/spring69-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_001/spring69-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_001/spring69-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_001/spring69-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_001/spring69-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_001/spring69-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_001/spring69-12.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 Amputations Below the Knee Creator An entity primarily responsible for making the resource Ernest M. Burgess. M.D. * Joseph H. Zettl, C.P. * https://staging.drfop.org/files/original/2fc85c60c7226a13a0b36a4c3f55b706.pdf 1015ca384fb4c55450ab7336157f0e12 https://staging.drfop.org/files/original/9870ea49ca3b524810cc617ce5a3d94f.jpg ab9b271621f72f599c670d82a60509c4 https://staging.drfop.org/files/original/14cc0167c932bde5447863a5f7b623a2.jpg 1cea191f2b4b6608ae4da1574d8fe317 https://staging.drfop.org/files/original/05e104352fa9f9e876932479241f9950.jpg 2f2d99f4d352e789d25910f31122d770 https://staging.drfop.org/files/original/6616944a8dfe6b9525902b40b9dd8b3f.jpg 0ae46995ab7fc9d9679598930bc78367 https://staging.drfop.org/files/original/4d92d55e81af301ff9120f73e722a5ea.jpg d6be1661567bf95eecc853d4a701e159 https://staging.drfop.org/files/original/7f6815a20e1116d8b330d4ffeedec915.jpg 70b9dc35d1c49d7b2367f5786110d7f4 https://staging.drfop.org/files/original/1a03792b27840a1c78fa47f1533aadcc.jpg a1f0ebfdcb8835c34368e4e18a0aa96f https://staging.drfop.org/files/original/d2e5e817ec855cf8a5090203ea04252a.jpg c2e18000a9d63f607414445538a5127a https://staging.drfop.org/files/original/99b1110729d5be53d5372632b1f99f5e.jpg e60ffa11bf1e0160104c6961469365f5 https://staging.drfop.org/files/original/179a4cb425c7c1c3e2b4e69d0deb4b0d.jpg 6936f368155280a6ee861a8d47eae6f4 https://staging.drfop.org/files/original/e257a61c4b3d755547715e26cd4cc4c8.jpg 7c20544d9553748d7ed0bdd741f458a3 https://staging.drfop.org/files/original/aeff19372033051006f60acf23519201.jpg 82814034b6a4eee6b8cea4b79c240fee https://staging.drfop.org/files/original/4c5243190441aaf3d7b39ae66ba22b05.jpg 55814a198f6be93b1165b6dc5f3131a1 https://staging.drfop.org/files/original/7de2b8f37e5098a8bc01f68f89dde50c.jpg 799a900e53acffb7eca6cc27c90c190d https://staging.drfop.org/files/original/ffe762e095ce674cba543f8c6b6af54c.jpg 3cc825142523b27489f284b2df669e90 https://staging.drfop.org/files/original/59e80fe2ca0645265ca467285ab4d708.jpg aaee867706a31c5316cec9088da436e1 https://staging.drfop.org/files/original/db34b03f5f13f15d12b39da96302664b.jpg d5f6e5526a745813d293d449c0128cc6 https://staging.drfop.org/files/original/b1801ada4ed2cd7b7840441a0fe940ba.jpg 187b96b2ae0c03c64bc3bb5daa73d350 https://staging.drfop.org/files/original/505d245ee4399ae61784d79459bbb730.jpg d9906c28819fc1c7f9a42256a7dd469f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_019.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 19 - 48 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_019.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_019.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Amputees and Their Prostheses</h2> <h5>Elizabeth J Davies. M.A. <a style="text-decoration:none;">*</a><br />Barbara R. Friz, M.S. <a style="text-decoration:none;">*</a><br />Frank W. Clippinger, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p> Information on 8,698 amputations was collected during a period of approximately two years, ending June 30, 1967. This information was extracted from case-record forms provided by 44 prosthetics facilities in 30 states. The case-record form used was initially developed and standardized by the Conference of Prosthetists of the American Orthotic and Prosthetic Association. Its purpose was to encourage prosthetists in the accurate recording of pertinent information relating to the amputee and his prosthesis. Duplicate copies of the case-record forms were submitted to the Committee on Prosthetic-Orthotic Education (CPOE)<a></a>, National Research Council, in order that significant data could be identified and reported. </p> <p> "The Facility Case Record Study: A Preliminary Report"<a></a> and "Children with Amputations"<a></a>, both reporting findings emerging from this study, have been published previously. </p> <p> Data analyzed in the study included those related to age, sex, level and cause of amputations, reamputations, stump length and contractures, work status of amputees, referrals, months to delivery of prosthesis, age of replaced prosthesis and reason for replacement, components most frequently prescribed for upper- and lower-extremity prostheses, and source of payment for prostheses. </p> <h4> Methods</h4> <p> Each of the 44 facilities submitted case record forms on amputees as they were seen. Three forms were utilized, one for the amputee's medical history, one for the lower-extremity prosthesis, and one for the upper-extremity prosthesis. In cases where the meaning of the data was uncertain, follow-up forms were sent to the prosthetics facilities to clarify or add to the information provided. </p> <p> A coding system was devised, and information was transferred from the case-record forms to coding sheets and then to IBM cards and magnetic tape. Selection of pertinent data for retrieval was determined by an ad hoc group and the staff of CPOE. </p> <p> In order to make comparisons between different areas of the country, the states represented in the study were arbitrarily grouped into five geographical regions <b>Fig. 1</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Subjects</h4> <p> The study included 8,323 amputees with a total of 8,698 amputations. Statistics in this study refer only to patients fitted with a prosthesis; amputees not fitted are not included. <b>Table 1</b> indicates the types of cases included in the study. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Amputees or amputations being fitted for the first time were considered "new" cases. Amputees or amputations being fitted with replacement prostheses were considered to be "old" cases. There was a total of 4,034 "new" amputations and 4,664 "old" amputations <b>Table 2</b>. Amputations in males accounted for 6,848 amputations, and amputations in females, 1,850-a ratio of 3.7:1. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Findings </h4> <p><i> Aage of Amputees</i></p> <p> <b>Table 3</b> shows the age of amputees fitted in prosthetics facilities during the two years covered by this study. The incidence of amputations for males peaked in the fifth decade; for females, the peak was reached in the seventh decade. Forty-eight per cent of the amputees were 51 years of age or older, 30 per cent were over 61 years, and 12 per cent were over 71 years. The fact that 23 per cent of the amputees were fitted with either a new or a replacement prosthesis after 65 years of age has Medicare implications. (It should be noted that Medicare was in effect during only the second year of data collection.) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i> Level of Amputations </i></p> <p> Amputations of the lower extremity accounted for 86 per cent of the total number of amputations <b>Table 4</b>. Of these, 53 per cent were at the below-knee level. In the upper extremity, 57 per cent of the amputations were at the below-elbow level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There was no significant difference in the incidence of left- and right- side amputation in either the upper or lower extremities. A total of 4,386 left-limb and 4,312 right-limb amputations was reported. The right upper extremity was involved slightly more than the left, 605 to 573, and the left lower extremity fractionally more than the right, 3,813 to 3,707. </p> <p><i> Cause of Amputation</i> </p> <p> Causes of amputation were considered in four categories: congenital, tumor, trauma, and disease. Cases of infection, gangrene, or osteomyelitis resulting from trauma were classified under "trauma." Cases of trauma associated with vascular disease were classified under "disease." </p> <p> Causes of amputation were analyzed by age group and level. Of the 8,698 amputations reported in this study, the cause was known for 8,487 cases; both cause and age were known for 8,394 cases. Fifty per cent of all amputations were caused by trauma, 37.3 per cent by disease, 8.4 per cent were of congenital origin, and 4.3 per cent were due to tumor. <b>Table 5</b> shows the relative incidence of amputation by cause and level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In <b>Fig. 2</b> the total number of amputations by cause of amputation and age is indicated. Amputees most frequently fitted or returning for replacement in the first ten years of life were those with congenital limb deficiencies. Amputations for trauma led all other categories fitted or returning for replacement between the ages of 11 through 50. In the third, fourth, and fifth decades, this group accounted for 76 per cent, 82 per cent, and 72 per cent, respectively, of all cases fitted or returning. Of those fitted in the sixth decade of life, the incidence was almost equally distributed between traumatic amputations and amputations due to disease. After age 60, the latter group led all other categories by a ratio of more than 2:1. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>"New" Cases by Cause</i> </p> <p> Analysis of all amputations entered in the study gives an overview of the type of amputee being seen and fitted in prosthetics facilities, as reported above. Analysis of those being fitted for the first time, however, provides a picture of persons amputated during the two-year period of data collection and gives a better current indication of cause related to age, sex, and level of amputation. </p> <p> It is probable that the statistics on age are slightly distorted, since age was reported as of the time of fitting. Age at the time of amputation, therefore, would be less, and to a variable degree. </p> <p> In the group of "new" amputees, cause was reported for 3,963 cases, and both cause and age for 3,920. <b>Fig. 3</b> indicates the incidence of amputation by age. Of the "new" cases, 60.2 per cent of amputations were caused by disease, 29.1 per cent by trauma, 5.9 per cent by tumor, and 4.8 per cent were of congenital origin. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The predominance of trauma as the cause of amputation in the overall amputee population of the study <b>Fig. 2</b> is in striking contrast to the predominance of disease as a cause of amputation when only new patients are considered <b>Fig. 3</b>. In the overall picture, the ratio of trauma to disease is 1.3:1, whereas in new patients the ratio is reversed, and disease as a cause of amputation outnumbers trauma 2:1. </p> <p> Thus, the total sample data obviously includes a considerable number of traumatic amputees who lost their limbs at an earlier age and survived to require replacement prostheses. However, the noteworthy finding is that, in the period surveyed, disease-caused amputations were occurring at double the rate of those attributable to trauma. </p> <p> <i>Congenital. </i>In the 191 reported n males, 86 in females <b>Table 6</b>. Of this number, 137 did not require amputation surgery, while 54 did. This surgery presumably involved the conversion of anomalous limbs to stumps that were more suitable for the fitting of a prosthesis. Eighty-three amputations occurred in the lower extremity, of which 44 were at the below-knee level. Of 108 upper-extremity amputations, 78 were at the below-elbow level. Thirty-two per cent of congenital amputations were not fitted until after 11 years of age. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Tumor. </i>Of 235 "new" amputations caused by tumor, 206 (88 per cent) were of the lower extremity <b>Table 7</b>. There were 120 amputations at the above-knee level, accounting for 58 per cent of the lower-extremity amputations. An additional 27 per cent were at a level higher than above-knee, i.e., hip-disarticulation or hemipelvectomy. Males outnumbered females 130 to 105. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The highest incidence of tumor (66 cases or 29 per cent) occurred in the second decade of life. Within this decade, no particular pattern of incidence is discernible <b>Table 8</b>. These data are somewhat at variance with those reported by Taft and Fishman<a></a> from a study conducted by the staff of New York University Child Prosthetic Studies. This study, which involved a larger sampling (278 children whose amputations were caused by tumor), showed a gradual increase in incidence beginning about the 6-8 year period and peaking in the 14-16 year group. Unfortunately, the age groupings are slightly different from those of our study, so an exact comparison cannot be made. However, both studies agree that tumor occurs most frequently in the second decade by a wide margin. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Trauma. </i>Of the 1,156 new cases of amputations resulting from trauma, amputations in males accounted for a total of 1,050, and those in females for 106, a ratio of approximately 10:1 <b>Table 9</b>. The highest incidence of trauma-related amputations occurred in the third decade (250 cases), followed closely by that in the fourth decade (216 cases). The number of amputees in these two decades accounted for 41 per cent of all new cases where age was known. The incidence of amputations in females varied only slightly in each decade between the ages of 11 and 60. The incidence of amputations in males exhibited a sharp rise through the second and third decades, and then receded gradually. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In every decade the involvement of the lower extremity exceeded that of the upper. Actually, the lower extremity was involved 1.9 times as often as the upper, 753 times as opposed to 403. </p> <p> <i>Disease. </i>Sixty per cent (2,381 cases) of all new amputations were caused by disease <b>Fig. 13</b>. Although males outnumbered females by more than 2:1 in this category, the relative percentages of males and females in each age group were closely parallel, e.g., 980 or 61 per cent of males were over the age of 61 years, while 464 or 62 per cent of females were also over the age of 61. After 40 years of age, a sharp rise in the incidence of amputations caused by disease was noticeable. Approximately one-third of the amputations occurred in the seventh decade. Eighty-five per cent of all new amputees in the disease category were over the age of 51 years, and 49 per cent were in the Medicare age group. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In disease-caused "new" amputations, involvement of the lower extremity greatly exceeded that of the upper, the ratio being 73:1. </p> <p> <i>Comparison with Amputee Census</i> </p> <p> The Glattly study<a></a>, reported in 1964 and commonly referred to as the "Amputee Census," included only "new" amputees. It is of interest to compare the findings of that study with the present one. Findings of our study relating to the sex and age of new amputees and the cause, side, and level of amputations closely parallel the findings of the Glattly study. Comparative data of the two studies are depicted in <b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b>, and <b>Fig. 7</b>, and <b>Table 11</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In our study, newly fitted amputees 51 years of age and older accounted for 60.2 per cent of the total, as compared with 58.8 per cent in the Amputee Census <b>Fig. 4</b>. In both studies, the highest incidence of amputation was in the seventh decade. Because many geriatric amputees are not fitted with prostheses, the incidence of amputation in the older age groups would presumably be even higher if statistics on nonfitted amputees were included. </p> <p> In both studies, male amputees exceeded female amputees by approximately three to one <b>Fig. 5</b>. </p> <p> The distribution of right- and left-side amputations was almost equal in both studies, and lower-extremity amputations still accounted for about 85 per cent of all new fittings <b>Table 11</b>. In <b>Fig. 6</b> a higher incidence of below-knee amputations and a lower incidence of above-knee amputations were evident in the more recent study. Among new patients in this study, there was a total of 3,254 above-and below-knee amputations. Of these, 50.9 per cent were above-knee. </p> <p> The relative incidence of trauma as a cause of amputation decreased by four per cent from the Glattly to the present study, and the incidence by cause in other categories increased, but by relatively small amounts <b>Fig. 7</b>. </p> <p> <i>Original Level of Amputation for Disease Correlated with Geographical Area and Age</i> </p> <p> The original level of amputation for disease was examined for 2,242 new cases whose amputations were at either the above- or below-knee level. Comparisons were made between below- and above-knee as the choice of amputation level in each of the five geographical areas <b>Table 12</b>. Below-knee appeared to be the site of choice in less than half the total number of cases. The South led the other geographical areas in percentage of amputations at the below-knee level (54 per cent), followed in order by the Midwest (51 per cent), New England (48 per cent), East Central (46 per cent), and the West (45 per cent). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A look at the site of the original disease-related amputation for new patients 41 years of age and above revealed some interesting statistics <b>Table 13</b>. In the fifth decade, below-knee was selected in preference to above-knee in 58 per cent of the cases. This percentage gradually decreased over the next two decades to a low of 43 per cent in the seventh decade. After the seventh decade, there was an increase to 47 per cent in the eighth decade and to 50 per cent after the eighth decade. For all new amputations for disease in patients 41 years of age and above, above-knee was selected in 52 per cent of the cases, below-knee in 48 per cent. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The lack of a consistent pattern in these data is intriguing. A progressive decrease in the proportion of below-knee amputations with increase in age might logically be anticipated. Surgeons, for example, might wish to be more sure of obtaining healing in older patients and elect to amputate at the above-knee level. However, other factors than age of patient obviously enter into the selection of amputation level. </p> <p><i> Specific Causes of Traumatic Amputations</i></p> <p> Trauma was listed as the primary or precipitating cause of 4,306 amputations ("old" and "new" cases). As noted earlier, some of this number were classified in categories other than trauma, since trauma was not considered the primary cause of amputation; hence, the number 4,306 exceeds the number of cases actually coded in the trauma category. Of these 4,306 instances where trauma was mentioned, there were 392 cases where the type of trauma was unknown, so, for purposes of this analysis, reference will be to the 3,914 cases where type was known. </p> <p> <b>Fig. 8</b> summarizes the causes of traumatic amputations. In this category, men were affected ten times as frequently as women: 3,561 to 353. In males, cars, industrial accidents, and war each accounted for approximately 20 per cent of the cases. On the other hand, automobiles were by far the outstanding cause of traumatic amputations in women (49 per cent), with no other cause approaching this in frequency. It is noteworthy that the ratio of male to female automobile-caused amputations was in the order of 4:1, in contrast to the 10:1 overall ratio. Since it is not known whether these female victims were predominantly drivers or riders, the full significance of these data is not clear. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <b>Table 14</b> relates cause of trauma to sex, side, and level of amputation. Involvement of the right upper extremity in males was greater than the left. This preponderance was especially evident in farm and industrial accidents and is doubtless related to handedness. In car accidents, the left upper extremity was involved significantly more than the right for both males and females, 62 per cent as compared with 38 per cent. One can speculate that this incidence might be attributable to the fact that many motorists ride with the left elbow extending beyond an open window. In the small sample of train accidents, the involvement of the left upper extremity in males was also considerably greater than the right but, because of the small number, this probably was without significance. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 14. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The left lower limb was involved slightly more than the right in males, and the right and left limbs almost equally in females. </p> <p> <b>Table 15</b> compares causes cited for "new" traumatic amputations in males with those given for "old" traumatic amputations. Twenty-six per cent of the amputations of "old" cases were due to war injuries, whereas only 2 per cent of the new cases were due to this cause. At the time of this study, the Vietnam War had not yet exerted its full impact. The greatest increase in trauma-caused amputations was seen in the industrial-accident category. Industrial accidents caused 29 per cent of the "new" traumatic amputations, but only 15 per cent of the "old" amputations. Elimination of war cases from the total number avoids distortion of the data due to the preponderance of old war injuries, and thus presents a somewhat truer comparative picture of other traumatic causes. With war injuries eliminated, industrial accidents accounted for 29 per cent of the "new" amputations and 20 per cent of the "old" amputations, which still reflects an increased incidence of amputations caused by industrial accidents. Industrial accidents exceeded all other categories as the cause of amputation in new patients. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 15. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i> Reamputations of the Lower Extremity</i></p> <p> Reamputations were studied in relation to cause, original level of amputation, and present level. Level was reported for 396 reamputations of the lower extremity. Some members of this group had second reamputations, but for the purposes of this study, only the original and present level of amputation were considered. An attempt was made to exclude simple revisions that involved no shortening of bone. </p> <p> In reviewing the figures presented here, it should be remembered, again, that only those patients fitted with prostheses at the time of the study are considered. Despite this limitation, analysis of the available data is thought-provoking. Of 396 reamputations reported, 189 were in the disease-related category involving a total of 3,122 cases <b>Table 16</b>, and 182 were in the trauma-caused group with 3,387 total cases <b>Table 17</b>. Thus, reamputations in the first group ran a shade over 6 per cent, those in the second group a shade under 6 per cent. Stated in reverse, approximately 94 per cent of the cases in both groups did not require re-amputation. The statistics for specific levels are also quite fascinating. In disease-related below-knee amputations, approximately 6 per cent required reampu-tation versus approximately 5 per cent in the like trauma group. In the above-knee group, the comparative proportions are 1 per cent versus 0.6 per cent. At the Syme's level, comparative figures are 25 per cent versus 28 per cent, and for partial feet 96 per cent versus 25 per cent. The reasons for the sharp increase in reampu-tations at the last two levels are worthy of further study. It would also be of interest to know whether partial foot amputations, for example, were or were not successfully performed on many patients who were never fitted with prostheses. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 17. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> For the 189 (48 per cent) reamputations due to disease, <b>Table 16</b> gives the final as compared to the original level. Of 93 below-knee amputations requiring ream-putation, 22 (24 per cent) remained in the same segment, 67 (72 per cent) were converted to an above-knee level, 3 to a knee-disarticulation, and 1 to a hip-disarticula-tion level. Of the 15 original above-knee amputations, 9 were reamputated in the same segment and 6 became hip disarticulations. </p> <p> Of the 11 Syme's reamputations reported, 2 were reamputated to an above-knee level and 9 to a below-knee level. Of the 67 reamputations at the partial foot level, 22 were converted to an above-knee, 41 to below-knee, and 4 to a Syme's level. </p> <p> Causes of reamputation for patients in the disease category were indicated for 181 of the 189 reamputations. In some instances, two causes of reamputation were cited. In each instance where a cause was mentioned, it was counted as contributing to the reamputation. The total number of contributing causes to reamputation in the disease category therefore was 192 <b>Table 18</b>. "Recurrence of the original cause of amputation" accounted for almost half (48 per cent) of the reasons cited for reamputations. This generalized response is interpreted as meaning a continuance of the original vascular problem responsible for the initial amputation. Specific causes cited were a nonhealing wound (18 per cent), gangrene (12 per cent), infection (5 per cent) stump breakdown (3 per cent), and "other" (14 per cent). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Most reamputations in the disease category occurred very shortly after the original surgery, 49 per cent occurring in less than 1 1/2 months, and 60 per cent occurring in less than 2 1/2 months. Eighty-two per cent occurred in the first year following the amputation. </p> <p> In the category of traumatic amputations, levels for 182 reamputations of the lower extremity were reported. Of the 114 amputations at the below-knee level requiring reamputation, 57 per cent (65 amputations) remained at the below-knee level, a percentage considerably higher than was the case for reamputations due to disease. Forty-five amputations were converted to above-knee levels and 4 were converted to knee disarticulations. There were 29 Syme's reamputations, of which 23 were converted to below-knee, 3 to above-knee, and 3 remained at the Syme's level. Of the 22 partial foot reamputations, 14 were converted to below-knee levels, 7 to Syme's and 1 to above-knee. </p> <p> Causes of reamputation were known for 157 of the trauma cases. As with reamputations in the disease category, every instance where a cause was mentioned was counted. There were 165 contributing causes to reamputations <b>Table 19</b>. In 71 instances (43 per cent), "other" was coded as the cause of reamputation. Included in the "other" category were causes that could not be readily classified, such as "stump not satisfactory for prosthesis," "shorten bone and remove neuroma," "painful stump." The median number of months between amputation and reamputation was six. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 19. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There were 16 reamputations for congenital amputees and 6 for patients whose amputations were caused by tumor. Three of the latter were reamputated because of recurrence of the tumor. Reported reasons for reamputations in congenital amputees were too diverse for classification, except that 4 reamputations were because of bony overgrowth. </p> <p> <b>Table 20</b> summarizes the total number of reamputations for each level and includes the percentage of reamputations converted to a higher segment or remaining in the same segment. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 20. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Bony overgrowth was cited eight times as a reason for reamputation: four tibial overgrowths, two fibular overgrowths, and two not specified. All of these reamputa-tions were performed on children, with the exception of one on a 27-year-old amputee. While not implicit in the data, it is conceivable that this 27-year-old had had bony overgrowth for a long time prior to reamputation (his first amputation occurred at age 10). </p> <p><i> Stump Length and Contractures</i></p> <p> There were 2,602 above-knee amputations for which the presence or absence of contractures of the hip was reported. Of this group, 1,345 had either no flexion contracture or a contracture of less than 5 deg, and are not included in this analysis, other than the notation that they comprised over half of the group reported. Stumps with 5+ deg of contracture ranged in length from 2 - 2 1/2<i> </i>inches to 14 - 15 1/2 inches. Three stumps had flexion contractures of more than 60 deg. Hip-flexion contractures were greatest in the very short stump. The average contracture at the above-knee level fell in the 5-9 deg range. </p> <p> There were 3,781 below-knee amputations for which the presence or absence of knee contractures was reported. Of this number, only 12 per cent were reported as having contractures of 5 deg or more. In general, the shorter the stump, the more severe the contracture. Considering only those cases reporting contractures of 5 deg or more, stumps averaging more than 7 1/2<i> </i>in. in length had average contractures of between 5 and 9 deg; for stumps between 4 and 7 1/2<i> </i>in. long, contractures averaged between 10 and 14 deg; and for stumps 3 1/2 in. and less in length, contractures averaged 15 to 19 deg. The average contracture, excluding those of less than 5 deg, was 10-14 deg. Three stumps had contractures of 60 deg or more. </p> <p><i> Work Status</i></p> <p> The work status of "old" male amputees between the ages of 21 and 64, with 2,694 amputations, was reported. "New" amputees were not studied, since the majority of the group had not yet had time to return to employment. Eighty-four per cent of the "old" amputees in the cited age group were employed, the highest employment rate (89 per cent) occurring in the 41- to 50-year-old age group <b>Fig. 9</b>. In each of the age groups studied, a higher rate of employment was reported for upper-extremity than for lower-extremity amputees. It should be noted here that only 6.4 per cent of amputees between the ages of 21 and 64 were reported as not being gainfully employed. The remainder of the group (9.3 per cent) were students, retired, or fell into some other category. This percentage of unemployment is a little higher than that reported for the national average for the years 1965, 1966, and 1967 (4.5, 3.8, and 3.8 per cent respectively). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The rate of employment in relation to each upper- and lower-extremity amputation level appears in <b>Fig. 10</b> and <b>Fig. 11</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Work status was reported for 383 female amputees between the ages of 21 and 64. Of this number, 200 were housewives, 148 were gainfully employed, and only 18 were not gainfully employed. Seventeen had either retired or reported their work status in some other category. </p> <p><i>Referrals</i></p> <p> The majority (58 per cent) of cases fitted at prosthetics facilities were referred by amputee clinics; 26 per cent were referred by physicians; 16 per cent were not referred. Of the "new" cases, 5 per cent were not referred to prosthetics facilities by either a clinic or physician, as contrasted to the 26 per cent of the "old" cases not so referred. </p> <p><i> Months to Delivery of Prostheses</i></p> <p> For "new" amputations, the time from amputation (or from birth for congenital amputees not requiring surgery) to date of delivery of the prosthesis was analyzed by level and cause for the five geographical regions <b>Table 21</b>. The median period to delivery for all prostheses was 6 months. Comparing geographical areas, the median was 5 months for New England, the Midwest and West, 6 months for the South, and 7 months for the East Central region. Of the 3,588 prostheses with times to delivery reported, 71 were delivered in 1 month or less, 67 were not delivered for 99 months or longer. Thirty-seven of the latter were for congenital amputations not requiring surgery, i.e., 37 children were not fitted with their first </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 21. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> prosthesis until after the age of eight years, three months. A comparison of time to delivery by levels indicated that the median time lapse was 5 months for the below-knee prosthesis and 6 months for all other levels. Time to delivery of prostheses ranged from a median of 4 months for below-knee prostheses in the New England area and the West to a median of 10 months for below-elbow prostheses in the East Central region. These data will provide a basis for later comparisons in areas where programs of immediate and early prosthetic fitting have been instituted. </p> <p> Data on months to delivery were analyzed by cause of amputation and related to geographical regions <b>Table 22</b>. The shortest median length of time for delivery was 3 months for congenital amputees who had had surgery. The longest time was for congenital amputations without surgery, where the median was 31 to 36 months; however, it should be recognized here that this median also represents the median age of congenital amputees not requiring surgery who were being fitted for the first time. Median time to delivery for amputations caused by tumor was 4 months; by trauma, 5 months; and by disease, 6 months. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 22. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i> Age of Replaced Prostheses and Reasons for Replacement</i></p> <p> The average age of replaced prostheses for all patients was 6.1 years. For children up to 21 years of age, it was 2.5 years, and for adults, 6.7 years. </p> <p> Comparisons of the ages of replaced prostheses for above- and below-elbow and above- and below-knee amputees in relation to the age of the patient (by decade) are shown in <b>Table 23</b>. In almost every instance, the "life" of the prosthesis increased with the age of the patient. The average life of above-elbow prostheses for 124 amputations was 9.2 years. The range was from 2.5 years for the child through the age of 10 years to 16.7 years for amputees over the age of 61. The average age of below-elbow prostheses for 349 amputations was 6.5 years, ranging from 2.5 years for the child through age 10, to 10.3 years for amputees over age 51. The average age of above-knee prostheses for 1,269 amputations was 6.2 years, with a range from 2.2 years for the child in the first decade, to 8.1 years for amputees over age 71. The below-knee prosthesis had the shortest life, averaging 5.8 years for 2,201 amputations, and ranging from an average of 1.7 years for the child through age 10, to 8.6 years for amputees over 71 years of age. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 23. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In comparing ages of replaced prostheses by cause of amputation and the sex of the amputee, it is found that prostheses for congenital amputees had the shortest life, averaging 3.5 years, and prostheses for traumatic amputees had the longest life, averaging 6.8 years <b>Table 24</b>. The growth rate of children in the congenital group undoubtedly accounts for the more frequent replacements of prostheses evident here. Replacement of prostheses for patients in the disease category occurred, on average, every 5 years, and there was very little difference between replacements for males and females. The life of prostheses for tumor patients also averaged 5 years; however, prostheses for males in this category needed more frequent replacement, lasting 4.5 years as compared with an average 5.6 years for females. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 24. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> It is interesting to note that the age of replaced prostheses for males averaged 6.2 years, and that of females 5.4 years. The large number of males in the trauma category may account for this difference, inasmuch as the average life of prostheses in this category is longer than in others. </p> <p> <b>Table 25</b> indicates the reason for replacement of prostheses. The majority of prostheses were replaced because they were worn out. "Worn out" was listed as the sole or contributing cause of replacing a prosthesis in 58 per cent of the cases. It was the leading reason for replacing prostheses of persons whose amputations were caused by tumor (50 per cent), trauma (67 per cent), and disease (44 per cent). As would be expected, the primary reason for replacing prostheses of congenital amputees was that the prosthesis was "outgrown." In 52 per cent of replacements for congenital amputees, the prosthesis was outgrown; in 33 per cent of the cases it was worn out. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> "Unsatisfactory" was cited as the reason for replacement in four per cent of the cases. However, it should be noted that although the "unsatisfactory" category was meant to include only those cases in which problems arose relating to fabrication or patient tolerance, it was often cited for other reasons which rendered the prosthesis unsatisfactory. Had this item been interpreted correctly, the percentage undoubtedly would have been lower. </p> <p> The average age of all "worn out" prostheses that were replaced was 7.6 years <b>Table 26</b>. This exceeds the average age of prostheses replaced for any reason (6.1 years) by a year and a half. This higher age undoubtedly reflects the longer life of the prostheses of traumatic amputees reported above, since "worn out" was the sole or contributing factor for 67 per cent of the replacements in the trauma category. Additionally, the lower average age of all the replaced prostheses was affected by the inclusion of children's prostheses, which had shorter lives. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 26. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ccomponents for Upper-Extremity Prostheses</i></p> <p> The components most frequently used for upper-extremity prostheses at the above- and below-elbow levels are depicted in <b>Fig. 12a</b>,<b>Fig. 12b</b>. The voluntary-opening hook was used with 87 per cent (201 instances) of the above-elbow prostheses and 90 per cent (517 instances) of below-elbow prostheses. The preference for this type of hook was reflected in all areas except the West, which showed a preference for the voluntary-closing hook with below-elbow prostheses. New England was the only area that did not prescribe the voluntary-closing hook at all. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12a. Most frequently used components for above-elbow prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12b. Most frequently used components for below-elbow prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The hand-type terminal device was utilized to a limited extent, being prescribed 309 times as opposed to the hook-type device which was prescribed 806 times. Many amputees for whom hooks were prescribed were also equipped with hands. Where hand-type devices were reported, the voluntary opening hand was prescribed for above-elbow prostheses 40 per cent of the time (36 cases) and for below-elbow prostheses 36 per cent of the time (79 cases). Both the East Central and Midwest areas preferred voluntary-closing hands for use with above-elbow prostheses. The East Central and Western areas preferred voluntary-closing hands for below-elbow prostheses. New England showed a preference for the passive hand with the below-elbow prosthesis. </p> <p> The simple friction wrist unit was overwhelmingly preferred to quick-change types in all geographical areas, being used with 83 per cent of above-elbow and 85 per cent of below-elbow prostheses. </p> <p> Although the triceps pad was used with 56 per cent of the below-elbow prostheses, its use ranged from 35 per cent in the South to 94 per cent in the New England area. The South preferred the half cuff. Plastic laminate was the cuff material of choice in 61 per cent of the total cases, although the East Central and Western areas preferred leather to the extent of 54 per cent and 55 per cent respectively. </p> <p> The double-wall socket was used in 89 per cent of the above-elbow and 77 per cent of the below-elbow prostheses. Pre-flexed sockets, some of which also had double walls, were used in 11 per cent of the below-elbow prostheses. Sixty-one per cent of the preflexed sockets were utilized by children. </p> <p> In 98 per cent of the upper-extremity prostheses, the sockets were made of plastic. </p> <p> The elbow unit with internal lock was the item of choice for above-elbow prostheses in all geographical areas, being used in 78 per cent of all fittings. Seventeen per cent of all elbow units had spring-flexion assists. Sixty-four per cent of the elbow hinges used in below-elbow prostheses were flexible, the range being from 44 per cent in the West to 92 per cent in New England. The Midwest showed almost equal preference for the single-pivot (47 per cent) and the flexible hinge (50 per cent). </p> <p> Dual-control systems were used in 80 per cent of above-elbow and single control in 96 per cent of the below-elbow prostheses. </p> <p> Eighty-three per cent of the harnesses for above-elbow prostheses were of the figure-eight type, the majority of this group (55 per cent) being equipped with the Northwestern University harness ring. The East Central area and the West showed a preference for the figure-eight harness without the ring. Of the 14 cases with reported type of harness in the West, none used the ring with the figure-eight. The South used the ring to the greatest extent for above-elbow prostheses. </p> <p> Ninety-two per cent of the below-elbow harness were of the figure-eight type, 59 per cent of these being equipped with rings. The East Central, South, and Midwest areas showed greatest preference for the ring figure-eight harness; the New England and Western areas used the figure-eight harness without the ring almost as often as with it. </p> <p> <i>Components for Lower-Extremity Prostheses</i> </p> <p> Components most frequently used for above- and below-knee prostheses appear in <b>Fig. 13a</b>,<b>Fig. 13b</b>. The various geographical areas showed more consistency in prescription of lower-extremity than upper-extremity components. In most instances, only the percentage varied, not the type of component. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13a. Most frequently used components for above-knee prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13b. Most frequently used components for below-knee prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The SACH foot was prescribed for 55 per cent of the above-knee and 73 per cent of the below-knee prostheses. In area comparisons, the South showed the greatest usage of the SACH foot, and the Midwest the lowest. For the above-knee prosthesis, prescription of the SACH foot rose from 76 per cent in the first to 83 per cent in the second decade, and then gradually declined with advancing amputee age. In the below-knee group, the SACH foot was prescribed 96 per cent of the time for children under 10 years of age; the percentage declined steadily to a low of 56 per cent in the eighth decade, then rose to 63 per cent for the group of amputees 81 years of age and over. </p> <p> Wood was used as the shank material in 95 per cent of the above-knee and in 90 per cent of the below-knee prostheses. </p> <p> The most frequently used knee component for above-knee prostheses was the single axis, with friction being used in 74 per cent of the fittings. Twelve per cent of the knees were single axis with manual locks. Eight per cent of the knees were hydraulic, with the West showing the greatest preference (17 per cent) and the Midwest the least (4 per cent). In instances where metal joints were reported for below-knee prostheses, the lap joint was specified in 48 per cent of the cases and the clevis joint in 22 per cent. The type of joint was not specified in 30 per cent of the cases. </p> <p> For above-knee amputees, the quadrilateral socket was used in 85 per cent of the prostheses. It was the overwhelming choice in each of the geographical areas. The socket of choice for below-knee amputations was the patellar-tendon-bearing. Preference for this socket averaged 58 per cent, the South and West showing greatest utilization, 79 per cent and 82 per cent respectively, and the New England and Midwest areas the least utilization, 44 per cent and 47 per cent respectively. </p> <p> Wood was used most often for above-knee sockets, averaging 57 per cent, although the South showed a preference for plastic, using it for 55 per cent of all sockets. Below-knee sockets were most often (55 per cent) fabricated in plastic. New England showed a preference for leather sockets, and the Midwest preferred wood (41 per cent) to either plastic or leather. </p> <p> The pelvic belt was the preferred method of suspension (56 per cent) for above-knee prostheses. Only in the West did the use of suction, either alone or in combination with other suspension, exceed the use of the pelvic belt. In correlating methods of suspension with age, it was noteworthy that during the second, third, and fourth decades, suction alone was preferred to all other types of suspension. In all other decades, the pelvic belt was preferred. </p> <p> In considering types of suspension reported for all below-knee prostheses, the knee cuff alone was the choice of suspension in 36 per cent of the cases. It was least used in the Midwest (22 per cent). The South and West utilized the knee cuff alone most frequently (55 per cent). When type of suspension for the patellar-tendon-bearing prosthesis is analyzed by age group, it is found that, while the knee cuff alone was used for 62 per cent of all </p> <p> the prostheses, greatest usage occurred in the second decade (73 per cent) and next greatest in the third decade (71 per cent). Least use of the knee cuff alone occurred in the very young child (48 per cent), but the inclusion of cases where a waist belt was used in conjunction with the knee cuff raised this percentage to 68. </p> <p><i> Sources of Payment </i></p> <p> <b>Table 27</b>, <b>Table 28</b>, and <b>Table 29</b> indicate the sources of payment for prostheses. More than one source was sometimes listed, in which case they are reported under "combinations of the above "or" "other". Medicare had been in operation only one year prior to the conclusion of this study and presumably would rank considerably higher as a source of payment at the present time. As mentioned earlier, over 23 per cent of the amputees in this study were in the Medicare age bracket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 27. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 28. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 29. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Source of payment was given for 8,631 prostheses <b>Table 27</b>. The greatest contributors to defraying the costs of prostheses were State Bureaus of Vocational Rehabilitation (22.5 per cent) and the patient himself (22.8 per cent). Next in order were the Veterans Administration (14.3 per cent), welfare (10.8 per cent) and insurance (9.9 per cent). </p> <p> The Children's Bureau paid for 46.5 per cent of the prostheses for children up to the age of 21. Through the wage-earning years, 21 to 64, State Bureaus of Vocational Rehabilitation paid for 31.9 per cent of the prostheses, the amputee for 24.3 per cent, and the Veterans Administration for 19.3 per cent. During the retirement years, 65 and over, the amputee alone paid for 29.9 per cent of the prostheses, Social Security and Medicare for 19.5 per cent, and welfare for 15.3 per cent. </p> <p> A further analysis of sources of payment relating to the wage-earning years yields some interesting facts <b>Table 28</b>. The Veterans Administration paid for 30 per cent of replacement prostheses, but only 10 per cent of new prostheses. This statistic doubtless reflects the continuing supply of prostheses to veterans of World War II and the Korean War and a decreased number of fresh cases. More "new" male amputees were supported by insurance or compensation than "old" male amputees, 24 per cent as opposed to 8 per cent. This may reflect the policy of some insurance companies to pay for the first prosthesis only. On the other hand, it may indicate an increase in opportunity for insuring oneself against disability and a greater awareness of the values of health insurance. In comparing source of payment for males and females in this age group, one notices the higher level of support by the amputees themselves and the Bureaus of Vocational Rehabilitation for the female group, and also the very low percentage of females supported by insurance or compensation. </p> <p> In correlating source of support with occupation, only "old" amputees were considered, since in most instances "new" amputees had not yet returned to work at the time the data forms were submitted. Amputees were studied in three categories: those gainfully employed, those not gainfully employed, and those who were students, housewives, or retired <b>Table 29</b>. </p> <p> Of the 3,055 "old" cases included above, only 187, or 6 per cent, were reported as not being gainfully employed. The Bureaus of Vocational Rehabilitation paid for 35 per cent of the prostheses for the gainfully employed group, the Veterans Administration for 28 per cent, and the amputee for 25 per cent. For the group of amputees not gainfully employed, the Bureaus of Vocational Rehabilitation were the source of payment for 28 per cent of the prostheses, the Veterans Administration for 27 per cent, and welfare for 24 per cent. In the 468 amputations of students, housewives, or retired amputees, 31 per cent of the prostheses were paid for by the amputee, 28 per cent by the Bureaus of Vocational Rehabilitation, and 17 per cent by the Veterans Administration. </p> <h4> Discussion </h4> <p> In recent years, there has been increasing interest in defining the characteristics of the amputee population, and also in providing amputees with functional stumps and prostheses. Much progress has been made in understanding the amputee and his problems, and in the fabrication of improved prosthetic components. This study has sought to document some of the characteristics of the amputee and his prosthesis during a particular period in time-the approximately two years ending June 30, 1967. </p> <p> Certain characteristics of amputees, namely sex and age, and the cause, side, and site of amputation, were well established in Glattly's study of 12,000 new amputees for whom data were collected over a two-year period, ending in 1963. In the present study of over 8,000 amputees, 4,034 of whom were new, data were likewise collected over a two-year period which ended in 1967, four years later. Unless some catastrophic event had occurred immediately before or during either of the two periods, it would be expected that in large samples such as these, the sex and age of the amputee and side and cause of the amputation would be relatively constant. Such was indeed the case, indicating that the sample in the latest study was a valid cross-section of the amputee population. As noted before, neither the Medicare Act nor the conflict in Vietnam had exerted a significant impact on this study. Although medical advances over a number of years have been largely responsible for the increasing age of the amputee, with a resulting shift from trauma to disease as a predominant cause of amputation, such changes would not be expected to exert a significant difference in as short a period as four years. </p> <p> In amputations caused by disease, the site of amputation can be influenced by medical judgment at a particular time. In the vast majority of cases where amputation is categorized as disease, the amputees had vascular insufficiency. For this condition, amputation at a level above the knee had been widely advocated for many years because it was felt that this procedure facilitated healing. It has been found, however, that amputation may be performed at a below-knee level, with primary healing occurring in the majority of cases.<a></a> By preserving the knee joint, amputation at this level greatly enhances the rehabilitation potential of the patient. </p> <p> Burgess has reported that most below-knee amputations for ischemia heal primarily, and with proper prosthetic care do not break down.<a></a> Lim reports that 92 per cent of below-knee amputations were successful when a popliteal pulse was present, and 75 per cent were successful when pulse was absent.<a></a> He also reports a lower mortality rate for below-knee amputees, 16 per cent as opposed to 35 per cent for above-knee amputations. Tracy cites a 90 per cent successful healing rate for below-knee amputations for ischemic gangrene.<a></a></p> <p> Although the increase in the percentage of below-knee amputations in our study, as compared with the Glattly study, is relatively small in view of the <i>potential </i>increase, it is nevertheless an encouraging trend, and it is to be hoped that a dramatic increase will be reflected in future surveys as the results of ongoing educational programs take effect. </p> <p> Although the incidence of amputations due to trauma appears to have declined, as far as percentage of the total amputee population is concerned, this does not necessarily imply a decrease in the overall incidence of traumatic amputations. Actually, the increasing age of amputees, with its corollary of increasing incidence of amputations due to disease, is certainly partly responsible for the decline in percentage of trauma cases. In the younger age groups, trauma continues as the major cause of amputations. The Public Health Service report<a></a> published in 1964 shows that "absence of major extremity," classified as an accident "while at work," occurred almost three times as often as amputation caused by "moving motor vehicles." In the present study, the ratio was closer to 1:1 than 3:1, i.e., moving vehicles as a cause of traumatic amputations was almost equal to that of industrial accident. A higher percentage of auto accidents than industrial accidents occurred in the female group, a pattern which is typical of other reported findings. These results may indicate improved safety controls in industry, or may underscore the soaring rate of automobile accidents, or both. The large number of amputations resulting from trauma continues to have strong implication for improved accident-prevention programs and more effective human-factors engineering. The need for greater safety of design, particularly in cars and industry, continues to be great. </p> <p> It is of interest to note that prosthetic prescription varied among the geographical areas, some areas having a greater tendency than others to incorporate newer prosthetic techniques. It might be expected that the latest prosthetic developments would be incorporated into prosthetic practice in those areas which were near the prosthetic-orthotic educational centers (New York, Chicago, and Los Angeles) or in areas of greatest concentration of prosthetic facilities (California, Pennsylvania, New York, and Illinois), or amputee clinics (New York, Pennsylvania, California, and Texas). With the exception of the West, where newer developments were used in a high percentage of cases, there appeared to be no relationship between the nature of prosthetic services provided and the factors cited above. Both the South and the West showed a more consistent use of newer techniques than did the other areas. </p> <p> The provision of prosthetic services reported in the study indicates that much improvement is to be desired as far as length of time for delivery of the prosthesis is concerned. The time between the date of amputation (or reamputation) and delivery of the prosthesis was inordinately long, ranging from a median of four months for patients whose amputations were caused by tumor to six months for patients with vascular disease. The provision of temporary prostheses and immediate postsurgical fitting of prostheses would help shorten this time lag. </p> <p> The finding that a relatively high percentage of congenital amputees (32 per cent) were not fitted until after their eleventh birthday is distressing. Since current philosophy is to fit congenital amputees at a very early age, it would be interesting to know the reason for this reported delay. Whether the fault lies with amputee clinics, or with parents who are either reluctant to take their children to clinics or are ignorant of the prosthetic opportunities available to them, is not evident from the present analysis. The implication is that more needs to be done at the educational level. The growth and implementation of dynamic treatment programs would surely result in a much more optimistic picture. </p> <p> A composite picture of amputees reported in this study would present the following profile: </p> <ol> <li>The congenital amputee seen in prosthetic facilities was a male under 10 years of age with involvement at the below-knee level. </li><li>The amputee whose amputation was caused by tumor was a male between 11 and 20 years of age whose amputation was at the above-knee level. </li><li>The traumatic amputee was a male now between the ages of 41 and 50 years who had received his amputation between the ages of 21 and 30 years. His amputation was at the below-knee level and was most likely received as a result of a car accident, industrial accident, or war injury. </li><li>The amputee whose amputation was caused by disease was also a male, between the ages of 61 and 70 years, who was amputated during these same years. His amputation was as likely to be at the above-knee level as at the below-knee level. </li></ol> <h4> Summary </h4> <ol> <li>This study, which extended over a two-year period ending in June 1967, presents data on 8,323 amputees with 8,698 amputations, all of whom were fitted with prostheses. </li><li>Of the "new" amputations seen in prosthetic facilities, 60 per cent were caused by disease, 29 per cent by trauma, 6 per cent by tumor, and 5 per cent were of congenital origin. </li><li>Of all amputations, "new" and "old," being fitted in prosthetic facilities, 50 per cent were caused by trauma, 37.3 per cent were caused by disease, 8.4 per cent were of congenital origin, and 4.3 per cent were caused by tumor. </li><li> The greatest incidence of disease-caused amputations occurred in the seventh decade, those of trauma in the third decade, and those of tumor in the second decade. </li><li>Males outnumbered females in every category, the ratio for "new" amputations of males to females being approximately 2:1 for disease, 10:1 for trauma, and 1.2:1 for both congenital causes and tumor. </li><li>Eighty-six per cent of the total number of amputations were of the lower extremity, with 53 per cent of this group being at the below-knee level. </li><li>Although automobile accidents were cited as the single greatest cause of all traumatic amputations, war injuries, industrial accidents, and automobile accidents were cited almost equally for male amputees. </li><li>Forty-eight per cent of all reampu-tations were in the disease category, 60 per cent of these occurring within two and one-half months of the original amputation. The reamputation rate for below-knee amputations caused by disease was not significantly higher than that for trauma-caused amputations-approximately 6 per cent in both instances. </li><li>Degree of contracture reported at both hip and knee varied inversely with the length of the stump. Excluding contractures of less than 5 deg, the average hip flexion contracture for above-knee amputations was in the 5-9 deg range; the average knee flexion contracture for be-low-knee amputations fell in the 10-14 deg range. Fifty-two per cent of those cases reporting presence or absence of contractures had either no contracture or one of less than 5 deg. </li><li> Unemployment rate for "old" male amputees between the ages of 21 and 64 was 6.4 per cent, slightly higher than the national average for the years covered by the report. </li><li>Fifty-eight per cent of patients were referred to prosthetic facilities by amputee clinics, 26 per cent by physicians, and 16 per cent were not referred. </li><li>The median time from amputation to delivery of a prosthesis was six months, the below-knee prosthesis being delivered in the shortest length of time. Congenital amputees who required surgery received prostheses in a median time of three months postsurgery. Patients in the disease category waited the longest time- six months. </li><li> Prostheses had an average life of 6.1 years, with the life of the prosthesis increasing with the age of the patient. Below-knee prostheses generally and prostheses for congenital amputees had the shortest life. Prostheses for males lasted longer than those for females. "Worn out" was the primary reason given for replacing a prosthesis. </li><li>Prosthetic prescription varied in the geographical areas, some regions demonstrating a greater tendency than others to incorporate newer prosthetic techniques. Generally, as the age of the amputee advanced, there was a tendency to use the older types of components, e.g., pelvic hands, articulated ankles. </li><li>The Children's Bureau was the largest single source of financial support for the purchase of prostheses for children, and the State Bureaus of Vocational Rehabilitation provided the greatest financial support for amputees during the wage-earning years. The Veterans Administration paid for a high percentage of prostheses for males who were in the "old" category. In all, the federal government paid entirely for 48 per cent of all prostheses and provided partial support for another 3 per cent. </li></ol> <h4> Acknowledgments </h4> <p> Grateful appreciation is extended to the 44 facility owners and their staffs who provided the data on which this study is based. </p> <p><b>References:</b></p> <ol> <li>Burgess, Ernest M., The below-knee amputation, <i>Bull. Pros. Res., </i>10-9:19-25, Spring 1968. </li> <li>Davies, E. J., B. R. Friz, and F. W. Clippinger, Jr., Children with amputations, <i>Inter-Clinic Inform. Bull., </i>9:3:6-19, December 1969. </li> <li>Friz, Barbara R., and Frank W. Clippinger, Jr., The facility case record study: a preliminary report, <i>Orth. and Pros., </i>23:1:8-17, March 1969. </li> <li>Glattly, H. W., A statistical study of 12,000 new amputees, <i>Southern Med. J., </i>57:1373-1378, November 1964, </li> <li>Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, <i>Surg. Gynec. Obstet., </i><b>125: </b>493-501, September 1967. </li> <li>Sarmiento, A., and W. D. Warren, A re-evaluation of lower extremity amputations, <i>Surg. Gynec. Obstet., </i>129:799-802, October 1969. </li> <li>Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, <i>Inter-Clinic Inform. Bull., </i>5:5:9-28, February 1966. </li> <li>Tracy, G. D., Below-knee amputation for ischemic gangrene, <i>Pacif. Med. Surg., </i>74:251-253, September-October 1966. </li> <li>U. S. Department of Health, Education, and Welfare, Public Health Service, <i>Impairments due to injury by class and type of accident, United States, July 1959-June 1961, </i>Washington, D.C., 1964. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">U. S. Department of Health, Education, and Welfare, Public Health Service, Impairments due to injury by class and type of accident, United States, July 1959-June 1961, Washington, D.C., 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Tracy, G. D., Below-knee amputation for ischemic gangrene, Pacif. Med. Surg., 74:251-253, September-October 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, Surg. Gynec. Obstet., 125: 493-501, September 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, Inter-Clinic Inform. Bull., 5:5:9-28, February 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Sarmiento, A., and W. D. Warren, A re-evaluation of lower extremity amputations, Surg. Gynec. Obstet., 129:799-802, October 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Glattly, H. W., A statistical study of 12,000 new amputees, Southern Med. J., 57:1373-1378, November 1964, </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, Inter-Clinic Inform. Bull., 5:5:9-28, February 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Davies, E. J., B. R. Friz, and F. W. Clippinger, Jr., Children with amputations, Inter-Clinic Inform. Bull., 9:3:6-19, December 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Friz, Barbara R., and Frank W. Clippinger, Jr., The facility case record study: a preliminary report, Orth. and Pros., 23:1:8-17, March 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, Surg. Gynec. Obstet., 125: 493-501, September 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frank W. Clippinger, M.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopaedic Surgery, Duke University; Chairman, Subcommittee on Prosthetics Clinical Studies, CPOE.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Barbara R. Friz, M.S. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetic-Orthotic Education, Division of Medical Sciences, National Academy of Sciences-National Research Council, Washington, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Elizabeth J Davies. M.A. </b></td></tr><tr><td class="clsTextSmall">Formerly Professional Assistant, Committee on Prosthetic-Orthotic Education.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Amputees and Their Prostheses Creator An entity primarily responsible for making the resource Elizabeth J Davies. M.A. * Barbara R. Friz, M.S. * Frank W. Clippinger, M.D. * https://staging.drfop.org/files/original/b3a2c7a0584c7b41faa78f8463cf4268.pdf f252ffd28bf2d19a88c0995299dca5af Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_004.pdf Text Any textual data included in the document <h2>An Advanced Approach Toward Improved Prosthetic Fittings</h2> <h5>David F.M. Cooney, R.P.T., C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Keith E. Vinnecour, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The importance of amputation surgery and dedicated follow-up cannot be underestimated by those clinicians who deal with the amputee population. A prosthetist who receives a patient with a residual limb that is of the optimum configuration to receive a prosthesis and permits the lowest energy cost with maximum unilateral weight bearing comfort, is too often the exception. A concerted effort by all professionals involved—physicians, nurses, physical and occupational therapists, psychologists, social workers, and prosthetists—is required for truly successful rehabilitation.</p> <h3>Delineation Of Level</h3> <p>Successful primary healing in patients who have experienced a trauma related amputation is not as great a concern since the average age of this group is much younger than the dysvascular amputee. For the majority of patients who require prosthetic care due to vascular insufficiency, predictions for successful healing, and therefore level of amputation, is a critical consideration and of primary address here. The following discussion and techniques employed, however, can apply to all prosthetic fittings.</p> <p>In the dysvascular patient, the correct assessment of tissue viability and level of limb amputation is paramount to successful rehabilitation. Correct assessment also serves to reduce the length of the hospital stay and, therefore, costs. Patient morbidity and mortality are also reduced.<a></a></p> <p>A number of methods are employed to determine amputation level. Absolute determinants include ischemia and necrosis. Skin temperatures, absence of hair, sensory deficits, and peripheral pulses are also clinical tools of relative, though unreliable, demarcation. A less direct way of determining level of amputation is the condition of the underlying tissues and skin bleeding during surgery.<a></a></p> <p>Objectively defined methods are being used to more accurately determine surgical level. Doppler pressure measurements use systolic pressure differentials between the level of concern and brachial pressure. The literature cited offers relative values for prediction of successful healing,<a></a> but also points out the Doppler method's fallibility.<a></a> Two other non-invasive tests, segmental systolic pressure readings and pulse-volume recordings, can provide a reasonably valid prediction of primary wound healing, but should not be used as the sole indicators for amputation site.<a></a></p> <p>Thermography has been used to estimate the optimal site of amputation. Infrared emissions from the involved extremity are displayed on a screen to show temperature differentials. One study claimed a 96 percent success rate with amputation levels recommended via thermography<a></a>.</p> <p>Skin blood flow by the Xenon-133 clearance techniques to predict primary healing levels in amputation surgery have shown positive results. A 100 percent primary amputation healing is claimed by these authors for surgeries where recommendations according to their standards were followed.<a></a></p> <p>The choice of any of the above methods rests with the abilities of the institution. Though most non-invasive means are available throughout the medical community, invasive techniques using radioactive isotopes, like Xenon-133, require the availability of a nuclear medicine department. Clearly, not all facilities have this capability.</p> <p>Once the level of tissue viability and surgical healing have been determined, operative procedures commence. A residual limb offering optimal function should be a "well muscled, durable stump of effective length with a pliable skin cover that has adequate sensation." The means to this end requires careful attention to the handling of the bone, nerves, and soft tissues.<a></a></p> <h3>Surgery</h3> <p>Subsequent to determining the amputation level is the actual surgical technique, which is an important adjunct to successful rehabilitation of the amputee. Handling of the bone requires close attention to the residual cortical shaping, and in standard practice it should be beveled to prevent sharp margins and potential socket problems.<a></a></p> <p>The reaction of the bone to surgical handling of the periosteum is not fully understood, but when dealing with tissues that are compromised initially, one cannot fault a "kid-glove" approach to dissection and ligation. Delicate handling may avoid subsequent spurring along the bony margins.<a></a> It has generally been considered that fibular length should be less (approximately 2.0 cm.) than the length of the tibia.<a></a> The authors feel that fibular length should be equal to or no more than 5 mm. shorter than the cut tibia. It is felt that this improves prosthetic medio-lateral stability, provides greater distal bulk, and serves to prevent mature conical shaping and increase total tissue contact and weight-bearing.</p> <p>In the procedure described by Ertl,<a></a> the lengths of the two bones are equal. A bony bridge, or periosteal flap, is then created to afford an end bearing residual limb. This synostosis also prevents any relative motion of the two bones. The tibiofibular osteoplasty closes the open medullary canals and can recreate the normal conditions of direct weight bearing pressures and circulation in the long axis of the bone. This can help prevent degeneration in the joints proximal to the amputation.<a></a> It would seem that this procedure should warrant greater attention in appropriately selected patients (especially in light of the much improved fitting techniques now available).</p> <p>Establishing stabilization in the distal musculature at the selected site of amputation is important to provide a more physiologically effective residual limb. Where surgically feasible, the muscles should be sutured to each other as well as to the periosteum and/or bone without excessive tension or laxity. This allows for a well contoured and generally less prosthetically troublesome limb.<a></a></p> <p>Nerve tissue should be handled meticulously to avoid residual problems once prosthetic wear is initiated. Each nerve should be individually dissected and have adequate traction applied. Severing of the nerve with traction maintained will cause it to retract far enough up into the soft tissue so as to be well protected and less threatened by weight bearing pressures.<a></a> Prosthetically crucial are the smaller sural and saphenous nerves, as they are sometimes neglected in lieu of the more major posterior tibial, deep and superficial peroneal nerves.<a></a> Redundancy of soft tissues should be avoided, but adequate coverage of the remaining structures is a must in order to provide a good limb for weight bearing. Closure of the wound should include careful suturing and handling of the already compromised tissues and care should be taken to avoid traction at the suture line so as to prevent contractures of the joint.<a></a></p> <p>It has been shown again and again that immediate post-surgical fitting procedures can improve residual limb viability, reduce pain and edema, and prevent contractures.<a></a> Rigid dressings are common practice in immediate post-surgical fittings, but variations on this theme include the use of pneumatic devices that can also afford the advantages of their more rigid counterparts.<a></a> More tenuous situations that may not allow for early weight bearing and ambulation, secondary to healing problems, can be approached through the use of Una boot dressings<a></a> and an innovative removable rigid dressing technique.<a></a></p> <p>Invariably, the independent and/or conjunctive use of any one of these methods can enhance the post-operative management of even the most difficult rehabilitation patient. By improving a patient's physical and mental status and by providing mobility through this approach, the clinical team can increase a patient's rehabilitation potential.<a></a></p> <h3>Prosthetic Evaluation</h3> <p>Little has changed in the physical aspects of evaluation. Standard anthropometric measures are still used to provide an objective record for modifications and fabrication, and for comparative purposes related to future changes. Accurately determining the anatomical joint range of motion (both in the involved and uninvolved limb) and strength/stability can provide criteria for prescription and serve to mediate problems during fitting.</p> <p>One new tool in the evaluative process is Xeroradiography®. Xeroradiography® is a process that yields an x-ray image on an opaque background. The picture records are easier to store than their x-ray counterparts and provide a clear definition of both the bony anatomy and soft tissue. Evidence of bone spurring, vessel calcification, and presence of vascular surgery staples is readily observed. Measurements are also easy to glean. The use of this information in the treatment of the amputee is obvious and can significantly improve and objectify the prosthetist's skills and, ultimately, improve patient management.<a></a></p> <h3>Casting</h3> <p>Adopting a "hands-on" technique in the quest of obtaining an anatomical replica of the residual limb should be the goal of the prosthetist. A careful volume study of the involved limb can serve to optimize the definitive results.</p> <p>The growing use of static and dynamic test sockets, and the information provided by them, has yielded a twist on the time tested practices utilized by many prosthetists. The technique of automatic build-ups over sensitive areas has been found to be less than necessary. Reversing this thought process to promote negative model modifications over areas of weight bearing can provide better total-contact, total-weight bearing sockets. Doing this in the molding process can reduce the amount of relatively educated guesswork necessary in cast modification by producing better initial cast molds. Methods which have been developed to aid in this pursuit include vacuum casting<a></a> or a three to four stage alginate casting technique.<a></a></p> <p>Another method to improve fit from the initial casting is to work toward a more dynamic casting method. As the casting is predominantly done under non-weight bearing conditions, working toward more "dynamic" casting methods which equalize the weight bearing pressures is warranted consideration. Where an Ertl procedure has been performed, distal weight bearing casting is preferred to achieve maximum results. The same intent should be attempted with the non-Ertl distal end as well. Ultimately, the better the quality of the cast and the less initial modification guesswork, the better the test socket fitting.</p> <h3>Test Socket</h3> <p>Use of clear test sockets for improving fit is well documented in the literature cited. Though the technology for transparent test sockets has been available since the 1950's, the current practice of direct weight bearing modifications to the socket are relatively new.<a></a></p> <p>During the initial static weight bearing period, areas of the residual limb are demarcated according to weight distribution and, therefore, load. This is evidenced by varying degrees of blanching or redness. The goal of a total tissue bearing socket is then pursued to decrease areas of excessive pressure (blanching) and to increase areas of inadequate loading (redness). This goal can be met through either static or dynamic test socket volume changes, or cast model modifications.</p> <p>Under weight bearing conditions, loose areas are marked by redness, and tension analysis is accomplished via "poking" the tissue through holes made in the socket. Various injectable materials (glycerine, alginate, pour-a-pad) are then added to equalize weight bearing pressures. Areas of excessive weight bearing, if not relieved by the weight borne by the newly injected materials, are either relieved in the socket or modified on the master mold.</p> <p>By achieving a careful stump-socket interface tension analysis as described, greater confidence in he ultimate result and an optimum fit is possible. Difficulty of fit dictates the number of check socket fittings. Unfortunately, fittings are also affected by the reimbursement source. The fact is undeniable, however, that a transition to the use of transparent test socket fittings can increase the level of prosthetic expertise and elevate the profession to a higher plateau of fitting success.</p> <h3>Dynamics</h3> <p>Advancements in prosthetic componentry and gait analysis techniques, when used in conjunction with improved evaluation tools and fitting methods, provides a greater arsenal for the prosthetist seeking to optimize his patient's abilities. An exciting variety of new techniques are surfacing throughout the country which not only render prosthetics more professionally demanding to the practitioner, but also challenging to the patient. Different socket styles and theoretical bends are adding to current thought and practice.</p> <p>The above-knee amputee now has a variety of alternatives in not only socket material and construction, but in functional design as well. The Swedish flexible socket offers a lighter weight, more "natural" feeling socket to the AK amputee. It also allows for greater transmission of heat via the polyethylene or Surlyn® material, and therefore a cooler feeling. The flexibility of the socket also encourages physiological muscle activity and provides sensory feedback through the thin material.<a></a></p> <p>Contoured Adducted Trochanteric Controlled Alignment Method (CATCAM) is an exciting new above-knee socket design. Proponents claim it increases comfort secondary to total soft tissue weight bearing, because the ischial tuberosity is no longer on the "seat" of the conventional quadrilateral design, but contained within the socket. The CATCAM also allows for more natural muscle activity by virtue of both the flexible design (a la Swedish flexible socket) and inherent socket mechanics. By improving the socket's purchase on the femur, whereby the ischium, trochanter, and adductor longus tendon are in essence "locked-in," stabilization increases, which then decreases the Trendelenberg tendencies experienced by many above-knee amputees. By obtaining a definite position of adduction of the femur, one can take advantage of the muscle stretch of the gluteus medius and therefore increase pelvic control with unilateral weight bearing.<a></a></p> <p>Ultralight weight components continue to be preferred in the above-knee prosthesis. The availability of titanium, carbon graphite, and higher density plastics in the manufacturing of the pylons, joints, and attachment plates allow for lighter weight limbs and, ultimately, decreased energy costs for the amputee.</p> <p>The below-knee amputee has a varied repertoire of options. A greater array of suspension methods—latex rubber, neoprene sleeves, total suction prostheses—are now available. The Flex-foot prosthesis<a></a> utilizes a sleeve suspension and is comprised of a carbon graphite and fiberglass pylon and a heel that is very strong, light weight, waterproof, and energy cost effective. The Flex-foot design provides "stored energy" upon weight bearing that "propels" the amputee forward, mimicking "normal" muscle activity in gait. This can also be used for the above-knee amputee. The Flex-foot is proving to be a great advance toward increasing the abilities of the athletic amputee and shows great promise for the elderly and less physically challenged.</p> <p>New liner materials have also provided alternatives for the below-knee amputee, with greater comfort as a result. Silicone gel and leather liners,<a></a> Ipocon gel,<a></a> and injection molded silicone gel liners<a></a> offer the amputee who has minimal tissue coverage and/or scarring the benefit of shock absorption and a "new skin" type feel. The active, athletic below-knee amputee also captures the benefit of the gel system and suffers less trauma as a result.</p> <p>Prosthetic feet, such as the Seattle<a></a> foot and S.A.F.E.<a></a> foot, appear to offer better gait characteristics and function, and also allow for increased activity by virtue of their functional, flexible designs.</p> <p>Ancillary methods of evaluating and improving gait performance are making their way into the more aggressive practices. John Sabolich, C.P.O.<a style="text-decoration: none;">*</a> in Oklahoma City has been utilizing a bio-feedback device with his above-knee patients in an attempt to re-educate the gluteus medius muscle during gait training. Utilizing the system in a dynamic fashion, i.e. patient ambulating with the electrodes over the targeted muscle, provides the patient audible feedback of muscle activity.</p> <p>Use of a video tape camera also provides patients with optimum benefits during the alignment and gait training period.<a></a> Careful analysis of the saggital and frontal views provides the practitioner with a better opportunity to critically analyze and improve his patient's gait. Improved problem-solving subsequent to delivery is also a benefit of this technique. The film serves as a learning tool for the new amputee and the practitioner, and also serves as a record of a patient's progress and delivery status for ironing out future fitting problems relative to gait induced complaints.</p> <p>The Computer Aided Design, Computer Aided Manufacturing (CADCAM) technique<a></a> is presently available for use in designing below-knee prosthetic sockets and will soon be available for design of above-knee prosthetic sockets as well. Measurements are taken from the residual limb and entered into the program. A screen display then allows for modifications to be made relative to the entered data and design scheme. Once the design is created, the information is transmitted to a computerized milling device that then carves out a model of the residual limb. From this model a socket is fabricated from polypropylene.</p> <p>In the future, "shape-sensing" will allow for modifications from the sensed data rather than the standard methodology. The ability to draw from the digitalized information of Computerized Axial Tomography (CATSCAN) or x-rays is also in the offing. This system is also an excellent, accurate record keeping tool. The potential to "sense" size and shape, store the information, recall, modify, or duplicate as desired is an enticing prospect. Further research is both warranted and forthcoming.</p> <h3>Conclusion</h3> <p>With the advent of better technology and methods, a concomitant increase in prosthetic professionalism occurs. Improved education must also follow. Industry-wide attention to continuing the trend will help prevent our field from lapsing into the mundane.</p> <p>The practice of this increased professionalism and improved techniques also commands a higher cost. Jan Stakosa, C.P.'s<a style="text-decoration: none;">*</a> method of using a wide variety of componentry per patient during the fitting and alignment phases in order to optimize function not only serves to improve the patient's quality of life, but carries with it an increased time commitment and cost. Due to this increased input and component variability, thorough education of the public and professionals per the costs involved is required. Ultimately, third party payers and the government will also have to be addressed. Until such time as these practices and advancements become standard, there will not be reimbursement for them.<a></a></p> <p>How do you value human needs in a marketplace in which the trend is toward price reduction? The reality is that all these advances will increase the cost of prosthetic care. Prosthetists, the public, third party payers, and the government will need to be willing to improve the quality of life for this sector of the population, who deserve to be rehabilitated to the maximum and be allowed to perform as well as any able-bodied individual.</p> <p>It is our hope that the prosthetic industry will take up the challenge to advance the profession and invest the time in testing preferred methods and improvements. Equally important is the quest to participate in their creation. Through improved knowledge of the mechanics of amputation surgery and the variables of follow-up care, combined with mutual professional dialogue, we can better serve the amputee population.</p> <p><b>References:</b></p> <ol> <li>Barnes, R.W.; Shanik, G.D.; and Slaymaker E.E., "An index of healing in below-knee amputation: Leg blood pressure by Doppler ultrasound," <i>Surgery</i> 79(1):13-20, 1976.</li> <li>Bonner, F.J. and Green, R.F., "Pneumatic airleg prosthesis: Report of 200 cases," <i>Archives of Physical Medicine and Rehabilitation</i>, 63:383-385, 1982.</li> <li>Burgess, E.M., "General principles of amputation surgery," <i>Atlas of Limb Prosthetics: Surgical and Prosthetic Principles</i>, St. Louis, MO, Mosby, Ch. 2, p.p. 14-18, 1981.</li> <li>Burgess, E.M., "Postoperative management," <i>Atlas of Limb Prosthetics: Surgical and Prosthetic Principles</i>, St. Louis, MO, Mosby, Ch. 3, p.p. 19-23, 1981.</li> <li>Burgess, E.; Hittenberger, D.; Forsgren, S.; and Lindh, D., "The Seattle foot," <i>Orthotics and Prosthetics</i>, 37(1):25-31, 1983.</li> <li>Campbell, J. and Childs, C, "The S.A.F.E. Foot," <i>Orthotics and Prosthetics</i>, 34(3):3-16, 1980.</li> <li>Cary, J.M. and Thompson, R.G., "Planning for optimum function in amputation surgery," <i>Atlas of Limb Prosthetics: Surgical and Prosthetic Principles</i>, St. Louis, MO, Mosby, p. 28, 1981.</li> <li>Ertl, J., "Uber amputationstumpfe," <i>Chirurg.</i>, 20:218, 1949.</li> <li>Gibbons, G.W.; Wheelock Jr, F.C.; Hoar Jr, CS., et al, "Predicting success of forefoot amputations in diabetics by noninvasive testing," <i>Archives of Surgery</i>, 144:1034, September, 1979.</li> <li>Graves, J., "Selectively placed silicone gel socket liners," <i>Orthotics and Prosthetics</i>, 34(2):21-24, 1980.</li> <li>Hanak, R., "Fabrication procedures for the ISNY above-knee flexible socket (instruction manual)." Course at New York University, Post-Graduate Medical School, Prosthetics and Orthotics, January, 1984.</li> <li>Henderson, H.P. and Hackett, M.E.J., "The value of thermography in peripheral vascular disease," <i>Angiology</i>, 29:65-71, 1978.</li> <li>Hittenberger, D.A. and Carpenter, K.L., "A below knee vacuum casting technique," <i>Orthotics and Prosthetics</i>, 37(3): 15-23, 1983.</li> <li><i>Ipocon Silicon Liner Technical Manual</i>. IPOS, Lune-berg, West Germany.</li> <li>Kerstein, M.D., "Utilization of an air splint after below-knee amputation," <i>American Journal of Physical Medicine and Rehabilitation</i>, 53(3): 119-126, 1974.</li> <li>Koniuk, W., Personal communication. San Francisco Prosthetic-Orthotic Service, Inc., San Francisco, 1985.</li> <li>La Noue, A.M., "More on Ertl tibiofibular synostosis," <i>Newsletter . . . Amputee Clinics</i>, (V)4:3-4, July, 1973.</li> <li>Leal, J., "The Flex-foot prosthesis" (instruction manual). Presented at UCLA Prosthetics Education Program, Advanced Below Knee Prosthetics Saturation Seminar, October, 1984.</li> <li>Loon, H.E., "Below-knee amputation surgery," <i>Selected Articles from Artificial Limbs</i>, January 1954 - Spring 1966. Huntington, NY, Krieger, p.p. 305-318, 1970.</li> <li>Malone, J.M.; Leal, J.M.; Moore, W.S.; et al., "The Gold Standard for amputation level selection: Xenon-133 clearance," <i>Journal of Surgical Research,</i> 30:449-455, 1981.</li> <li>Malone, J.M.; Moore, W.S.; Leal, J.M. and Childers, S.J., "Rehabilitation for lower-extremity amputation," <i>Archives of Surgery</i>, 116:93-98, January, 1981.</li> <li>Mehta, K.; Hobson II, R.W.; Jamil, Z; et al., "Fallibility of Doppler ankle pressure in predicting healing of transmetatarsal amputation," <i>Journal of Surgical Research</i>, 28:466, 1980.</li> <li>Mooney, V. and Snelson, R., "Fabrication and application of transparent polycarbonate sockets," <i>Orthotics and Prosthetics</i>, 26(1):1-13, 1972.</li> <li>Moore, W.S.; Henry, R.E.; Malone, J.M.; et al., "Prospective use of Xenon Xe 133 clearance for amputation level selection," <i>Archives of Surgery</i>, 116:86-88, January, 1981.</li> <li>Pike, A.C. and Black, L.K., "The orthoglas transparent test socket-an old idea, a new technology," <i>Orthotics and Prosthetics</i>, 36(4):40-43, 1982-83.</li> <li>Pollack Jr, S.B. and Ernst, C.B., "Use of Doppler pressure measurements in predicting success in amputation of the leg," <i>American Journal of Surgery</i>, 139:303, 1980.</li> <li>Reger, S.I.; Letner, I.E.; Pritham, CH.; et al., "Applications of transparent sockets," <i>Orthotics and Prosthetics</i>, 30(4):35-39, 1976.</li> <li>Sabolich, J. and Guth, T., "The C.A.T.C.A.M. above knee prosthesis pilot course" (instruction manual). Course at UCLA Prosthetic Education Program, March, 1985.</li> <li>Saunders, C.G., "Computer-aided socket design: A computer-aided design and manufacturing package for fitting below-knee amputees with sockets," <i>Medical Engineering Resource Unit</i>, Shaughnessy Hospital, Vancouver, BC, Canada, March, 1984.</li> <li>Saunders, C.G. and Fernie, G.R., "Automated prosthetic fitting." Proceedings of the 2nd International Conference on Rehabilitation Engineering, Ottawa, 1984.</li> <li>Schmitter, E.D., "Surgical principles and practice: Lower Extremity amputations." Lecture-Prosthetics and Orthotics Course for Physicians and Therapists. Provided by Prosthetic-Orthotic Education Program, School of Medicine, Department of Surgery (Orthopaedics). University of California, Los Angeles, April 5-9, 1982.</li> <li>Staats, T.B., "Advanced prosthetic techniques for below knee amputations," <i>Orthopedics</i>, 8(2):249-258, 1985.</li> <li>Stakosa, J.J., "Prosthetics for lower limb amputees," <i>Vascular Surgery: Principles and Techniques</i>, Norwalk, CT, Appleton-Century-Crofts, p.p. 1143-1162, 1984.</li> <li>Sterescu, L.E., "Semirigid (Una) dressing of amputations," <i>Archives of Physical Medicine and Rehabilitation</i>, 55:433-434, September, 1974.</li> <li>Varnau, D.; Vinnecour, K.E.; Luth, M.; and Cooney, D.F., "The enhancement of prosthetics through Xerora-diography," <i>Orthotics and Prosthetics</i>, 39( 1): 14-18, 1985.</li> <li>Whipple, L. and Stakosa, J., "The not so simple ABC's of high technology," <i>Disabled USA</i>, Washington, D.C., July, 1983.</li> <li>Wu, Y.; Keagy, R.D.; Krick, H.J.; et al., "An innovative removable rigid dressing technique for below-the-knee amputation," <i>Journal of Bone and Joint Surgery</i>, 61-A(5):724-729, 1979.</li> </ol> <div style="width: 400px;"><b>Footnote</b> Jan Stakosa, C.P. is Director of the Institute for the Advancement of Prosthetics, Lansing, Michigan. <br /><br />John Sabolich, C.P.O., is Vice-President of Sabolich Orthotics-Prosthetics Center, Oklahoma City, Oklahoma.<br /><br /></div> <div style="width: 400px;"><em><b>*Keith E. Vinnecour, C.P.O. </b> Keith E. Vinnecour, C.P.O., is owner and president of Beverly Hills Prosthetics Orthotics, Inc., Beverly Hills, California.</em><br /><br /><em><b>*David F.M. Cooney, R.P.T., C.P.O. </b> David F.M. Conney, R.P.T., C.P.O., is a senior vice-president at Beverly Hills Prosthetics and Orthotics, Inc.</em><br /><br /><br /></div> Page Number(s) 4 - 9 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Advanced Approach Toward Improved Prosthetic Fittings Creator An entity primarily responsible for making the resource David F.M. Cooney, R.P.T., C.P.O. * Keith E. Vinnecour, C.P.O. * 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.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>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.</p> <h3>History</h3> <p>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.</p> <p>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.</p> <p>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></p> <h3>Fabrication Technique</h3> <p>After the patient has been assessed by the rehabilitation team and the orthotic design has been determined, the patient is seen by the orthotist.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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"><b>Fig. 1</b></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"><b>Fig. 2</b></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.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg">Figure 1.</a> Preparation for casting fingers.</strong><br /><br /><strong><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.</strong><br /> <p>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.</p> <p>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.</p> <p>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.</p> <p>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"><b>Fig. 3</b></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.</p> <strong><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.</strong><br /> <p>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"><b>Fig. 4</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.jpg"><b>Fig. 5</b></a>). Patient training and minor adjustments are done following regular rehabilitation procedures.</p> <strong><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.</strong><br /><br /><strong><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.<br /></strong><br /> <h3>Summary</h3> <p>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.</p> <h3>Acknowledgments</h3> <p>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.</p> <p><b>References:</b></p> <ol> <li>Nickel, V.L., Perry, J., and Garrett, A.L., "Development of Useful Function in the Severely Paralyzed Hand," <i>Journal of Bone and Joint Surgery</i>, 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." <i>Archives of Physical Medicine &amp; Rehabilitation</i>, January, 1967, pp. 43-52.</li> <li>Bisgrove, J.G., "A New Functional Dynamic Wrist Extension-Finger Flexion Hand Splint-A preliminary report, <i>Journal of Ass. Phys. Ment. Rehab.</i>, 8, September-October 1954, pp. 162-163.</li> <li>Redford, J.B., ed. <i>Orthotics Etcetera</i>. Baltimore, Md. Williams and Wilkins, 1980, pp. 238-248.</li> </ol> <em><b>Greg Moore, R.T.O. </b> 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.</em> <div style="width: 400px;"><br /><br /></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/fa104bc2df9d1eb8a2e3fcfe1be372dc.pdf 3cac7ed2272aa4b36cb461ab73d777af https://staging.drfop.org/files/original/03c6dab500bcc8abcf2064a69651e3fb.jpg 78f6ebbe4d49f0e3d87c4a2431800fec https://staging.drfop.org/files/original/ef57e986fd642949abac655e0ddfbb48.jpg f228ca3d4b1bb1b07a591f5647f82f55 https://staging.drfop.org/files/original/6f3713a26a2d78a1af84b3371b05ee26.jpg 4cbdb84cf8ff35a7778b82dbb1364778 https://staging.drfop.org/files/original/984d8d4e3f3b4d44a11796f074d966bc.jpg fd661aac55fb812af0850e8319a6494b https://staging.drfop.org/files/original/a0e1497de95803eedb7c9bae27189933.jpg 86578a267fce21bebb761d96df09ad56 https://staging.drfop.org/files/original/ac40bae7d01bf2c9df78320ef938a453.jpeg 121965bd03be3afd015cb87750d6b2f5 https://staging.drfop.org/files/original/6ac0309f920adb45f06a6d73b90dbb23.jpeg 822b8149c492fcc9a1b2e8791f80a98d https://staging.drfop.org/files/original/ad272a01fb6edf60c48e85a6111e0d64.jpeg 28953020850578f0557a831f57db00da 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/1980_03_003.pdf Text Any textual data included in the document <h2>An Ankle-Foot Orthosis Providing Mediolateral Stabilization While Allowing Free Plantar and Dorsiflexion of the Foot</h2> <h5>Lucia Klemmt, CO&nbsp;<br />Fritz Klemmt&nbsp;</h5> <p>The development of an ankle-foot orthosis (AFO) providing mediolateral stabilization while allowing free plantar and dorsiflexion of the foot was prompted by a patient (W. F.) seen some months ago, who was wearing a posterior solid ankle-foot orthosis (PSAFO). However, rather than providing ankle stability, it was ineffective and an irritant during stance. W. F. was unhappy with it, and discouraged.</p> <p>In evaluating his condition, he was found to have good plantar and dorsiflexion, but suffered from mediolateral ankle instability. He was shown a conventional AFO with a metal stirrup and metal uprights, demonstrating the mediolateral protection the orthosis provides, while allowing free motion at the ankle. The fact that it was less cosmetic than a plastic orthosis did not concern the patient, if it allowed him to walk normally again and not with a stiff ankle. But considering his physician's preference for plastic over a metal orthosis, with its advantages, e.g., free choice of shoes, better appearance, etc., it occurred to us to combine mediolateral protection of the ankle with free ankle plantarflexion and dorsiflexion in a plastic orthosis.</p> <p>This idea was realized by incorporating an ankle joint similar to that used in fracture bracing in a PSAFO (<a href="/files/original/03c6dab500bcc8abcf2064a69651e3fb.jpg"><b>Fig. 1</b></a>). From a plaster mold of the patient's limb, a PSAFO was fabricated with an anterior section for added tibial support. The distal aspect of the calf section was trimmed to clear the Achilles tendon. The proximal edge of the footplate was trimmed so as to include the malleoli (<a href="/files/original/ef57e986fd642949abac655e0ddfbb48.jpg"><b>Fig. 2</b></a>). A contoured bar was riveted to the lateral aspect of the posterior calf portion and joined with the footplate over the malleoli, creating a pivot point allowing, rotation necessary for flexion or extension (<a href="/files/original/6f3713a26a2d78a1af84b3371b05ee26.jpg"><b>Fig. 3</b></a>). Two velcro straps provided an intimate fit around the limb. The patient was pleased with the function and support provided by this orthosis.</p> <p>The second patient fitted with this type of orthosis (R. R.) had a similar ankle problem. A slight change in the design was made. A separate ankle joint as with W. F.'s orthosis was not used. Rather, the proximal edges of the footplate were extended to the proximal aspect of the malleoli. The distal edges of the posterior calf section were then made to overlap the malleoli portions of the foot plate (<a href="/files/original/984d8d4e3f3b4d44a11796f074d966bc.jpg"><b>Fig. 4a</b></a> and <a href="/files/original/a0e1497de95803eedb7c9bae27189933.jpg"><b>Fig. 4b</b></a>). This joint system works smoothly and is more cosmetic, although it requires a little more work. R. R. was delighted with the orthosis since he can wear it with regular Oxfords or boots (<a href="/files/original/ac40bae7d01bf2c9df78320ef938a453.jpeg"><b>Fig. 5</b></a> and <a href="/files/original/6ac0309f920adb45f06a6d73b90dbb23.jpeg"><b>Fig. 6</b></a>).</p> A third patient (P. B.) with a similar problem of ankle instability was fitted with the same type of orthosis made for R. R., but eliminating the anterior portion. This patient, too, was happy with the freedom of motion it allowed (<a href="/files/original/ad272a01fb6edf60c48e85a6111e0d64.jpeg"><b>Fig. 7</b></a>).<br /><br />In these three cases, free plantar and dorsiflexion were allowed while mediolateral ankle stability was achieved. Though it involves extra work and time during fabrication of this type of ankle joint on a posterior solid ankle foot orthosis, the security of the ankle on weight bearing, the freedom of movement while walking, and the satisfaction of the patients wearing the orthosis are achievements justifying the extra effort and expense. Page Number(s) 3 - 5 Year 1980 Volume 4 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-3.jpg Figure 4 FIGURE 4A http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-4.jpg FIGURE 4B http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-5.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-6.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/1980_03_003/1980_03_003-7.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-8.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 An Ankle-Foot Orthosis Providing Mediolateral Stabilization While Allowing Free Plantar and Dorsiflexion of the Foot Creator An entity primarily responsible for making the resource Lucia Klemmt, CO  Fritz Klemmt  https://staging.drfop.org/files/original/a6215b76e14080dd6c7ca38556f64bd7.pdf 4e4651dcdc97cadd4a5eb1206df0da68 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_001.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>An Evolution in the Care of the Child Amputee</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>During the past twenty years the child amputee has emerged as a clinical entity requiring specialized medical and paramedical services. Prior to World War II, no precise methods of management existed. Common practice in fitting a child amputee with a prosthesis involved procrastination. </p> <p>The extent of the change that has occurred is well illustrated by two articles appearing in this issue of <i>Artificial Limbs: Recent Concepts in the Treatment of the Limb-Deficient Child</i>, by Cameron B. Hall, M.D., and the report of the Consultants to the Subcommittee on Child Prosthetics Problems on <i>Nomenclature for Congenital Skeletal Limb Deficiencies</i>. Dr. Hall's article presents an overview of current thinking on the subject, while the nomenclature focuses attention on the precise identification of congenital limb malformations. Many events have contributed to this evolution in thinking and practice. </p> <p>In September 1946, under the aegis of the Michigan Crippled Children Commission, an amputee training center was inaugurated at the Mary Free Bed Guild Children's Hospital and Orthopaedic Center in Grand Rapids, Mich. This project was inspired by the late Carleton Dean, M.D., who was then Director of the Michigan Crippled Children Commission. In the early 1940's, Dr. Dean had recognized that something was amiss in the habilitation of child amputees. He was vitally interested in the amputee program that had been developed by the Armed Services and the Veterans Administration. The science of prosthetics was advancing at a phenomenal pace. New mechanical components were being developed and were proving to be superior to anything heretofore available. Plastic protheses were supplanting the old conventional wooden limbs. Dr. Dean argued that there was no reason why these advances could not be used for child amputees. </p> <p>Little (if any) literature on the management of the child amputee was available, although Dr. Atha Thomas, of Denver, had written a very interesting and instructive chapter entitled "Prostheses for Children" in his book, <i>Amputation Prosthesis</i> <a></a>. In this chapter he advocated amputation in tibial hemimelia, foot removal in proximal femoral focal deficiency, and in pseudoarthrosis of the tibia. Dr. Thomas discussed overgrowth of the fibula as a complication of the child amputee and advocated osteoplastic procedures as described by Nikitin<a></a> and Barber.<a></a> Of singular significance is the fact that Thomas advocated "early fitting." </p> <p>Four years after the opening of the child amputee center in Grand Rapids, the professional personnel presented a formal paper on <i>The Juvenile Amputee</i> at the annual meeting of the American Academy of Orthopaedic Surgeons in February 1950. One hundred ninety-two cases were analyzed in detail. In addition to this presentation, a 28-minute motion picture depicted the problems of the child amputee and demonstrated fitting and training techniques. A scientific exhibit outlining the methods utilized in the care of the child amputee through the team approach was also displayed. Thus, for the first time, the child amputee was identified as an entity to the medical community. Five principles of treatment were stressed: </p> <ol> <li>Physical examination and stump evaluation. </li><li>Utilization of physical and occupational therapeutic methods. </li><li>Detailed coordination of prosthetic fabrication and fitting. </li><li>Inpatient prosthetic training. </li><li>Regularly scheduled outpatient follow-up in an organized child amputee clinic. </li></ol> <p>In January 1954 a workshop was held in Grand Rapids to review the total child amputee problem. Representatives of the Children's Bureau of the Department of Health, Education, and Welfare, the University of California at Los Angeles, New York University, and the Army Prosthetics Research Laboratory (now the Army Medical Biomechanical Research Laboratory) attended. The individual members of the conference enthusiastically endorsed the proposition that an organized program of treatment for child amputees in the United States was definitely indicated. An attempt was made to define the child amputee as compared to the adult amputee. It was agreed that the child amputee could be described as a growing, immature, dependent individual whose long bone epiphyses were still "open." </p> <p>In December 1955, in formal session, the Prosthetics Research Board appointed an <i>ad hoc</i> committee of seven members charged with developing recommendations relative to child amputees in the United States. The outcome of this effort was the formation of the Subcommittee on Child Prosthetics Problems. Its mission was to develop information, and to advise the Prosthetics Research Board on all aspects of the child amputee situation in the United States. </p> <p>During March 1956 the Subcommittee on Child Prosthetics Problems mailed questionnaires to 84 prosthetists and 25 orthopaedic clinics throughout the United States. The response was prompt and enlightening. Analysis of the returns indicated universal interest in child amputee treatment procedures. Shop practices were sharply individualized, and no precise criteria for training existed. At this time there appeared to be only four specialized juvenile amputee clinics in the United States.<a style="text-decoration:none;">*</a></p> <p>With this background of information, the Subcommittee proceeded to encourage the development of child-sized prosthetic components. This endeavor involved not only the miniaturization of adult-sized components but also the introduction of specially designed features so that the devices could be operated by young children. With the assistance of the Army Prosthetics Research Laboratory under the direction of Colonel M. J. Fletcher, the Child Amputee Prosthetics Project at UCLA under the direction of Drs. Craig Taylor and Milo Brooks, and the sound evaluation services of New York University under the direction of Dr. Sidney Fishman, components were gradually developed, fitted, and evaluated relative to their efficiency on child amputees. </p> <p>Stimulated by Dr. Arthur J. Lesser of the Children's Bureau (who was then a member of the Subcommittee on Child Prosthetics Problems), significant steps were taken to encourage the formation of specialized child amputee clinics as a means of standardizing practices in the management of juvenile amputees throughout the country. With the ultimate goal of having a clinic within reach of every child amputee in the nation, definite criteria outlining the requirements for the operation of a satisfactory amputee clinic were formulated. As qualified clinics were established, the cooperative investigation of difficult clinical problems was undertaken. Since these clinics were devoting their efforts exclusively to the child amputee, techniques, appliances, and practices could be introduced and critically evaluated through New York University. Over the years the findings of these studies, which have been analyzed and published, have resulted in the evolution of standards of management never before attained. The fruitfulness of these endeavors is well illustrated by the fact that the Committee for Care of the Handicapped Child of the American Academy of Orthopaedic Surgeons, in conjunction with the Children's Bureau, recently published a document entitled <i>Standards for the Care of the Juvenile Amputee</i>. These standards, which have had nationwide distribution, are essentially the same as those that have evolved through the cooperative research program. </p> <p>The growth in the number of child amputee clinics has been most gratifying. As of January 1966 they numbered twenty in the United States and two in the Dominion of Canada. </p> <p>During the early years of the child amputee program, clinical statistics indicated a ratio of two post-traumatic or postsurgical amputees to one congenital amputee. However, in a period of eight to ten years, a dramatic change has occurred: First, because of the publicity given to the treatment program, children began to appear in clinics at a much younger age than previously. At this very young age, the majority of patients have limb deficiencies that are congenital in nature. <i>Second</i>, the logical consequence was a tipping of the scales of etiological incidence to the congenital type. At present, the majority of clinics report a ratio of five congenital types of deficiencies to two acquired types. </p> <p>Thus the meaning of the term "juvenile amputee" has broadened to encompass post-traumatic amputees, postsurgical amputees, and congenital limb deficiencies and malformations. </p> <p>In 1961 another significant step was taken by the Subcommittee on Child Prosthetics Problems. In that year it initiated publication of the <i>Inter-Clinic Information Bulletin</i>. The first issue was published in October 1961, and the <i>Bulletin</i> has appeared monthly ever since with articles written by the clinic chiefs pertinent to the child amputee. The success of this project is attested by the figures of March 1966 when 1,700 copies were printed and 1,565 were distributed; 351 individuals and institutions received 630 copies. In addition 400 copies were sent to the World Rehabilitation Fund for distribution to its members and 535 to the American Orthotics and Prosthetics Association for distribution to its membership. </p> <p>The impact of the thalidomide tragedy in Europe (West Germany and England) in 1959-1962 focused attention again on the need to improve prostheses, especially when malformed limbs or the complete absence thereof made it difficult to fit conventional suspension and power and cable systems. </p> <p>Heidelberg University had worked with pneumatic power and applied its principles very successfully to these children. Since then there has been a concerted effort in the United States to exploit external power, utilizing compressed carbon dioxide and electricity as power sources. At the present time, a significant number of children throughout the country are wearing externally powered prostheses on an experimental basis. </p> <p>Laboratories are continuing to develop devices in an effort to decrease weight, provide easier application, and improve power sources. There is good reason to believe that as time goes on these endeavors will bear fruit in improved, practical prosthetic function. Interest in child amputees is growing steadily in all parts of the world. These children—many of them multihandicapped—now have a much greater hope for better appliances and services than they ever had in the past. </p> <p>In retrospect, it is evident that much has been achieved by the Subcommittee on Child Prosthetics Problems during the past ten years, but also that much remains to be done. Hopefully, the foundations have been laid for further advances. </p> <p><b>References:</b></p> <ol> <li>Barber, G. C. P., <i>Amputation of the lower leg with induced synostosis of the distal ends of the tibia and fibia</i>, J. Bone and Joint Surg., 13:68, 1939.</li> <li>Nikitin, A. A., <i>Comparative evaluation of late results of various amputations of lower extremities in children</i>, Ortop. i travmatol, Kharkov, (Nos. 4-5) 13:68-75, 1939.</li> <li>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis</i>, J. B. Lippincott, Philadelphia, 1945.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Area Child Amputee Center, Michigan Crippled Children Commission, Grand Rapids, Mich., George T. Aitken, M.D., and Charles H. Frantz, M.D. (1946); Kessler Institute for Rehabilitation, West Orange, N.J., Henry H. Kessler, M.D. (1949); University of Illinois Amputee Clinic, Chicago, Ill., Claude N. Lambert, M.D. (1952); Child Amputee Prosthetics Project, University of California, Los Angeles, Calif., Milo B. Brooks, M.D. (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Barber, G. C. P., Amputation of the lower leg with induced synostosis of the distal ends of the tibia and fibia, J. Bone and Joint Surg., 13:68, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Nikitin, A. A., Comparative evaluation of late results of various amputations of lower extremities in children, Ortop. i travmatol, Kharkov, (Nos. 4-5) 13:68-75, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputation prosthesis, J. B. Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Subcommittee on Child Prosthetics Problems, December 5, 1955-June 30, 1966. When the Subcommittee was formed in 1955 it was a part of the Prosthetics Research Board, the predecessor of the present Committee on Prosthetics Research and Development. The Subcommittee became a standing subcommittee of CPRD when CPRD was formed in 1959. Dr. Frantz, an orthopaedic surgeon in Grand Rapids, Mich., is Medical Co-Director of the Area Child Amputee Program, Michigan Crippled Children Commission. On July 1, 1966, Dr. George T. Aitken, who also is an orthopaedic surgeon in Grand Rapids and Medical Co-Director of the Area Child Amputee Program, Michigan Crippled Children Commission, became Chairman of the Subcommittee on Child Prosthetics Problems.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Evolution in the Care of the Child Amputee Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * https://staging.drfop.org/files/original/13d59df7eaa0bb5ef10ecff3a8fa4fd9.pdf 0247ed6219932127b8f05567d483ea5a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_003.pdf Text Any textual data included in the document <h2>Analysis of the Results From the Questionnaire on Metal vs. Plastic Orthoses</h2> <p>By May 1st, fifty-four (54) responses had been received, considerably more than usual. Fifty-two (52) respondees were certified personnel, one was a physician, and one was an unspecified "other." Interestingly enough, the individual listing himself as other was by far the most negative in his comments.</p> <p>The results were as follow:</p> <ol> <li> <p>Percentage of plastic vs. metal orthoses prescribed:</p> <ul> <li> <p>100% plastic—17%</p> </li> <li> <p>75% plastic, 25% metal—61% of the time</p> </li> <li> <p>25% plastic, 75% metal—13%</p> </li> <li> <p>100% metal—2%</p> </li> </ul> </li> <li> <p>Percentage of staff trained in plastic:</p> <ul> <li> <p>100%—74% of respondees</p> </li> <li> <p>75%—9%</p> </li> <li> <p>50%—9%</p> </li> <li> <p>25 %—7%</p> </li> </ul> </li> <li> <p>Most significant advantages:</p> <ul> <li> <p>lightweight—43%</p> </li> <li> <p>cosmesis—28%</p> </li> <li> <p>versatility—26%</p> </li> <li> <p>correction increased—17%</p> </li> <li> <p>other—11%</p> </li> <li> <p>total contact—9%</p> </li> </ul> <p>Many individuals checked more than one.</p> </li> <li> <p>Most significant disadvantage, most commonly indicated factors (actual numbers):</p> <ol> <li> <p>Inability to adjust dorsiflexion/plantarflexion—20</p> </li> <li> <p>Fluctuating edema—7</p> </li> <li> <p>Fitting a proper shoe and heel height—5</p> </li> </ol> </li> <li> <p>Durability of plastic and hybrid orthoses vs. metal orthoses:</p> <ul> <li> <p>more durable, less maintenance—40% equal—30%</p> </li> <li> <p>less durable, more maintenance—22%</p> </li> </ul> </li> <li> <p>Do you agree with Mr. Shurr's arguments for the use of traditional metal upright orthoses?</p> <ul> <li> <p>yes—69%</p> </li> <li> <p>no—30%</p> </li> </ul> </li> <li> <p>Do you share Mr. Shurr's skepticism regarding prefabricated plastic AFO's?</p> <ul> <li> <p>Yes—83%</p> </li> <li> <p>No—13%</p> </li> </ul> </li> </ol> <p>This seems to be one issue about which considerable unanimity exists within the profession. Questions one and two seem to indicate that plastic plays a major role in the practice of many orthotists and that most of them are versed in its usage. The response to question 5 indicates that most practitioners are not experiencing significant problems with durability, probably as good an indication of good fabricating technique as any. In looking at questions 3, 4, 6 and 7, it appears that most respondents understand the role of plastic in orthotics and its advantages and disadvantages.</p> <p>In light of this unanimity of opinion it is interesting that the question of plastic vs. metal should excite enough interest to spark so large a response, particularly as plastic orthoses have now been in use for over ten years. It may be that orthotists still confront the need to defend plastic orthoses and justify their use. Contrarily it may be that enough individuals have enough experience with plastic that they feel comfortable responding to the issue.</p> <p><b>Additional responses:</b> The following samples are chosen somewhat at random as examples of differing opinions:</p> <p><i>Comments on question 4</i>:</p> <ol> <li> <p>It is my firm belief that the fixation of any joint will have the result of severe atrophy and eventual fusing of the joint. The long term results of the use of the (non-jointed) plastic AFO are not known. Putting it simply:</p> <p>What's the use of working toward recovery of use of an extremity (and that return gradually takes place) when the 'treatment' by an orthotic device has created other problems that the degree of recovery is not able to overcome?</p> </li> <li> <p>I feel there has been an overemphasis on plastic AFO/prefab AFO used by R.P.T.'s which have a limited application, and may be used with some success on geriatric patients in convalescent areas. They do make damned good night splints and that's about all. If used on hilly terrain or streets the patient usually ends up on his butt or smashes his face.</p> </li> <li> <p>How anyone could argue the cause for plastic AFO's is unreal. Any amount of comparisons with the traditional AFO reveals less durability and limited function. Seven out of 10 patients have disabilities necessitating metal over plastic, numerous modifications [to plastic] are a <i>must</i>, and medial lateral support is nil. In my experience, I have found that very mild cases necessitate the use of a plastic AFO when drop-foot (only) is the reason for bracing. Instability in the M-L plane is often accompanied by drop-foot, thus ruling out the plastic AFO.</p> </li> <li> <p>I feel that the plastic AFO is definitely a more desirable type of orthosis for all the reasons mentioned in question #3. However, not every patient is a candidate for a plastic AFO, especially if the patient has edema or needs adjustability at the ankle.</p> </li> <li> <p>Most students coming out of schools at this time only know how to make plastic AFO's and are not proficient or comfortable in making conventional orthoses. These "students" who usually possess degrees never spend sufficient time working in the lab to become bench technicians and most, when handed a pair of bending irons, are in jeopardy of hurting themselves.</p> </li> <li> <p>I agree with Mr. Shurr, but only from the standpoint of a therapist. Adjustment of plastic AFO's requires more than just a general knowledge of thermoplastics. During patient rehabilitation, minor changes in the degree of dorsi or plantar flexions that the orthosis is set in can make a drastic change in patient function. In clinical settings, this should always be done by the orthotist. However, physicial therapists working with patients wearing AFO's may not have accessibility to an orthotist whenever they want to "experiment" with different ankle settings. I can therefore understand Mr. Shurr's interim preference. This is, however, no comparison between the superiority of plastic systems over metal. Orthotists should be involved with any change made to their patients orthotic system.</p> </li> </ol> <p><i>In response to question 6</i>:</p> <p>Therapist adjustment syndrome (TAS) is not a valid RX criterion.</p> <p><i>General Comments</i>:</p> <p>Far more important than durability is the ability to provide superior fit alignment and function. Improperly fitting plastic orthoses, by their very nature, are far more obvious and as a result more nearly considered unacceptable than the traditional Brace—which by its very nature masks improper fit and alignment and of course results in improper braces being worn. In 1980, we introduced a policy of providing all necessary repairs and adjustments without additional cost for the life of any plastic orthosis. This policy specifically excludes traditional metal/leather braces.</p> Page Number(s) 3 - 4 Year 1983 Volume 7 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Analysis of the Results From the Questionnaire on Metal vs. Plastic Orthoses https://staging.drfop.org/files/original/79a235e1d4c4ac4171b6ad7c96f90851.pdf 7d14943ca2f5c25f952db617169ffdde https://staging.drfop.org/files/original/d93a7f5e6bfbb40a83f52c51fc6a67a0.jpg db9f1ea0b3a5c0dae6916c1ef66fda44 https://staging.drfop.org/files/original/7cfe500718aa89f77b72e9954ceaa92a.jpg bc918fbb4fd53f2e78ad4605c3abc065 https://staging.drfop.org/files/original/f998e66b14d6b1f834d759185e8e31cc.jpg 690db42406a21e4599e9835f0033c37a https://staging.drfop.org/files/original/559362f3b4c65498619fab8d04b2e42d.jpg f404f1ed2a48fcbad91850fac32efb17 https://staging.drfop.org/files/original/7af014f5d48267ea4832e4f0ba735e65.jpg 609b9bfd8cf0cad72c5cf2fd2ea68995 https://staging.drfop.org/files/original/6da85b1d4d85e1ce07a103930d4575b1.jpg c18a528ba271b6327ebd72aa14550653 https://staging.drfop.org/files/original/1c2e54190c5087e85a7fbc06ef5d358c.jpg 475202f1811c126dfb0443740358cd5a https://staging.drfop.org/files/original/77afa88f7126e3389bfeddccc24b5a2f.jpg 96215102b821993251b391e9acb6d3f2 https://staging.drfop.org/files/original/2371fc89399f73ef4387072b2b40d799.jpg 18b9d437398b6a98ea408c303b0a1ee2 https://staging.drfop.org/files/original/d8cedb74083df4c71c32c360d03b67b8.jpg 5808de98d275b210021d7c661d2ff3d9 https://staging.drfop.org/files/original/163c3b8f65e454aba7ec0bfafdbca66a.jpg 0cb901d66c2c9cdede16bf37b1b551a7 https://staging.drfop.org/files/original/345ce876e71543363ff3c14412c219fb.jpg 8d1848456d7991653f7e3dcad092df20 https://staging.drfop.org/files/original/24ae1765809e82da9084f33c1af4ad5d.jpg 45f56fde2581a9b627c3e7b20f49bae8 https://staging.drfop.org/files/original/684aa5896d82c06bec7a0f958890cadb.jpg b8ce7048f8e79c9339b98b24877b4692 https://staging.drfop.org/files/original/c0e25772039790e312707e0a3e972640.jpg 74351e8b3732f843b1e09d0acc3a1e30 https://staging.drfop.org/files/original/fa307185379e510f725ef82250490487.jpg 90909e24310f83b7ade0e3c07b5cd24b https://staging.drfop.org/files/original/339a789db42e3eea242dd8c322350790.jpg 50a04b08971e95aabb20ffd944f2163c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_004.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 4 - 15 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Anatomical and Physiological Considerations in Below-Knee Prosthetics</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br />A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>One of the most difficult problems in the design of prostheses is the development of the best means of attaching the prosthesis to the wearer. In lower-extremity cases, transmission of forces between stump and prosthesis is of primary importance. To effect efficient transmission of forces, a stable connection between stump and prosthesis is necessary. At the same time comfort and freedom of motion must be maintained to as high a degree as possible. All of these goals are affected by anatomical and physiological characteristics of the stump and the next proximal joint, and often of the joint above that.</p> <p>Stability is provided most often by encasing the stump in a socket to a point near the first proximal joint. The soft tissues of the stump are not especially ideal for providing resistance to the torques and moments imposed on them by a socket during use of a prosthesis. If the tissues are compressed in an attempt to provide maximum stability, circulation will be impaired; if the socket is too loose, a false-joint effect is produced resulting in abnormally high unit pressures at proximal and distal points, chafing, and a reduction in ability to control the prosthesis. Thus, extreme care must be exercised in socket design and fabrication if the optimum condition is to be obtained.</p> <p>When weight-bearing can be achieved through the long bones, as in the case of many disarticulations and certain special types of amputation, the socket is designed to permit loads to be carried through the end of the bone in the stump. If most of the weight-bearing needed cannot be achieved through the end, some other areas must be found to provide the transmission of forces necessary during standing. For all of these reasons, then, it is extremely important that prosthetists and others responsible for the design of sockets take into consideration certain anatomical and physiological factors in the management of the amputee. In no other case is it more important than in that of the below-knee amputee.</p> <h3>Function of the Below-Knee Stump</h3> <p>Because most of the insertions of the muscles and ligaments that control the knee are located on the tibia and fibula at points close to the knee joint (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>), amputation below the knee rarely affects the function of the knee joint. An exception is the gastrocnemius which originates from the posterior portion of each of the femoral condyles and has for its insertion the Achilles tendon, thus acting as a flexor. Upon amputation, however, the distal end of the gastrocnemius often becomes reattached to the tibia, and the remaining musculature is thus available to assist the flexors and perhaps to aid in preventing dislocation of the fibula with respect to the tibia. Thus the moment that can be generated about the knee in the parasagittal plane by a typical below-knee amputee is approximately the same as that before amputation. Because, in general, the ligaments are left untouched, mediolateral stability of the below-knee amputee usually is not affected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Posterior view of left knee joint, showing anterior ligaments. Redrawn from Gray's <i>Anatomy.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The major muscles that flex and extend the knee joint. From <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis (4).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. X-rays of a typical below-knee slump <i>. A,</i> Anterior view; <i>B,</i> medial view. Courtesy <i>Veterans Admlnistration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those muscles which have origins on the tibia and fibula, and which control ankle and foot motion, have been severed and consequently atrophy, resulting generally in a bony, conical-shaped stump (<b>Fig. 4</b>). The amount and type of atrophy that takes place depend of course upon surgical technique and postoperative care.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Lateral and anterior views of a typical well formed, right below knee stump Courtesy <i>Veterans Ad-ministration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In very short below-knee stumps, removal of the fibula (<b>Fig. 5</b>) is sometimes performed to prevent lateral and posterior deviation with uncomfortable protrusion at the distal end. Such deviation is generally thought to be caused by frictional engagement on the socket wall (with inadequate relief) or by action of the biceps femoris. In any below-knee amputee, the distal ligamentous attachment near the ankle is missing, and in short stumps the interosseus membrane (<b>Fig. 6</b>) between the remnants of the tibia and the fibula is presumably inadequate, partly because the proximal opening for the vessels leaves only a small amount of the membrane, and particularly because atrophy of intervening muscles leaves some slack in the membrane. Removal of the fibular head, though, implies that the tendon of the biceps femoris, as well as the fibular collateral ligament, should be reattached with appropriate lengths and at suitable centers on the tibia. A bone bridge from fibula to tibia that would restore stability between tibia and fibula as well as increase the possibilities for bearing weight on the end of the stump would seem to be preferable to removal of the fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Roentgenogram of a short below-knee stump in which lateral deviation and rotation of the fibula have taken place. <i>Courtesy University of California Medical School.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6. Anterior ligamentous structure of the right knee.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Knee Joint</h3> <p> The knee joint formed by the condyles of the femur and tibia (<b>Fig. 3</b>, <b>Fig. 7</b>) allows about 160 dcg. of flexion. It is classified as a synovial joint, or one that is provided with synovial Quid, and the friction developed between the moving surfaces of an unimpaired joint is of an unusually low magnitude as compared with moving joints in machinery.<a></a> It is not a simple hinge joint with a single axis of rotation. Because movement of the tibia with respect to the femur is a combination of gliding and rolling actions, and because of the shape of the contacting surfaces, the instantaneous center of rotation of the knee varies with each degree of flexion. Though the exact course of the instantaneous centers for different individuals cannot be described with present knowledge, a general idea of the typical area through which they move can be had (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Major structures that form the knee joint. From <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis (4).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8. Section through the medial condyle of the femur and through the tibia. The center of curvature is shown for three parts of the articular surface. As gliding occurs in the joint, the instantaneous center moves along the curve connecting these centers of curvature. From Elftman (2).</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For many years it has been common practice to divide the responsibility of weight-bearing between the below-knee stump and the thigh by use of simple hinge joints (located along the medial and lateral aspects of the knee) connecting a thigh corset to the socket and shank (<b>Fig. 9</b>). But, because the center of rotation of the knee moves constantly while flexion or extension takes place, any artificial joint attached on the outside of the leg and thigh that does not follow the complex pattern of the human joint will cause relative motion between the body parts and the prosthesis. Since there is not available an artificial joint that simulates normal movement, it appears highly desirable to provide the below-knee amputee with a prosthesis that does not require side joints, even though the tissues in the stump and thigh are capable of absorbing the effects of some relative motion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9. Some examples of the so-called "conventional" below-knee prosthesis offered by prosthetists for more than a century. Note the sidebars, corset, relatively low brim, and free space at distal end of socket.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Weight-Bearing</h3> <p>If sidebars are to be avoided, obviously all of the weight-bearing loads must be transmitted through the stump to the skeletal system. Some areas on the stump are better suited to assume these loads than others. In the light of present knowledge and technology it is necessary to design and construct the socket so that the pressures imposed on specific areas, whether by normal repeated loads encountered during walking or whether by single emergency loads, are not of values that exceed the varying tolerances of the different tissues of the stump. And just as obviously some means other than sidebars and thigh corset must be found to maintain the limb on the stump. If, however, the necessary mediolateral stability is not present, there is no known recourse except to use at least one sidebar and generally two.</p> <h4>The Patellar Ligament</h4> <p>Extension of the knee is effected by the contraction of the quadriceps muscle, so named because it has four distinct components. However, they merge into a single tendon which inserts on the anterior portion of the tibia just below its head (<b>Fig. 6</b>). Embedded in this tendon is the patella (<b>Fig. 7</b>), which is therefore a sesamoid bone, the largest in the body. Its function is twofold. While acting as a guide for the quadriceps tendon by following the vertical groove between the femoral condyles, it also tends to increase the lever arm of the quadriceps acting about the knee axis. Its cartilaginous underbody tends to produce very little friction as it slides over the anterior surface of the femur. That part of the quadriceps tendon between the patella and the insertion, frequently referred to as the patellar ligament (<b>Fig. 10</b>), is composed of extremely tough fibers which stretch insignificantly under normal tensile loads along the long axis and is particularly suited to take compressive loads anteroposteriorly. Because of the inextensible quality of the quadriceps tendon, there can be little or no relative motion between the patella and the tibia when the quadriceps develops tension, a condition which permits compressive loads over the quadriceps tendon, perpendicular to the fibers, up to the proximal edge of the patella. The sharp lower edge of the patella, though, is relatively unsuited for weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Schematic drawing showing the nearly complete lack of relative motion between patella and tibia during flexion of the knee. The inextensibility of the patellar ligament prevents the patella from moving proximally with respect to the tibia. From Marks <i>(3).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Branching out from the quadriceps tendon on each side above the patella are the lateral and medial retinacula (<b>Fig. 6</b>), which insert on the flares of the tibia. Like the patellar ligament, these tendons are capable of weight-bearing.</p> <p>If the socket wall contains an indentation (<b>Fig. 11</b>) between the lower edge of the patella and the tendinous insertion, some initial tension is placed on the tendon. The upper surface of the indentation also permits the tendon to assume a load with a larger vertical component than would be the case if the indentation were not present (<b>Fig. 12</b>). Moreover, when the socket is aligned so that a slight amount of initial flexion is present when the wearer is in the standing position, both initial tension in the quadriceps tendon and the vertical components of load-bearing are enhanced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Vertical cross-section of anterior portion of socket designed to take maximum advantage of patellar ligament for transmission of weight-bearing loads. Compare with Figure 12.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Vertical cross-section of anterior portion of socket with little provision for use of the patellar ligament for transmission of weight-bearing loads. Note the small vertical component of the force between socket and stump in this area as compared to the condition shown in Figure 11.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Flares of the Tibial Condyles</h4> <p>By virtue of its wedgelike shape and the nature of its thin, tough, overlying tissues, the upper portion of the tibia can assume part of the weight-bearing load by distribution of pressure over the medial and lateral flares of the condyles. Because part of the lateral flare of the tibial condyle is obscured by the head of the fibula, the medial flare offers most of the weight-bearing area.</p> <p><b>Fig. 13</b> shows horizontal cross sections of the tibia below the condyles superimposed on each other. Thus it can be seen that there is available potentially a considerable difference in horizontal area over which to distribute vertical forces to balance body weight. If the socket is aligned so that the stump is forced into a slightly flexed position when the wearer is standing erect, the horizontal components are reduced, the requirements for counter-pressure over the posterior wall are less, and therefore the risk of pressure over the major vessels and nerves in the rear is reduced. Proximity to relatively sensitive zones like the head of the fibula (typically present under the lateral flare), the sharp tibial crest, and the rough tibial tubercle greatly reduces the useful area on the anterolateral portion. The medial flare, though seemingly smaller than the lateral, is quite effective in providing support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Horizontal cross-sections of leg at four different levels. View below leg shows level <i>A</i> superimposed on level <i>D</i> to illustrate the horizontal area potentially available for vertical support along the sloping areas of the tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Tibial Crest</h4> <p>The shaft of the tibia is roughly triangular in horizontal section, one apex, the tibial crest, lying in the anterior portion of the leg (<b>Fig. 13</b>). The anteromedial wall of the tibia is covered with a thin layer of tissues and is admirably suited to assume some of the weight-bearing stresses. In the normal limb, the anterolateral wall of the tibia is covered by the tibialis anterior, which inserts in the region of the foot. Upon amputation, the tibialis atrophies but can still transmit, without discomfort, considerable load to the anterolateral wall. But the tibial crest itself cannot assume a weight-bearing load because of the high unit pressures that would necessarily develop over the knifelike ridge. For the same reason, compressive stresses cannot be tolerated either at the lateral aspect of the distal end of the fibula or at the anterior aspect of the distal end of the tibia.</p> <h4>The Head of the Fibula</h4> <p>Because the common peroneal nerve passes on the lateral side below the head of the fibula, only very low pressure can be tolerated in that area. Also, for bony stumps it is sometimes necessary to provide a groove proximally from the region of the head of the fibula in order to permit entry of the stump into the socket. <b>Fig. 14</b> shows in a somewhat exaggerated way how a socket is shaped to preclude the application of pressure in tender areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14. Cross-section showing typical method of avoiding pressure between socket and tender areas on stump, in this case the area about the head of the fibula.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Distal End of the Stump</h4> <p>Few below-knee stumps will tolerate very much pressure on the distal end, presumably because of the shearing stresses developed between soft tissues and the cut end of bone. Short stumps, where amputation was made through cancellous bone, and those cases where a bridge of bone has formed between the distal ends of the tibia and fibula, accidentally or surgically, are exceptions to the rule.</p> <h3>Stability</h3> <p> Vertical pressures on the areas projected on the horizontal plane, and hence total vertical forces, unhappily can be obtained only as <i>components</i> of the larger unit pressures and total forces exerted at right angles to the obiquely sloping surfaces of the stump, the thin but tough underlying tissues, and ultimately the bone (<b>Fig. 15</b>). Because these surfaces slope, there must be forces <i>in</i> the horizontal plane. Because the slowly curving surfaces slope generally <i>inward</i> toward the longitudinal axis of the tibia, in the frontal plane that fraction of the horizontal components of the sloping forces from the socket acting on the broad medial aspect of the condyles must oppose the corresponding components of the force acting on the more limited lateral aspect, resulting in over-all compression or constriction of the stump. Any net imbalance near the condyles may be counteracted by a distal horizontal force to yield in the frontal plane a moment balanced elsewhere. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 15. Schematic drawing showing the approximate direction of forces acting on the flares of the tibial condyles. The vector representing the force on the lateral side is shown in true view in the lower sketch. Note the components developed in the horizontal plane. The components shown must of course be balanced by other forces in the horizontal plane.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Because both the medial and lateral condyles slope generally <i>backward,</i> the horizontal components in parasagittal planes would tend to force the stump backward and hence allow it to slip downward off the sloping shelves matching the tissues overlying the condyles. Similarly, forces on the patellar ligament and retinacula have components directed rearwardly. Obviously, counterpressures from the rear wall must be so distributed over the stump as to develop adequate counter-forces without pressure sufficient to cause pain at any point, restrict return circulation, or interfere with adequate knee flexion during sitting. Superimposed on these forces acting in the horizontal plane as a result of vertical weight-bearing there generally are other forces, high on one aspect of the stump and low on the opposite, forming couples related to mediolateral stability, forcible knee extension, and so on. </p> <p>The optimum level for the rear brim of the socket is the popliteal crease. Though as high a brim as feasible is desirable to provide greater area for horizontal counterpressure, a rigid socket brim above this level on the posterior aspect will seriously restrict knee flexion; one below results in bulging of the tissues over the brim during flexion.</p> <p>The medial and lateral aspects of the socket wall should be carried to about the level of the proximal edge of the patella to enhance mediolateral stability.</p> <h3>The Hamstrings</h3> <p>The most important flexors of the knee are the hamstrings, which have two areas of insertions-one on the posterior aspect of the medial tibial condyle, the other on the posterolateral aspect of the head of the fibula (<b>Fig. 2</b>). As flexion occurs and the tibia and fibula rotate with respect to the femur, the hamstrings move away from the center of the femur. To prevent bunching of the tissues in the popliteal space during substantial knee flexion, especially during sitting, the brim of the socket should be brought precisely to the level of the popliteal crease. Because the two insertions of the hamstrings are below this level, interference between the hamstring tendons and the brim of the socket would occur when the knee is flexed were appropriate grooves, or cutouts, not provided in the rear portion of the brim. The medial groove is generally deeper than the lateral because the insertion of the semi-tendinosus is more distal on the tibia than the insertion of the biceps femoris is on the fibula.</p> <h3>Edema</h3> <p> One of the causes of edema is an unbalanced condition in the interchange of materials between blood and body cells by way of the capillary and lymphatic systems, <i>i.e.,</i> more fluid is pumped temporarily into the exchange system than is pumped out. An imbalance can be the result of either mechanical or biochemical factors. The wearing of a limb is not likely to lead to the formation of chemicals that produce edema, but it can produce mechanical factors that do. The action of voluntary muscle working within the normally intact fascial envelope is responsible in part for the return of the blood to the venous system via the capillary and lymphatic systems, and hence factors that alter normal muscle activity can contribute to the formation of edema. Further, concentrated pressures in one area can cause edema in a distal area either by inhibiting muscle action or by restricting the low-pressure venous or lymphatic return systems and thus are to be avoided. For this reason, when relief is required for bony prominences or tender areas, the indentation in the socket wall should be flared gently. Relief should never be provided by a hole or window which removes external counterpressure from a localized area while maintaining support or even constriction elsewhere. </p> <p>Also to be avoided is a combination of a tight fit in the proximal portion of the socket and a loose fit distally. Under such circumstances the venous and lymphatic systems can be constricted to the point that edema is produced.</p> <p>Gentle external pressure on soft tissues offers a mechanical aid to the return of blood to the venous system. The equivalent can be obtained by encasing the entire stump with the socket in such a manner that at least a slight amount of pressure is brought to bear over the soft tissues as the prosthesis is used.</p> <h3>The Composite Socket</h3> <p>The shape of the socket in which the anatomical and physiological factors discussed above are taken into account is shown in <b>Fig. 16</b> and <b>Fig. 17</b>. The anterior brim is brought to the level of the center of the patella; a horizontal indentation is provided at the midpoint of the patellar ligament to induce tension in the ligament and at the same time to afford a more horizontal weight-bearing surface; the lateral and medial aspects of the brim are brought about level with the proximal edge of the patella to assist in providing mediolateral stability; grooves are incorporated into the posterior brim of the socket to accommodate the hamstring tendons during flexion; the entire stump is encased; and areas for relief of bony prominences are flared gently to avoid radical changes in pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16. Cutaway view of the patellar-tendon-bearing socket incorporated in a thin-walled plastic shank. Note especially cuff-suspension strap, high lateral and medial walls, and the total-contact feature.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17. Posterior view of brim of PTB socket for a right stump. Note that the medial wall is slightly lower than the lateral. Not shown is the soft inner liner commonly used.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The socket shown was developed by the Biomechanics Laboratory of the University of California<a></a> after a thorough study of previous practices and after an analysis of the anatomical, physiological, and biomechanical factors involved. The socket is installed in the prosthesis so that the knee is in some 5 to 8 deg. of flexion when the patient is standing erect. This slight degree of initial flexion not only places the weight-bearing loads on the stump in a direction that reduces the unit stresses and shearing forces but also relieves the popliteal area of some pressure as well. In addition, use of the quadriceps is encouraged, and the risk of overloading ligaments as a result of excessive hyperextension is reduced. </p> <p> Because of the difficulty in achieving a truly intimate fit, and for lack of an accurate method of measuring forces between the stump and the socket, use of a soft liner is recommended. The liner, usually of sponge rubber 1/8 in. thick on the sides, slightly thicker on the end, and covered with leather, reduces the chances of abrupt changes in stress. </p> <p>Suspension usually can be effected by a simple cuff above the femoral condyles attached to the shank by flexible straps, but a waist belt or sidebars and corset may be used if necessary.</p> <p>The entire prosthesis has come to be known as the "patellar-tendon-bearing leg," or simply the "PTB leg," perhaps useful as a code name but an unfortunate nomenclature if taken literally, not only because it describes only a part of one functional aspect offered by the prosthesis but also because even that portion would more rightly be termed "patellar-liga-ment-bearing" or "quadriceps-tendon-bearing."</p> <p>Sidebars and corset may be indicated in cases where rather extreme mediolateral instability of the knee is present or where muscles which control the knee have been impaired to the extent that exercise will not strengthen them. Sidebars and corset with ischial support may be indicated either for cases where bone or joint impairments prevent any of the long bones from assuming weight-bearing loads or for those where the skin is of such nature that the imposition of the required loading is simply out of the question. In addition, certain occupations might be carried out more readily if sidebars were used. Except for such limitations, virtually all below-knee amputees with healthy stumps can derive benefit from the PTB prosthesis with cuff suspension, provided the clinic team fully understands the underlying principles in the design and provided also that the prosthetist has the skill necessary to incorporate the essential features into the finished prosthesis.</p> <h3>Acknowledgment</h3> <p>The authors wish to acknowledge the gracious assistance and guidance afforded by Herbert Elftman and Gabriel Rosenkranz in the preparation of this article.</p> <p><b>References:</b></p> <ol> <li> Charnley, John, <i>The lubrication of animal joints,</i> in <i>Symposium on Biomechanics,</i> The Institution of Mechanical Engineers, London, 1959, pp. 12-22. </li> <li> Elftman, Herbert, <i>The functional structure of the lower limb,</i> Chapter 14 in Klopsteg and Wilson's <i>Human limbs and their substitutes,</i> McGraw-Hill, 1954. </li> <li> Marks, George E., <i>Treatise on artificial limbs,</i> A. A. Marks Co., New York, 1899. </li> <li> University of California, Biomechanics Laboratory (Berkeley and San Francisco), <i>The patellar-tendon-bearing below-knee prosthesis,</i> 1961. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> University of California, Biomechanics Laboratory (Berkeley and San Francisco), The patellar-tendon-bearing below-knee prosthesis, 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Charnley, John, The lubrication of animal joints, in Symposium on Biomechanics, The Institution of Mechanical Engineers, London, 1959, pp. 12-22. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Academy of Sciences - National Research Council, 2101 Constitution Avenue, Washington 25, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Avenue, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-17.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 Anatomical and Physiological Considerations in Below-Knee Prosthetics Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/b45df324d6e6eb3062561af4ba9ca31c.pdf fe6df163464ebb5485158fcdc77801d6 https://staging.drfop.org/files/original/42f3cf78c258ae2747437e3c837288cc.jpeg 2b66e681fb1e8c1d4ab08e11a80b7f95 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_01_001.pdf Text Any textual data included in the document <h2>Ankle Foot Orthoses: Metal vs. Plastic</h2> <h5>Joanne A. Klope Shamp, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Since the late 1960's, when Yates <a></a> and Lehneis <a></a> wrote the first articles pertaining to the use of plastics in orthotics, the debate has continued comparing conventional metal to thermoformed orthoses. But debate is no longer necessary as the well-informed clinic team finds that plastic orthotic systems have come of age and should be prescribed on a routine basis.</p> <p>The advantages of thermoformed orthoses are numerous, extending far beyond the obvious factors of improved cosmetic and weight considerations. These, however, have significant merit in themselves. American society is appearance-conscious and highly competitive, an atmosphere in which individuals with disabilities are finding their rightful place among the non-disabled. The influence that the appearance of a device has on the effective interrelationships at home and in the workplace cannot be ignored. Thermoplastic devices are form-fitting, fleshtone, hygienic, and noise-free, unlike the metal devices of yesterday, and assist the individual in breaking the stereotypes of disability set by society. Of particular importance to the patient is the ability to interchange shoes, as long as the heel height remains consistent.</p> <p>The devices' light weight means a decrease in energy expenditure and, in many cases, makes a marked difference in the patient's ability to perform hip and knee flexion adequate for a full day's activities. This also allows the patient to life the involved extremity for climbing stairs, getting into an automobile and other actions requiring flexibility. A recent study by Smith, Quigley, and Waters <a></a> concluded that the "lighter" polypropylene Ankle Foot Orthosis promotes more efficient advancement of the involved limb, allowing a greater percentage of the gait cycle to be devoted to the stance phase of gait." This accounted for the "more normal pattern of foot-floor contact at initial contact and at terminal stance" <a></a>^{, p. 54}.</p> <p>Hygienic concerns are easily met with plastic orthoses that may be cleaned daily with soap and water, rubbing alcohol, or chemicals such as acetone. To incontinent children and adults this means an increased life for the orthosis, as well as cleanliness and an improved self-image.</p> <p>In the same manner that prosthetic practice was revolutionized by the concept of total contact, so too has orthotics experienced a renaissance. With the total contact features of thermoformed orthoses, increased force may be applied to the skeleton without discomfort and skin breakdown as the area receiving the force is multiplied. Prevention and correction of deformity is greatly enhanced as compared to the metal bands of conventional double upright orthoses with their small surface areas.</p> <p>The force-distributing properties of plastic orthoses are of particular benefit in the case of insensitive feet where decubitus ulcers must be aggressively prevented. The use of well-formed total contact orthoses may preclude the need for expensive custom shoes in these cases and allow healthy feet in affordable and attractive footwear.</p> <p>Although cosmesis, weight, hygiene, and total contact features are important assets of thermoformed orthotic systems, versatility is the major advantage to the prescribing physician and clinic team. Design potentials are unlimited and allow the customizing of the orthosis to the exact biomechanical needs of the patient, without excess bulk or "over-bracing." As von Werssowet stated ". . . a brace should be selected with the most simple design that will accomplish the purpose and mission" <a></a>^{, p. 364}.</p> <p>At the knee and ankle joints, free motion and some degrees of limited motion are easily obtained with a total plastic orthotic system. When a specialized assist or stop is required, a hybrid system <a></a> utilizing metal joints within the plastic design may be more satisfactory in meeting the patient's needs. Where total immobilization is indicated, plastic orthoses may be fabricated with corrugations or carbon composite inserts <a></a> that afford rigidity. Ankle position may be altered to provide a stabilizing effect to the knee joint at midstance or to prevent recurvatum when posterior structures are compromised.</p> <p><b><a href="/files/original/42f3cf78c258ae2747437e3c837288cc.jpeg">Fig. 1</a>: The controversy illustrated—metal double upright ankle-foot orthosis vs. plastic ankle foot orthosis.</b></p> <p>A striking advantage of plastic orthotic systems is their superior control at the ankle in the frontal plane. A result of both the total contact nature of the device, as well as the individuality of possible designs, this provides excellent control in cases presenting equi-novarus (hemiplegia secondary to CVA), clubfoot deformities, and other mediolateral instabilities. Varying the thickness of the plastic and the configuration of the trimlines creates an appropriate three point pressure system that will not require force application over boney prominences, as the ankle strap of a conventional double upright orthosis requires over the lateral malleolus.</p> <p>Plastic orthoses are beginning to play a role in work regarding inhibitive casting and the effect upon spasticity. Eberle, Jeffries, and Zachazewski <a></a> recently reported success with an inhibitive AFO, a concept that was not feasible with metal orthotics. Their report stated that "the technique of fabrication used for construction of a molded polypropylene AFO allows for all of the tone-inhibiting characteristics of casting ... to be built into the AFO. . . (including) hyperextension of the toes, pressure under the metatarsal heads, a stable ankle position, and deep tendon pressure along the tendo calcaneus" <a></a>^{, p. 454}. The molded footplate offers excellent control as compared to conventional metal orthoses where "modification must be made to the shank of the shoe in cases of severe spasticity, lest it break at the anterior edge of the tongue and thus allow the foot to adopt a position of equinus" <a></a>^{, p. 1}.</p> <p>The hydrostatic features of plastic fracture orthoses have, in many regions, radically changed the orthopaedic approach to fracture management. Their effective application has been well documented by Sarmiento <a></a> and others. Their light weight (6-10 oz.), excellent hygiene, and wear with street shoes <a></a>, allows the patient a safe and speedy return to a near-normal lifestyle that often includes employment, even in cases of delayed healing.</p> <p>Hybrid and total plastic systems are easily adjusted for volume change and progressive positional correction through the use of heat forming techniques. Longitudinal growth in children can be predicted and the appropriate length adjustability feature can be an integral part of the orthotic design.</p> <p>Some unique and exceptionally biomechanical designs have been made possible through the use of thermoplastics. The spiral and hemispiral AFO designs <a></a> employ the physical characteristics of the coiled configuration of plastic to store energy and serve as a functional assist to weakened dorsi- and plantar-flexor musculature, with little effect on knee stability.</p> <p>The prescription and use of thermoplastic orthotic systems is no longer confined to regions with specialized clinic teams. Although their use originated in the research of large medical centers in major cities, the private practice sector nationwide now has ten years experience in these management concepts. The professional literature of the prosthetic and orthotic profession abounds with information on all aspects of design rationale and fabrication techniques utilizing today's total plastic and hybrid systems.</p> <p>I challenge each of you to break through the stereotypes of your conventional metal orthotic prescription and management practices. The potentials of current thermoformed based orthotic design are limitless, and will provide the patient with an immeasurably improved functional outlook and self-image.</p> <p><b>References:</b></p> <ol> <li>Yates, G. ,"A Method for Provision of Lightweight Aesthetic Orthopaedic Appliances," <i>Orthopaedics</i>: Oxford, 1:2, 153-162, 1968.</li> <li>Lehneis, H.R., Ph.D., CPO, "New Concepts in Lower Extremity Orthotics", <i>Medical Clinics of North America</i>, 53:3:3, pp.585-592, 1969.</li> <li>Lehneis, H.R., Frisina, W., Marx, H.W., "Bioengineering Design and Development of Lower Extremity Orthotic Devices. Final Report, Project #23-p-55029 2-03," Institute of Rehabilitation Medicine, New York University Medical Center, October, 1972.</li> <li>Smith, A.E., Quigley, M., Waters, R., "Kinematic Comparison of the BiCaal Orthosis and the Rigid Polypropylene Orthosis in Stroke Patients" <i>Orthotics and Prosthetics</i>, 36:2, pp.49-55,1982.</li> <li>von Werssowetz, O.F., "The Use and Abuse of Braces in Rehabilitation of Neuromuscular Disorders," <i>Archives of Physical Medicine and Rehabilitation</i> 35:1, pp. 363-368, 1954.</li> <li>Behsman, A.S., and Lossing, W.W., "A New Ankle-Foot Orthosis Combining the Advantages of Metal and Plastics," <i>Orthotics and Prosthetics</i> 33:1, pp. 3-10, 1979.</li> <li>Fillauer, C, "A New Ankle Foot Orthosis With a Moldable Carbon Composite Insert," <i>Orthotics and Prosthetics</i>, 35:3, pp. 13-16, 1981.</li> <li>Eberle, E.D., Jefferies, M., and Zachazewski, J.E., "Effect of Tone-Inhibiting Casts and Orthoses on Gait: A Case Report," <i>Physical Therapy</i>, 62:4, pp. 453-455, 1982.</li> <li>Rosenberger, R. and Pritham, C.H., "Instep Strap," <i>Newsletter. . .Prosthetics and Orthotics Clinic</i>, 3:1, pp. 1-3, 1979.</li> <li>Sarmiento, A., and Sinclair, W.F.,"Tibial and Femoral Fractures-Bracing Manegement," University of Miami School of Medicine, circa 1973.</li> <li>Stills, M., "Vacuum-Formed Orthoses for Fracture of the Tibia," <i>Orthotics and Prosthetics</i>, 3:2, pp. 43-55, 1976.</li> </ol> <div style="width: 400px;"><em><b>*Joanne A. Klope Shamp, CPO </b> Shamp Prosthetic Center, Inc. Norton, OH</em><br /><br /><br /></div> Page Number(s) 1 - 3 Year 1983 Volume 7 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1983_01_001/1983_01_001-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Ankle Foot Orthoses: Metal vs. Plastic Creator An entity primarily responsible for making the resource Joanne A. Klope Shamp, CPO * https://staging.drfop.org/files/original/c79f3f5c06fbbad81bc534504137ea3e.pdf 56cedf7cb099c7fc851bdff7afeb1c91 https://staging.drfop.org/files/original/a7ac4b8b00ef3f5830653ebc22e659b2.jpg 335d2e274b5821d0d91ccc0338e156c0 https://staging.drfop.org/files/original/33504c7b98ac0853055ccefc9bc6b9c8.jpg 1a330b00bafa9bb15ec2d099bb159f06 https://staging.drfop.org/files/original/e71bdbc6078fbbac96e8b81e5d6678d2.jpg e1943727ad52b90951b681daddfdda85 https://staging.drfop.org/files/original/9408796397f1cbfaa3f48fa88b387d62.jpg 6bf9efb5b675a3eab952bd92fc036d38 https://staging.drfop.org/files/original/6e93d0f1a716dd100e308fbf39a5cd4b.jpg df5d4bd7e85ebc7852ce93f8010a48f7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_028.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 28 - 32 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_028.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Application of Prosthetics-Orthotics Principles to Treatment of Fractures</h2> <h5>Augusto Sarmiento, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>Greater knowledge and understanding of bioengineering by the prosthetics and orthotics industries during the past twenty years have resulted in the development of highly functional and sophisticated appliances. For example, modern prostheses for lower- and upper-extremity amputees are now designed with proper attention given to energy expenditures and other physiological factors based on scientific information obtained from laboratory and clinical studies. Close liaison between medical and engineering disciplines has contributed enormously to the revolutionary changes that prosthetics and orthotics have undergone during the past two decades.</p> <p>Experience in the management of amputees has given the authors the opportunity to study the possibilities of utilizing prosthetics principles in the management of orthopaedic conditions. The first of these came as a result of clinical work with below-knee amputees. Prior to the development of the patellar-tendon-bearing (PTB) prosthesis in 1957, the below-knee amputee ambulated with an appliance which required a thigh corset to provide stability and to assist in the distribution of weight-bearing forces. The PTB prosthesis proved that the below-knee stump could take the pressures necessary for weight-bearing during ordinary activities without assistance from a thigh corset. The snug, total-contact fit and the firm contouring of the tibial flare and patellar tendon make possible weight-bearing ambulation without undue pressure being exerted over small areas or appreciable telescoping of the stump in the prosthesis.</p> <p>The traditional belief in orthopaedic circles has been that fractures of the tibia require the joints above and below the fracture site to be immobilized, the knee joint to be held in flexion to increase rotational stability, and weight-bearing to be avoided until fracture healing is complete. Some reports have appeared in the literature where ambulation on the fractured extremity is encouraged while the injured limb is stabilized in a groin-to-toe cast. This method, however, makes motion of the knee and ankle joints impossible <a></a>.</p> <p>Convinced that the patellar-tendon-bearing prosthesis can adequately stabilize the stump without excessive piston action or rotation, the senior author applied the principles of this appliance to the treatment of tibial fractures. Three and a half years ago, he constructed a total-contact, below-knee cast firmly molded over the entire leg and contoured over the proximal tibia in a.manner identical to that of the patellar-tendon-bearing prosthesis (<b>Fig. 1</b>). The results were encouraging, since the fracture united without loss of the reduction originally obtained and without additional shortening, angulation, or rotation of the fragments. Since then we have treated 200 patients with various fractures of the tibia, malleoli, or os calcis <a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Short-leg total-contact PTB-like cast for tibial fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The impossibility of providing flexion in the proximal segment of the cast, as in the case of the PTB prosthesis, soon convinced the authors that the patellar tendon was not a major contributor to the distribution of weight-bearing pressures. In most cases, we do provide the patellar-tendon indentation and high condylar wings because they appear to be valuable in enhancing rotational stability, particularly in cases of high tibial fractures.</p> <p>With this short-leg, total-contact PTB-like cast, weight-bearing forces are transmitted from the ground to the proximal tibia, virtually bypassing the fracture site. At first glance, such a method of treatment appears to conflict with orthopaedic principles. It is the authors' belief, however, that it utilizes to a fuller degree the knowledge of basic principles governing osteogenesis and fracture repair. The active use of the extremity in a near-normal manner seems to place the fractured limb in a physiological environment more conducive to uneventful healing.</p> <p>Experience with the first 200 cases and the addition to the staff of the University of Miami School of Medicine of the junior author of this paper made it possible to attempt elimination of the foot and ankle portion of the cast, the object being the transmission of weight-bearing forces from the ground to the proximal tibia by means of metallic uprights attached distally to the patient's shoe and proximally to the cast (<b>Fig. 2</b> and <b>Fig. 3</b>). We have treated 40 tibial fractures with this cast-brace with encouraging results.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Short-leg total-contact cast-brace used in the treatment of tibial fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Bilateral short-leg total-contact cast-braces used in delayed union of tibial fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In order to utilize the benefits of a near-normal physiological environment in fractured limbs, we have used short-leg, total-contact casts with or without the orthotic components in many instances of delayed unions with or without associated chronic osteomyelitis. A complete report on these cases will be published in the near future.</p> <p>In the same manner that the patellar-tendon-bearing prosthesis led to the development of the short-leg, total-contact cast, we have introduced the principles of the quadrilateral, ischial weight-bearing prosthesis to the treatment of fractured femurs. We have constructed a cast-brace that stabilizes the fractured femur but permits freedom of motion of the hip, knee, and ankle joints (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Ischial weight-bearing cast-brace for femoral fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This cast-brace is applied with the patient standing on his normal limb while the ischium on the affected side rests on the platform of an above-knee casting stand. Ambulation results in transmission of weight-bearing pressures from the ground to the ischium, thus preventing shortening of the fractured fragments, angulation, and rotation. Our experience has been limited, and so we are in no position at this time to state whether or not this cast-brace will earn a place in the armamentarium of the orthopaedic surgeon.</p> <p>We have utilized the basic construction design of the Munster prosthesis as applied to the very short below-elbow amputee, and have constructed a cast in a manner similar to that of this prosthesis. To prevent rotation of the forearm, the cast is molded in such a manner that its anteroposterior diameter is as narrow as possible. The high condylar wings firmly contoured over and around the bony prominences of the forearm and humerus enhance rotational stability. A metal joint makes possible freedom of motion of the wrist joint (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cast-brace with articulated wrist joint for forearm fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The possible applications of these cast-braces may be numerous in the everyday practice of orthopaedics. Additional investigations should be conducted before arriving at any final conclusions regarding the value of these approaches.</p> <h3>Conclusion</h3> <p>Familiarity with prosthetic appliances has resulted in the application of their basic principles to the management of orthopaedic conditions of the upper and lower extremities.</p> <p>A functional short-leg, total-contact cast based on the patellar-tendon-bearing (PTB) prosthesis was developed and used in 200 cases of tibial, malleolar, and os calcis fractures. In addition, a short-leg, total-contact cast-brace which permits motion of the knee and ankle joint has been utilized in 40 cases of fresh and old tibial fractures.</p> <p>Attempts have also been made to stabilize femoral and forearm fractures with cast-brace appliances. These cast-braces are constructed with features resembling those of the ischial weight-bearing quadrilateral socket and the Munster prostheses used by above-knee and below-elbow amputees, respectively.</p> <p>There are many clinical situations in orthopaedics which provide opportunities for further study of the utilization of prosthetics-orthotics principles.</p> <p><b>References:</b></p> <ol> <li>Dehne, Ernest, C. W. Metz, P. A. Deffer, and R. M. Hall, Nonoperative treatment of the fractured tibia by immediate weight bearing, J. Trauma, 1:514-535, 1961.</li> <li>Sarmiento, Augusto, A functional below-the-knee cast for tibial fractures, J. Bone and Joint Surg., 49A:5, July 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, A functional below-the-knee cast for tibial fractures, J. Bone and Joint Surg., 49A:5, July 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Dehne, Ernest, C. W. Metz, P. A. Deffer, and R. M. Hall, Nonoperative treatment of the fractured tibia by immediate weight bearing, J. Trauma, 1:514-535, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Augusto Sarmiento, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_02_028/aut67-11.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_02_028/aut67-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_02_028/aut67-13.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_02_028/aut67-14.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_02_028/aut67-15.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Application of Prosthetics-Orthotics Principles to Treatment of Fractures Creator An entity primarily responsible for making the resource Augusto Sarmiento, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/a266195253e839079dde8975e42d8087.pdf c594dc2a840e8199425e981f66117aec https://staging.drfop.org/files/original/7f05ccb8586557cc7b0183cdafe725aa.jpg 63616a4cd1eb71d495e9a1972785cec8 https://staging.drfop.org/files/original/34baa4d0c9f50173d122a1fc9f03237c.jpg 17ba15b4ce63bb3be5f4808d51a3ea39 https://staging.drfop.org/files/original/1c09d56923228c1e807060fe9577bb4b.jpg c44f04d953c3e6e8897a4cd1e4634223 https://staging.drfop.org/files/original/2cc047309ed120bc63aa3b83a308d3fb.jpg 725142c35120be7cfc9eeda3881c00aa https://staging.drfop.org/files/original/616d272e127cadd9ddfd4dfa00a6ada9.jpg aecf21517233b63d0e773199af09d87e https://staging.drfop.org/files/original/d91b0ee4dc2e5f1b5d29d240c9cc5019.jpg e4c5b9f5516409a4f2feb3f7440c342e https://staging.drfop.org/files/original/ab13b0cc1721ab18b7969a2d89777bff.jpg 6dda6cc8254a02d70975f70817cf72de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_025.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 25 - 29 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Artificial Arm Checkout Procedures</h2> <h5>Lester Carlye, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>The story of civilization's slow but steady march of progress from the days of the Roman Empire, through the Industrial Age, and into the present Technological Age is the story of measurements. The standardization of such common units as the inch and the foot required thousands of years, but once that was accomplished, it paved the way for an almost unbelievably rapid technological advance. One need only compare the developments that have occurred since the metric system was devised in 1793 with those of all the preceding centuries. Replacement of the craftsman's personal art with clearly understood, standard methods has enhanced the lives of all of us my making simple necessities, as well as more luxurious items, available in more adequate quantities and at more reasonable prices.</p> <p>Just as mankind in general profited from measurement standardization, so can those who have lost a limb or limbs and those who devote themselves to replacing lost members. Every person concerned with the manufacture and fitting of a prosthesis-whether he be a prothetist, amputee, trainer, or representative of the paying agency-has felt the need for some set of standards to determine the worth of the prosthesis. Development of such a "yardstick of performance" was just as necessary to the advancement of the prosthetics industry as was the standardization of the inch to the Industrial Age. The so-called "checkout procedures" provide the prosthetist and other members of the clinic team with an invaluable tool for measuring the biomechanical effectiveness of all upper-extremity prostheses. Such questions as "Does this prosthesis fit as well as your last one?" or "Can you work it?" receive only a vague, often uncertain, answer, but such criteria are too often accepted as a measure of performance. One of the first steps in establishing a set of standards is to determine which variable factors can be measured accurately. In upper-extremity prosthetics, some of the measurable factors are ranges of motion with and without the prosthesis, control-system efficiencies, forces necessary to flex the forearm, live-lift of the forearm, socket stability, movement of the terminal device when locking the elbow, plus several others. Once the factors are determined, a test program must be set up and carried out. The results of such a test must first be analyzed, then a trial set of standards must be established, and finally the standards must be laboratory-tested on as great a number of amputee subjects as possible.</p> <p>To this end, a test station was established, and 29 amputees, selected at random from a mailing list, were tested. Approximately 30 tests were applied to these amputees and their prostheses. By combining the test data with research and practical experience, a preliminary set of liberal standards was drawn up. The standards were then applied to more than 70 amputees during the two-year existence of the Case Study Program at the University of California at Los Angeles. Certain modifications and refinements in the tests were made until the procedure attained present form.</p> <p>One of the prime requirements in establishing the tests was that their application be kept simple, with respect both to the equipment and to the procedures to be followed. Sufficient accuracy of measurement can be obtained with a ruler and a spring scale, and the test standards are liberal enough to allow minor inaccuracies without rejecting the prosthesis. The most important concern is, first, that all tests be applied in a similar manner and, second, that the results be compared to a universally acceptable standard.</p> <p>The tests and standards may be conveniently listed in three groups: general tests, applicable to all types of prostheses; tests for below-elbow prostheses; and tests for above-elbow prostheses.<a style="text-decoration:none;">*</a></p> <p>All tests should be performed with the amputee wearing his prosthesis. In the case of a bilateral amputee, each side should be tested separately, but the amputee should have almost complete independence of action on each side while wearing both prostheses.</p> <h3>General Tests</h3> <h4>Test No.1-Compression Fit and Comfort</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Push the prosthesis onto the stump while the wearer resists the push (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Test for compression fit and comfort. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should feel no undue discomfort or pain when the prosthesis is forced onto the stump.</p> <h4>Test No. 2-Tension Stability</h4> <p><i>Test</i>: Straighten the prosthesis at the side (<b>Fig. 2</b>). Hook the scale over the terminal device and apply a force of 50 lb. straight down. (A force of 30 lb. is sufficient for children.) Standard: The prosthesis should not slip more than 1 in. in relation to the stump, and no part of the prosthesis or harness should fail when a 50-lb. distal load is applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Test for tension stability. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 3-Hook-Opening Facility (Normal Use)</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Have the wearer actively operate the terminal device.</p> <p><i>Standard</i>: The wearer should be able to obtain full range of terminal-device operation actively with the forearm flexed to 90 deg.</p> <h4>Test No.4-Hook-Opening Facility (At Mouth And Perineum)</h4> <p><i>Test</i>: Flex the forearm so the terminal device is near the mouth (lock if AE). Have the wearer actively operate the terminal device. Repeat this procedure with the terminal device near the perineum.</p> <p><i>Standard</i>: The wearer should be able to obtain at least 70 percent of full range of terminal-device operation actively at the mouth and perineum.</p> <h4>Test No. 5-Control-System Efficiency</h4> <p><i>Test</i>: a) Disconnect the control cable from the terminal device, and attach the scale to hook-operating lever or hand-operating cable (<b>Fig. 3</b>a). Place a 3/4-in. block between the fingers and pull until the block slips out of a voluntary-opening hook or until the fingers of a voluntary-closing hook or hand just close on the block. Note the force at this instant.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Test for control-system efficiency. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>b) Reconnect the control cable to the terminal device, and apply the scale to the T-bar. or terminal, at the other end of the control cable. Pull along the line of the harness unti. the block slips or the fingers touch, as before (<b>Fig. 3</b>b). Note the force at the instant this occurs.</p> <p>c) Multiply the force measured at the terminal device by 100. Then divide by the fora measured at the cable terminal as in the following formula:</p> <blockquote><p>Efficiency = (Force measured at terminal devices X 100)/(Force measured at cable terminal)</p> </blockquote> <p><i>Standard</i>: The control-system efficiency should be at least 70 percent.</p> <h3>Below-Elbow and Below-Elbow Biceps-Cineplasty Tests</h3> <p>All of the following tests apply to the conventional below-elbow prosthesis and to the below-elbow biceps-cineplasty prosthesis.</p> <h4>Test No. 1-Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm flexion with and without the prosthesis.</p> <p><i>Standard</i>: Active flexion with the prosthesis on should be as great as active flexion without the prosthesis.</p> <h4>Test No. 2-Forearm Rotation<a style="text-decoration:none;">*</a></h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm rotation (extreme pronation the extreme supination) with and without the prosthesis (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Test for forearm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: Active rotation with the pros-thesis on should be at least half that obtained without the prosthesis.</p> <h3>Above-Elbow and Shoulder-Disarticulation Tests</h3> <p>All of the following tests apply to the above-elbow prosthesis, and most of them apply to the shoulder-disarticulation prosthesis. Those which do not apply to the shoulder-disarticulation case are marked with an asterisk.</p> <h4>Test No. 1-Ranges Of Stump Motion*</h4> <p><i>Test</i>: Have the amputee straighten the prosthesis and lock the elbow. Then move his stump and prosthesis through the maximum ranges of flexion, extension, elevation, and rotation.</p> <p><i>Standard</i>: The amputee should be able to satisfy the following minimum requirements while wearing the prosthesis: flexion, 90 deg.; extension, 30 deg.; elevation, 90 deg.; rotation, 45 deg.</p> <h4>Test No. 2-Range of Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum active range of prosthetic forearm flexion with the maximum manual range. Note the amount of initial forearm flexion built into the prosthesis.</p> <p><i>Standard</i>: The amputee should be able to flex actively to 135 deg. of forearm flexion, no more than 10 deg. of which should be due to initial flexion.</p> <h4>Test No. 3-Humeral Flexion Required to Flex Forearm*</h4> <p><i>Test</i>: Have the amputee flex the prosthetic forearm actively through its entire range using humeral flexion, and note the degrees of flexion of the humerus required to do so.</p> <p><i>Standard</i>: Humeral flexion required to flex the prosthetic forearm fully should not exceed 45 deg.</p> <h4>Test No. 4-Force Required to Flex Forearm</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Insert the spring scale through the cable attachment, and flex the forearm to 90 deg. while holding the socket stationary. Pull along the normal line of the cable until further flexion of the forearm just starts, and note the force.</p> <p><i>Standard</i>: The force required to start flexion of the forearm from 90 deg. should not exceed 10 lb.</p> <h4>Test No. 5-Live-Lift</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Hook the spring scale over the prosthesis at a distance of 12 in. from the elbow pivot using a leather strap if necessary (<b>Fig. 5</b>). Flex the forearm to 90 deg., and have the amputee actively resist while applying a straight-down pull on the scale. Note the scale reading when the amputee can no longer completely resist the pull and the forearm slips below 90 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Test for live-lift. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should be able to resist actively a downward force of at least 3 lb. located 12 in. from the elbow center when the forearm is flexed to 90 deg.</p> <h4>Test No. 6-Involuntary Operation of the Elbow Lock*</h4> <p><i>Test</i>: Face the amputee and have him abduct the prosthesis 60 deg. Note whether or not the elbow lock operates. Then have him walk a short distance swinging the prosthesis in a normal manner, and note whether the elbow lock operates involuntarily or not.</p> <p><i>Standard</i>: The elbow lock should not operate involuntarily when the prosthesis is abducted 60 deg. nor during normal walking. In addition, a natural-appearing arm swing should be exhibited while walking.</p> <h4>Test No. 7-Movement of Terminal Device When Locking Elbow*</h4> <p><i>Test</i>: Have the amputee actively flex the forearm to 90 deg. Then have him actively lock the elbow. Note the movement of the terminal device as the elbow is locked.</p> <p><i>Standard</i>: The terminal device should not move more than 6 in. during active operation of the elbow lock when the forearm is flexed to 90 deg. (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Test for motion of terminal device when locking elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 8-Socket Stability During Arm Rotation*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Have the amputee abduct the prosthesis 60 deg. and rotate his stump and prosthesis. Note any slippage of the socket about the stump.</p> <p><i>Standard</i>: The amputee should be able to control the prosthesis during arm rotation, and there should be no slippage of the socket about the stump (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Test for socket stability during arm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 9-Stability of Socket Against Torque*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Hook the scale over the prosthesis at a distance of 12 in. from the elbow center, using a leather strap if necessary. Have the amputee resist while pull is applied, first laterally, then medially, on the socket with a force of 2 lb. Note any slippage of the socket about the stump, or of the turntable, which may occur.</p> <p><i>Standard</i>: The amputee should be able to resist both lateral and medial pulls of 2 lb. located 12 in. from the elbow center, and the turntable should not turn with this force.</p> <h3>Conclusion</h3> <p>That the test procedure has reached a sufficient degree of refinement to be used successfully in the field is evidenced by its widespread adoption. Such agencies as the United States Veterans Administration, the State Departments of Vocational Rehabilitation of California and Illinois, and others include fulfillment of the standards as a contract stipulation. It must, however, be borne in mind that these test procedures are not to be considered as the final answer. Additions, revisions, and general improvements constitute a never-ending project in the field of prosthetics evaluation.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">This test need not be applied when the stump is only half the normal forearm length or less.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">These tests and standards may not apply in cases where atrophy, bone blocks, loss of muscles, and the like are in evidence.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Lester Carlye, M.E. </b></td></tr><tr><td class="clsTextSmall">Engineer, Artificial Limbs Project, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-007.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 Artificial Arm Checkout Procedures Creator An entity primarily responsible for making the resource Lester Carlye, M.E. *