10 20 371 https://staging.drfop.org/files/original/7a75c3d9c233cf93787c08c21ed693e3.pdf e5110d02dd384bb6a5f6f5a10d2586ba https://staging.drfop.org/files/original/dd9cefbe75906e9bba04a5826a47ec5f.jpg 7703fefe919d06bde880ad14c32d7f75 https://staging.drfop.org/files/original/1ec821d58a0459aef4c5528b6090c4c4.jpg bcb495632b7e2d3954e57ff157efed5e https://staging.drfop.org/files/original/1379cb8157b2580aa03fb6a64d890b95.jpg a581fb1c72db3af322da27e57eaa0f6e https://staging.drfop.org/files/original/5bdb4472cef92dc9646b1510876e7782.jpg 1591cb62ca55a5fe3e1780a2e5b6a80d https://staging.drfop.org/files/original/4fce8019d5930c0d95a39cb58a87c9c3.jpg 528c9b83635d9135a577534f3859d802 https://staging.drfop.org/files/original/657b4b73124d4aa6f38ae9451948f8ba.jpg 8b789aec8e717b99d01ede87115e9e6d https://staging.drfop.org/files/original/736753da520fdd6d08411546b891cd1a.jpg 69932579ec5c82657a8978acf7988bf4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_049.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 49 - 57 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_049.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_049.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>The Use of External Support in the Treatment of Low Back Pain</h2> <h5>Jacquelin Perry. M.D. <a style="text-decoration:none;">*</a><br /></h5> <p> The origin of therapeutic procedures can generally be traced to local efforts directed toward resolving continuing disability of the patient. In the treatment of low back pain, this approach often included designing special supports by individual physicians and orthotists. Such independent activity in numerous locales resulted in a long list of brace designs, many of which carry impressive eponyms that tend to stress differences rather than elements of commonality. </p> <p> To compile the available information concerning bracing, the American Academy of Orthopaedic Surgeons published the <i>Orthopaedic Appliances Atlas</i><a></a> in 1953. Of the 30 types of spinal support described in that volume, 17 were specifically designed for the sacroiliac or lumbosacral areas. Ten years later, in 1962, a survey of orthopedic services in the United States by Nattress and Litt<a></a> identified 30 braces, of which 22 corresponded to the design customarily considered effective at the lumbosacral region. These two reports, along with the present study, described a total of 40 different devices designed for low back problems. </p> <p> Details of designs are readily available, but objective criteria to weigh the relative merits of the different devices are almost nonexistent. As a consequence, physicians generally make their selection either by adopting the customs observed during their training, or by accepting the preference of the local orthotist. Undoubtedly, some braces have withstood the test of time, while others have become items only of historical interest. Superimposed on this background, the more recent introduction of prefabricated parts for brace construction has probably influenced the frequency with which certain types of braces are prescribed.</p> <p> The extent to which these influences have altered the availability and prescription of brace designs today has not been reported. Also unknown is the nature of the relationship between the etiology of the low back pain and the type of support that clinicians have found to be effective. Identification of this type of information is pertinent because the subject of orthotics is now being presented in formally organized courses on a nationwide basis. </p> <p> This paper records the results of a three-phase study conducted in 1968-69 by the Subcommittee on Orthotics, Committee on Prosthetic-Orthotic Education (CPOE) of the National Research Council. Approval of the Executive Committee of the American Academy of Orthopaedic Surgeons was obtained. The purpose of the survey was to identify the current practices of orthopedic surgeons with respect to external supports for the management of low back pain. </p> <h4> Method</h4> <p><i> Pilot Study </i></p> <p> An unstructured pilot questionnaire was sent to 150 orthopedic surgeons selected because of their considerable experience in the management of low back pain. They were asked to list the types of support they prescribed, and to indicate the clinical conditions for which each support was chosen. The results of this pilot study formed the basis for the next phase of the investigation. </p> <p> The 90 physicians (60%) who responded were explicit in their choice of a device and the clinical indication for its use. Eighty-three reported frequent prescription of external support as part of their therapeutic program. (Two said they never used external supports, and five indicated they rarely prescribed such aids.) </p> <p> Within each class of support (brace, corset, cast), a similar pattern of practice was evident. Numerous designs were listed, but most were mentioned only occasionally. The majority of the respondents preferred one or two types of support. Within a total of 12 different braces reported, three-fourths of the physicians listed the Chairback (Knight) and Williams braces (<b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>). Six other designs were mentioned only once. Identification of corset preference was a bit clouded by the indiscriminate use of both generic and trade names. The generic term "lumbosacral" was specified by half of those responding. An additional one-fourth of the pilot-study participants used trade names such as Camp, Spencer, and Winchester. The next most frequently mentioned device was the sacroiliac belt (8%). Of the six casts identified, the flexion jacket was preferred by more than half of the pilot-study orthopedists; the second choice was the body jacket (19%). In designating the clinical conditions warranting external support, two response patterns developed in the pilot survey. Seven types of disability were mentioned frequently and in explicit terms, viz., postoperative fusion, spondylolisthesis, chronic backache, acute strain, disc syndrome, degenerative joint disease, and the postoperative disc. Several other conditions, identified by a wide variety of terminology, were mentioned with moderate to rare frequency. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The Knight dorsolumbar brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A typical modification of the Knight brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The Williams lumbosacral brace. (Illustrations from Orthotics for Physicians and Therapists, Prosthetic-Orthotic Education, Northwestern University Medical School, Chicago, HI.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>National Survey of AAOS</i></p> <p> The findings of the pilot survey were used to construct a questionnaire applicable for a comprehensive national study. This questionnaire was sent to the membership of the American Academy of Orthopaedic Surgeons (AAOS). The form (presented at the end of this article) was a check sheet on which physicians were asked to match the types of support they prescribed with the clinical conditions they treated in this manner. </p> <p> The following supports, all of which were more than rarely mentioned in the pilot study, were included. (The restriction on corset choice was the result of a decision to use generic rather than trade names in order to avoid repeating the confusion produced in the pilot study.) </p> <p><b><i>Braces</i></b></p> <ol> <li> Chairback (Knight) </li><li>Williams </li><li>Norton-Brown </li><li>Goldthwaite </li><li>Bennett </li></ol> <p> <i>Corsets</i> </p> <ol> <li>Lumbosacral </li><li>Sacroiliac </li></ol> <p> <i>Casts</i> </p> <ol> <li>Flexion </li><li>Body jacket </li><li>Cast with one leg </li></ol> <p> Eleven clinical conditions were selected for the national inquiry, based upon the </p> <p> returns of the pilot study and upon the clinical experience of the NRC committee. Provision was made throughout for physicians to indicate devices or clinical problems other than those listed on the form. The questionnaire was also designed to indicate the relative frequency ("usually" or "rarely") of the prescriptions. </p> <p><i> Survey of the Functions of Support</i></p> <p> Late in 1968, a second national survey was conducted among the AAOS membership to determine prevailing opinions about the functions of the various types of support. The purpose of this phase of the study was to attempt to relate the anticipated function of the external support to the different preferences in prescription. </p> <p> Profiting from the findings of part one of the national survey, the list of supports was again shortened. This time, the orthopedists were queried about two braces (Williams and Chairback [Knight]); "corset" was listed as a single category, as were the flexion casts. A miscellaneous category was added for other comments. (The questionnaire appears on page 57.) </p> <p> Six probable functions were selected for study. These included: immobilization of the spine, restriction of lumbosacral motion, unloading of the intervertebral disc, support of the abdomen, correction of posture, and psychological effect. As always, there was a provision for other choices. </p> <h4> Results </h4> <p> On the first national survey, 5,215 questionnaires were mailed. With the aid of one follow-up, 3,140 (60%) were returned completed. An additional 1% of the returns were incomplete because the physicians had retired or their practices did not include patients with low-back problems. </p> <p> In the second phase of the study, the same number of forms were sent out, with 2,192 (42%) being filled in and returned. No follow-up mailing was conducted, </p> <p> Annotated responses or explanatory letters accompanied 1,034 (33%) of the questionnaires. These consisted of: (<i>a</i>) identification of the type of device they preferred if it was not specifically mentioned on the form; <i>(b) </i>comments regarding precise fitting or construction characteristics considered to be important; (<i>c</i>) reasons for not prescribing external support; and (<i>d</i>) other modes of treatment which should accompany use of a support. </p> <p><i> Use of Supports for Low-Back Problems</i></p> <p> Most of the orthopedic surgeons indicated use of a judicious selection of braces, casts, and corsets; the average physician reported that he used three different devices in his practice. A small group stated that they used only one type of device: a brace (4%), a corset (4%), or a cast (1%). Only 14 respondents stated that they "never used support" for the patient with a low-back problem. </p> <p> Among the clinical indications, the inclusion of the term "fracture" caused considerable confusion in the information collected. Either all types of braces are used for fractures in the "low back," or the orthopedist's attention was directed to fractures of the spine in general. The latter seemed highly probable, as most indicated that a brace other than those listed was used. Typically, these were the Jewett, Taylor, and Baker types, commonly used for lesions in the thoracic and thoracolumbar areas. As the extent of this confusion could not be identified, all data referring to "fracture" were omitted from the analysis. </p> <p> Certain characteristics in the prescription of external support became evident. A majority of the profession used the same groups of devices. The nature of the disability dictated the frequency of prescription as well as the type of support preferred. </p> <p><i> Support Preference </i></p> <p> The lumbosacral corset is the most popularly used low-back support, followed by the Chairback (Knight) spinal brace. Utilization of the other types of support fell far behind these two leaders <b>Table 1</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 /> <p> The degree of dominance by the lumbosacral corset varied with the method of comparison; 28.5% of the physicians indicated use of the lumbosacral corset for at least one condition. When all clinical indications were considered, preference for the lumbosacral corset was 44.2%. The Chairback brace was used by 21% of the physicians for 22% of the clinical conditions listed. All other types of support were used less than 9% of the time. The Williams brace was third in popularity. A variety of casts preceded any other choice of brace or corset <b>Table 1</b>. </p> <p> As "lumbosacral corset" is a generic term that overlooks design differences between the Camp, Winchester, Spencer, and other specific corset styles, a comparison was made with the designated preferences for the total group of "low-back braces." The relative preference between the corset and the low-back brace again depended on the method of comparison. The use of a brace at some time was indicated by 40.2% of the physicians, in comparison to 32.4% for corsets. However, when all the clinical indications were totaled, the preference reversed, with the corsets dominating (46.7% in contrast to 39.0% for braces). </p> <p> Some geographic patterns for brace preference were found, especially for those used less frequently <b>Table 2</b>. The middle and southeastern sections of the United States were the only areas where the Williams brace was used widely; it was fourth in preference on the West coast. With the exception of New York, no mention of it was made in the eastern or New England states. The Bennett brace was second in popularity in Maryland and third in Ohio. Predominance of the Norton-Brown<a></a> brace was restricted to Massachusetts and Maine, a note consistent with the fact that the originators are from Boston. </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> <i>Clinical Indications</i> </p> <p> The survey form asked the physician to check whether he rarely or usually used some type of support for each of ten clinical conditions listed <b>Table 3</b>). Three patterns of use were apparent. The responding physicians seldom used external support in the treatment of an acute strain (17%), for an obese person with pain (19%), or during the postoperative period following disc surgery (28%). When support was used for these conditions, it was generally a corset. </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> At the other extreme, most physicians used support following spine fusion (84%), for treatment of spondylolisthesis (70%), and for pseudoarthrosis (66%). In these instances, the most common type of support was a brace. </p> <p> The orthopedists were evenly divided as to the advisability of prescribing any type of support in treating the degenerative back, the disc syndrome of chronic backache, or as a preoperative trial. A similar lack of agreement was indicated concerning the type of support preferred. As a preoperative trial, there was equal preference for a brace or cast. For the other disabilities, the preferred support was the lumbosacral corset. </p> <p> Comparison between the specific brace design and the clinical condition <b>Table 4</b> showed that the Chairback was the most frequently used brace in each situation, and the Williams brace ranked second in preference. Spondylolisthesis and the disc syndrome were the most common indications for the Williams brace. Spondylolisthesis was also the primary reason for using the Bennett brace. Otherwise, preference for the Norton-Brown, Goldthwaite, and Bennett braces paralleled the use of back support in general. </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> <i>Function of External Supports</i> </p> <p> Three approaches to the data collected on functions of supports seemed pertinent: the general expectation for external supports, the types of support chosen for each of these functions, and the functions expected of each of the support designs. </p> <p> The function most commonly ascribed for external support was restriction of lumbosacral motion (30%); abdominal support was second (19%), followed by postural correction (15%) and immobilization of the spine (12%). </p> <p> To restrict lumbosacral motion, the Chairback (Knight) brace or a corset were equally preferred. The Williams brace was the third specific device indicated for this purpose, although a larger number of physicians indicated that they used some type of cast to restrict motion. </p> <p> Abdominal support was most often assigned to the corset. This dominated its next competitor, the Chairback (Knight) brace, by a ratio of two to one. Again, the Williams brace ranked third for the function of supporting abdominal muscles. </p> <p> Postural correction was almost equally divided between the corset and a Williams brace, although the use of casts was not uncommon. </p> <p> An interesting situation developed in the category of spinal immobilization. It was the only function identified for the flexion cast, yet this device was fourth in preference. The support most often indicated for spinal immobilization was the Chairback (Knight) brace, a finding which probably reflects its national popularity. </p> <p> While external supports are seldom used for psychological reasons, when the practice is followed the corset is the most popular device, followed by the Chairback brace. </p> <p> The concept of unloading the disc has obviously not been accepted by the majority of orthopedic surgeons, since only 8% indicated this as a function of external support. However, those who did think in these terms showed a strong preference for the Williams brace, with a cast as an alternate. </p> <p> Focus on the individual types of support showed that the prime functions of the corset were considered to be abdominal support and restriction of lumbosacral motion. The Chairback (Knight) brace was assigned the same functions, but with greater emphasis on restriction of motion. This function was also considered the main purpose of the Williams brace, with correction of posture as its second indication. Casts were generally used to restrict lumbosacral motion, although a surprisingly larger number were also assigned the function of correcting posture. Consistent with the belief that immobilization, as opposed to restriction of lumbosacral motion, is seldom accomplished with external support, even casts were assigned this as a third function. </p> <p> In addition to completing the survey form, a third of the respondents (1,034) added notes to further explain their preferences. These varied from a single listing of a specific brace to lengthy letters explaining their philosophies of low-back management. A majority of these replies were focused on either the fitting or construction characteristics of their support preferences. </p> <p> Sixty respondents emphasized the advantages of using exercise early in the treatment of low back pain. Two purposes were expressed: to avoid external support and to overcome the muscle weakening and contracture development that accompanies prolonged immobilization. One respondent summarized this philosophy very succinctly by stating he "never prescribed support without a plan to eliminate it." A smaller group (30) felt that the disadvantages were sufficient to preclude any prescription of external support. All who said they "never" or "rarely" used support emphasized instead their reliance on an organized program of exercise. Specific application of this philosophy was frequently mentioned in relationship to postoperative management of spine fusions. Many respondents also brought out the fact that the treatment of low back pain must be individualized to fit the particular patient's need. This fact must never be forgotten, of course, and the purpose of the survey was not to contradict the concept of individualized patient care, but merely to identify the spectrum of external support which physicians have found adequate to meet their multiple goals. </p> <h4> Discussion </h4> <p> The potential list of 40 external-support designs for low back pain has been severely pruned by the influences of prolonged clinical experience, greater intermingling of orthopedists through professional meetings, and the use of prefabricated parts. Notes by some of the respondents indicated that cost, emphasis on exercise, and early surgery are other important influences. </p> <p> The clinical indications for use or non-use of external support were rather sharply defined, but there is no comparable distinction between the accepted styles of support. The latter was indicated by the overlap between clinical entity and support design, as well as by the identification of the functions of the different devices. The mechanical characteristics and the limitations of these various designs which lead to such ambiguity have yet to be objectively identified. </p> <p> Investigators<a></a> have found that, unless the support is carefully designed, motion at the lumbosacral joint could be increased with the support rather than </p> <p> restricted. Personal experience indicates that this might also lead to increasing the patient's pain. </p> <p> A problem still not studied is identification of the characteristics of the patients which govern the choice of support. </p> <h4> Summary </h4> <p> The lumbosacral corset is the most commonly prescribed external support for low back pain. The Chairback (Knight) and Williams braces are next in preference, with a cast being used least frequently. There is a definite relationship between the etiology of the low back pain and the type of support chosen. The major indication for support prescription is to restrict lumbosacral motion. </p> <p><b>References:</b></p> <ol> <li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic appliances atlas, vol. 1, braces, splints, shoe alterations, </i>J. W. Edwards, Ann Arbor, Mich., 1952. </li> <li>Nattress, LeRoy Wm., Jr., and Bertram D. Litt, <i>Orthotic services USA 1962, report 2, survey to determine the state of services available to amputees and orthopedically disabled persons, </i>American Orthotic and Prosthetic Assoc, Washington, D.C., 1962. </li> <li>Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, <i>J. Bone Joint Surg., </i>39A:111-139, January 1957. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, J. Bone Joint Surg., 39A:111-139, January 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, J. Bone Joint Surg., 39A:111-139, January 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Nattress, LeRoy Wm., Jr., and Bertram D. Litt, Orthotic services USA 1962, report 2, survey to determine the state of services available to amputees and orthopedically disabled persons, American Orthotic and Prosthetic Assoc, Washington, D.C., 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>1.</b> </td><td class="clsTextSmall">American Academy of Orthopaedic Surgeons, Orthopaedic appliances atlas, vol. 1, braces, splints, shoe alterations, J. W. Edwards, Ann Arbor, Mich., 1952. </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>Jacquelin Perry. M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Kinesiology Service, Rancho Los Amigos Hospital, Downey, Calif.; Associate Clinical Professor of Orthopaedic Surgery, University of Southern California School of Medicine, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Use of External Support in the Treatment of Low Back Pain Creator An entity primarily responsible for making the resource Jacquelin Perry. M.D. * https://staging.drfop.org/files/original/c9f248aba5f777b90137fc5f653684ca.pdf f8b086eeef728c09345c4e2f59e8dd7e https://staging.drfop.org/files/original/c065f49a310f10a589f0a327d3e553c5.jpg 186d2ba85e30b71c039fa0154657cdce https://staging.drfop.org/files/original/bff051b61f6196998c950cf38167980c.jpg f771a9bfcf3050739cc85923b4f49d6f https://staging.drfop.org/files/original/d9d6a4e0ab4404f5bbe8bc6f1cc09fd1.jpg 1f970c7584285f498d6bf17c65c6f630 https://staging.drfop.org/files/original/febaffd06b576a9e62a93e9a0b40cd51.jpg 6acd7a71a2979ec382b0556569e30af1 https://staging.drfop.org/files/original/2bfcdb6e9deb8c4cf2472673f5174ef5.jpg 89553677fd4b9ef73da3014c83f7f72e https://staging.drfop.org/files/original/3e612a67d3f33d4c3dda57bb05207afc.jpg 23c4714870273c39c3ba99be300cd7c5 https://staging.drfop.org/files/original/8e70952489609f15226daf7eab16de3f.jpg 14e82719d1cbe0351948564744c75375 https://staging.drfop.org/files/original/1376f07c00973223d41d772b54427ee4.jpg 01ff296c026fd5f2d7c9b038490105b2 https://staging.drfop.org/files/original/0613d64bd48e27b9c797a6d197e3e2fc.jpg 106950e908dfdc134018cf1c8ecc0bf6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_074.pdf Text Any textual data included in the document <h2>Orthopedic Walkers: Effect on Plantar Pressures</h2> <h5>James A. Birke, P.T., M.S.&nbsp;<a style="text-decoration: none;">*</a><br />Deborah A. Nawoczenski, P.T., M.Ed.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Short leg (SLW) and patellar tendon bearing walkers (PTBW) are orthotic appliances<a style="text-decoration: none;">*</a> which have been recently designed as alternative devices to traditional plaster cast immobilization. The indications for use of lower leg walkers include severe ankle sprains, and ankle and foot fractures. Orthopedic walkers are convenient to use, lightweight, and removable to perform joint range of motion or inspect the extremity. Short leg walkers have been shown to be as effective as walking casts in healing stable ankle fractures, and patients treated with short leg walkers have shown significantly less edema, tenderness, and joint stiffness after six weeks of immobilization.<a></a> The authors feel that orthopedic walkers may also prove to be a beneficial alternative to traditional management of neuropathic fractures and plantar ulcerations, which are commonly seen in diabetes mellitus and Hansen's disease.</p> <p>Neuropathic foot lesions are the result of abnormal or repetitive stress.<a></a> Treatment techniques for neuropathic foot conditions should be effective in reducing pressure and shear stress. Traditional methods of treating neuropathic foot lesions include walking casts, fixed ankle braces, and PTB braces.<a></a> Plaster walking casts and PTB braces have been shown to significantly reduce pressure on the plantar surface of the foot during walking.<a></a> The total contact walking cast is considered effective in reducing pressure on the foot by redistributing forces on the plantar surface of the foot and lower leg. Several features of PTB orthoses shown to be important in achieving maximal weight bearing reduction on the foot include a rigid closure PTB shell, a heel-shoe clearance of 3/8" to 1", a fixed ankle joint, and a rocker sole.<a></a> Orthopedic walkers incorporate these same design features to varying degrees which has generated our interest in studying their effectiveness in reducing pressure on the foot.</p> <p>The SLW has a fixed ankle joint, rocker sole, and a polyurethane liner which is snugly secured to the leg with Velcro® closures (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg"><b>Fig. 1</b></a>). The PTBW incorporates all the features of the SLW, as well as a non-custom molded, semi-rigid polyethylene PTB shell (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg"><strong>Figure 1. Short Leg Walker.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg"><strong>Figure 2. Patellar Tendon Bearing Walker.</strong></a><br /> <p>The effectiveness of the SLW or PTBW in reducing pressure or shear stress on the foot has not previously been studied. The potential value of these devices in managing the neuropathic foot may be evaluated by their effectiveness in reducing pressure and shear stress. Currently, there are unreliable methods for measuring shear stress. However, shear is directly related to the perpendicular forces acting on the foot. Pressure equals the perpendicular forces per unit area. Pressure transducers provide a repeatable measurement of relative pressure inside footwear when the material interfacing with the transducers is controlled.<a></a></p> <h3>Purpose</h3> <p>The purpose of this study was to determine the effectiveness of SLW and PTBW in reducing the pressure distribution on the normal foot during walking.</p> <h3>Method</h3> <p>Ten subjects (6 male and 4 female) without a history of foot pathology participated in this study. Capacitive pressure transducers<a style="text-decoration: none;">*</a> 2mm thick and 1.5cm in diameter were taped to the first metatarsal head (MTH), third MTH, fifth MTH, and plantar heel of the right foot of each subject (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg"><b>Fig. 3</b></a>). The foot was covered with a thin cotton stockinette which remained undisturbed during the study. Transducers were calibrated according to the manufacturer's instructions prior to testing each subject. Pressure recordings were made using a four-channel capacitive impedance bridge amplifier<a style="text-decoration: none;">*</a> and oscillographic recorder<a style="text-decoration: none;">*</a> while subjects walked in a cast shoe (CS-1) (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg"><b>Fig. 4</b></a>), short leg walker (SLW), patella tendon bearing walker (PTBW), and again in a cast shoe (CS-2). All the walking devices were fabricated by the same manufacturer.<a style="text-decoration: none;">*</a> The cast shoe was identical to the foot component of both the SLW and PTBW, utilizing identical rocker out-ersoles and 2.4mm polyurethane material insoles. SLW and PTBW were applied to the leg with a 3/8" heel-shoe clearance. Subjects walked a distance of 100 meters for each treatment condition. The testing order of treatments SLW, PTBW, and CS-2 was randomly assigned to eliminate systematic error.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg"><strong>Figure 3. Pressure transducer placement on selected areas of the foot.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg"><strong>Figure 4. Cast Shoe.</strong></a><br /> <p>Relative pressure was measured in millimeters of peak to peak chart deflection for 24 steps for each treatment condition. The middle distance of each run was used for analysis in order to eliminate pressure variations due to the acceleration and deceleration phases of each trial. Percent pressure change relative to CS-1 was calculated for treatments SLW, PTBW, and CS-2. Means and standard deviations were computed for treatments at each transducer site. An analysis of variance for repeated measures was used to determine whether treatment differences were significant within each site. Duncan's test was used for post-hoc analysis of means. A significance level of 0.05 was used for comparisons.</p> <h3>Results and Discussion</h3> <p>An analysis of variance (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg"><b>Table I</b></a>) for mean percent reduction in pressure was highly significant at all sites tested (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg"><b>Fig. 5</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg"><b>Fig. 6</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg"><b>Fig. 7</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg"><b>Fig. 8</b></a>). Duncan's test was performed to establish which treatments differed. Significant differences were found between the percent reduction in pressure walking in SLW and PTBW as compared to the CS-2 at all sites. No difference was found between SLW and PTBW at any site. The percent pressure reduction using the walker devices was comparable at all the sites tested.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg"><strong>Table I. Analysis of Variance of Percent Pressure Reduction.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg"><strong>Figure 5. Percent pressure reduction at the first metatarsal head (1 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg"><strong>Figure 6. Percent pressure reduction at the third metatarsal head (3 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking to in cast shoe-1.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg"><strong>Figure 7. Percent pressure reduction at the fifth metatarsal head (5 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg"><strong>Figure 8. Percent pressure reduction at the heel walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</strong></a><br /> <p>This study demonstrated the effectiveness of the short leg and patellar tendon bearing walkers as compared to the cast shoe in reducing plantar pressure on the foot. Since all the devices in this study had the same sole design and insole materials, treatment differences must be attributable to proximal orthotic components including the polyurethane liner, fixed ankle uprights, and Velcro® closures. The SLW and PTBW differed only by the polyethylene, non-custom molded patellar tendon cuff. Since no treatment difference was seen between these devices, the PTBW cuff design must not have been effective. However, in follow-up, single subject trials, we were not able to change walking pressures by redesigning the PTBW cuff using polyethylene or plaster custom molded PTB cuffs. An alternative conclusion is that the SLW design alone optimally reduced plantar pressure by the fixed ankle joint and uprights snugly supporting the lower leg and calf.</p> <p>In this study, orthopedic walkers were equally effective in reducing pressure at all sites tested on the foot. In previous studies, casts were shown to reduce pressure more effectively in the forefoot than the heel, and PTB orthotics reduced pressure more effectively in the heel than the forefoot.<a></a></p> <p>Based on the results of this study, othopedic walkers may be effective devices in the reduction of plantar foot pressure in patients with neuropathic conditions of the foot. There is no evidence to show that the PTBW will be more effective than the SLW. Further study utilizing a patient population is recommended.</p> <h3>Conclusions</h3> <p>Within the scope of this study, it is possible to conclude the following: (1) SLW and PTBW orthopaedic walkers are effective in reducing pressure at the first MTH, third MTH, fifth MTH and heel in normal subjects during walking, and (2) there is no difference in pressure distribution between the SLW and PTBW during walking.</p> <p><b>References:</b></p> <ol> <li>Anderson, J.G., "Treatment and Prevention of Plantar Ulcers," <i>Leprosy Review</i>, 35, 1964, pp. 251-258.</li> <li>Birke, J.A. and D.S. Sims, "Walking Casts: Effect on Plantar Foot Pressures," <i>Journal of Rehabilitation Research and Developement</i>, 22:3, July, 1985, pp. 18-22.</li> <li>Brand, P.W., "The Insensitive Foot," Editor M.H. Jahss, <i>Disorders of the Foot</i>, Vol. II, W.B. Saunders, 1982, p. 1266.</li> <li>Cterctecko, G.C., M. Dhanendran, W.S. Hutton, and L.P. LeQuesne, "Vertical Forces Acting on the Foot of Diabetic Patients with Neuropathic Ulceration," <i>British Journal of Surgery</i>, 68, 1981, pp. 609-614.</li> <li>Coleman, W.S., P.W. Brand, and J.A. Birke, "The Total Contact Cast: A Therapy for Plantar Ulceration of the Insensitive Foot," <i>Journal of the American Pediatric Medical Association</i>, 74:11, November, 1984, pp. 548-552.</li> <li>Enna, CD., P.W. Brand, J.K. Reed, and D. Welch, "The Orthotic Care of the Denervated Foot in Hansen's Disease," <i>Orthotics and Prosthetics</i>, 30:1, March, 1976, pp. 33-39.</li> <li>Gristina, A.G., A.L.W. Thompson, N. Kester, W. Walsh, and J.A. Gristina, "Treatment of Neuropathic Conditions of the Foot and Ankle with a Patellar-Tendon-Bearing Brace," <i>Archives of Physical Medicine and Rehabilitation</i>, 54, December, 1973, pp. 562-564.</li> <li>Hall, O.C. and P.W. Brand, "The Etiology of the Neuropathic Plantar Ulcer," <i>Journal of the American Pediatric Medical Association</i>, 69:3, March, 1979, pp. 173-177.</li> <li>Helm, P.A., S.C. Walker, and G. Pullium, "Total Contact Casting in Diabetic Patients with Neuropathic Foot Ulcerations," <i>Archives of Physical Medicine and Rehabilitation</i>, 65, 1984, pp. 691-693.</li> <li>Lang-Stevenson, A.I., W. Sharrard, R.P. Betts, and T. Duckworth, "Neuropathic Ulcers of the Foot," <i>Journal of Bone and Joint Surgery</i>, (British) 67B, 1985, pp. 438-442.</li> <li>Lehmann, J.F., CG. Warren, D.R. Pemberton, B.C. Simons, and B.J. DeLateur, "Load-bearing Function of Patellar Tendon Bearing Braces of Various Designs," <i>Archives of Physical and Medical Rehabilitation</i>, 52, August, 1971, pp. 366-370.</li> <li>Patterson, R.P., and S.V. Fisher, "The Accuracy of Electrical Transducers for the Measurement of Pressure Applied to the Skin," <i>IEEE Transactions on Biomedical Engineering</i>, 26:8, August, 1979, pp. 450-456.</li> <li>Polakoff, D.R., S.M. Pearce, D.P. Grogan, and W.Z. Burkhead, "The Orthotic Treatment of Stable Ankle Fractures," <i>Orthopedics</i>, 7, 1984, pp. 1712-1715.</li> <li>Pollard, J.P., and L.P. LeQuesne, "Method of Healing Diabetic Forefoot Ulcers," <i>British Medical Journal</i>, 286, February, 1983, pp. 436-437.</li> <li>Pollard, J.P., L.P. LeQuesne, and J.W. Tappin, "Forces Under the Foot," <i>Journal of Biomedical Engineering</i>, 5, 1983, pp. 37-40.</li> <li>Sabato, S., Z. Yosipovitch, A. Simkin, and J. Sheskin, "Plantar Trophic Ulcers in Patients with Leprosy," <i>International Orthopedics</i>, 6, 1982, pp. 203-208.</li> <li>Soderberg, G., "Follow-up of Application of Plaster-of-Paris Casts for Noninfected Plantar Ulcers in Field Conditions," <i>Leprosy Review</i>, 41, 1970, pp. 184-190.</li> </ol> <b>Footnote</b> 3D Orthopedics, Inc., 10520 Olympic Drive, Dallas, Texas 75220.<br /><br /><b>Footnote</b> Gulton TR-400a, Gulton Industries, Inc., East Greenwich, Rhode Island.<br /><br /><b>Footnote</b> Hercules Orthoflex Data System, Allegany Ballistics Lab, Cumberland, Maryland.<br /><br /><b>Footnote</b> Hercules Orthoflex Data System, Allegany Ballistics Lab, Cumberland, Maryland.<br /><br /><br /><em><b>*Deborah A. Nawoczenski, P.T., M.Ed. </b> Deborah A. Nawoczenski, P.T., M.Ed., is Assistant Professor at the Department of Physical Therapy for the College of Allied Health Professions at Temple University, Philadelphia, Pennsylvania 19140.</em><br /><br /><em><b>*James A. Birke, P.T., M.S. </b> James A. Birke, P.T., M.S., is Chief of the Physical Therapy Department at G.W. Long Hansen's Disease Center, Carville, Louisiana 70721.<br /><br /></em> Page Number(s) 74 - 80 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg Figure 5 TABLE I http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 FIGURE 5 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg Figure 9 FIGURE 8 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.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 Orthopedic Walkers: Effect on Plantar Pressures Creator An entity primarily responsible for making the resource James A. Birke, P.T., M.S. * Deborah A. Nawoczenski, P.T., M.Ed. * https://staging.drfop.org/files/original/f922814d211b608a697466e29490333b.pdf e5a35d98b2c617e7f9ded283ff5dafa7 https://staging.drfop.org/files/original/48cf7ac67e217521f3acb7e40d6b2a38.jpg f5a6cea41ca17f732cb253daf7918897 https://staging.drfop.org/files/original/16410b5f62b683ff0be5f6a0ef4730a6.jpg d8aa785829781cb0896ecc82863c789c https://staging.drfop.org/files/original/433b014b1a43a6614856053945b2243c.jpg 2b4c04387bc7f8a8bdc413c6109662d3 https://staging.drfop.org/files/original/843d131b77b5dc6c8f18d58702881340.jpg 5f4eff514a08be3ae5daaa303dc0cf7d https://staging.drfop.org/files/original/e575b525f13cc42d25f865c4db4ecb9e.jpg fc78601c78357e69128fc5a5290b83fd https://staging.drfop.org/files/original/e6ca2fa5bfd699bce64bf63899c6d86a.jpg ce75e70e35780221d326a363fc1dc05e https://staging.drfop.org/files/original/d803b3cc574d377eee5137bfd10f9db9.jpg 29d55e95bcb3a6b15f4a6b98f2c189e0 https://staging.drfop.org/files/original/5bc2ecf5e9ba7ac10a96388a62f09100.jpg e82f3d9d247bb7790f21711a8885532f https://staging.drfop.org/files/original/4de87b8d2e769e4c1287a208354fc8dc.jpg 70855f2c86c26331cc6fba80045e7553 https://staging.drfop.org/files/original/197022ec795072639ae32d2c689f1dc8.jpg 3cfec86e35d1b3315dafa497908e73ac https://staging.drfop.org/files/original/b4962dbe7236d6656d2297e42960d167.jpg 0970a72bbd0016a1fd49b37ead35272e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_005.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 5 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_02_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>External Power in Prosthetics and Orthotics, an Overview</h2> <h5>James B. Reswick, Sc.D. <a style="text-decoration:none;">*</a><br />Lojze Vodovnik, D.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>The large number of persons who could be materially helped if highly developed orthotics and prosthetics systems were available is not generally appreciated. The conquest of infectious diseases has increased life expectancy to the point where disability caused by the failure of physiological systems is common in old age. The ever-increasing rate of injuries resulting from vehicle accidents adds to the numbers of paralyzed and maimed, and at the present time the Vietnam conflict is adding its toll.</p> <p>Detailed statistics are difficult to obtain, but it has been estimated that there are 25,000 to 30,000 amputations per year in the United States from all causes. The Veterans Administration reported 25,000 lower-extremity and 6,000 upper-extremity service-connected cases treated during 1967 (incomplete figures), resulting from several wars. There are no immediately available statistics related to the Vietnam conflict.</p> <p>Dr. Virginia Badger <a style="text-decoration:none;">*</a> has estimated the numbers of patients in the United States with various types of rheumatic, arthritic, and neurological disorders, including quadriplegia, as follows: <b>Table 1</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 /> <p>Of these patients, Dr. Badger estimates that <i>2</i> million could benefit markedly from orthotic devices, provided that the difficult problems of patient acceptance could be overcome.</p> <p>Unfortunately, much remains to be done in defining the need more precisely. Many persons suffering from neurological disorders are not recorded in hospital statistics; and, if they are, the nature of their disability is not. The specific types and numbers of disabilities need to be codified in a way which could lead to the development of engineering specifications and decisions on priorities of effort and specific engineering designs.</p> <h3>The Man-Machine System</h3> <p>The human being and his assistive device comprise a man-machine system. When the orthotics or prosthetics system uses external power and is operated by means of feedback control, the result is a cybernetic system in the true sense of the term. <b>Fig. 1</b> illustrates the possible information paths of an orthotics or a prosthetics system. The following important elements are depicted: I. Signal Sources; II. Transducers; III. Signal Processors; IV. Output Systems; V. Feedback Receptors; and VI. Local Feedback. In addition to these physically identifiable elements, an important element in the performance of the system is the capability of man to learn to use a complex assistive device (VII. Adaptive Learning). Here, age and motivation are important; for example, "thalidomide children" show tremendous learning capacity with complex prostheses, while many geriatric lower-extremity amputees are not able, or are not motivated, to use an artificial leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Elements of a prosthetics or an orthotics system. I. Signal Sources: muscle motion, electromyographic, electroneurographic, electroencephalographic, eyeball motion, sound. II . Transducers: direct connections, switches, valves, proportional analog, proportional digital, electrodes, radio transmitters. III. Signal Processors: on-off, electromyographic, coupled function devices, proportional or velocity control systems, adaptive computer. IV. Output Systems: communication devices, environment and tools designed to work with the orthotics or prosthetics system, vehicles controlled by the orthotics or prosthetics system. IV. A. Prosthetic: terminal devices, upper-extremity components, lower-extremity components. IV. B. Orthotic: splints and casts, implant bone supports, body-powered splints, externally controlled splints, externally powered splints, functional electrical stimulation. V. Feedback Receptors: vision, hearing, proprioception, touch, "stereo" vibration, "stereo" electrical stimulation. VI. Local Feedback: Pressure sensors, slippage sensors, position, velocity, force. VII. Adaptive Learning. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This article will discuss each of the elements of the prosthetics or orthotics system depicted in <b>Fig. 1</b>, briefly indicating the present levels of research activity and future possibilities.</p> <h4>I. Signal Sources</h4> <p>The human desire to initiate movement of an orthotics or a prosthetics system originates at some conscious level in the central nervous system, but it must take the form of some voluntary physical action if a result is to be achieved. This action may be, for example, a simple muscle movement resulting in the closing of a switch, the pressing of a key, or the very sophisticated use of the tongue (<b>Fig. 2</b>) to activate a keyboard of miniature switches.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The Rancho Los Amigos Hospital electric arm orthosis. The various degrees of freedom are actuated by a series of bidirectional microswitches placed in front of the patient's mouth and operated by his tongue. A number of these devices are in use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Recently, electrical signals associated with muscle and neuron activity have been explored for use as control signals. Although electro-neurographic (ENG) signals seem attractive because of their proximity to the central nervous system<a></a>, the practical difficulty of maintaining electrodes proximal to nerves in human subjects over extended periods of time has not been overcome. Instead, the more accessible electromyographic (EMG) signals have been used as sources of control signals. Most practical to date has been the use of so-called surface EMG signals obtained by means of electrodes resting on the surface of the skin near a muscle whose electrical activity is to be detected.</p> <p>A number of prosthetic hands and some hand orthoses have been developed to operate from EMG signals picked up through surface skin electrodes.<a></a> More recently, interest has grown in obtaining EMG signals from within a muscle. Such intramuscular EMG signals exhibit a wider range (from single motor unit pulses to signals of many asynchronous pulse combinations) and are more free from "cross talk" resulting from the activity of neighboring muscles.<a></a> Practical use of intramuscular EMG signals requires either wire electrodes which penetrate the skin and which can exist for long periods of time without breaking or promoting infection (<b>Fig. 3</b>), or the development of implantable radio transmitters capable of long-term operation (<b>Fig. 4</b> and <b>Fig. 5</b>) <i>(35,37.) </i>Future research will undoubtedly press in both of these directions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. A monopolar, helically wound, percutaneous electrode. It is used to detect electrical activity within a muscle. The electrode is inserted into the proper muscle by a hypodermic needle which, when withdrawn, leaves the electrode comfortably implanted. A surface connector protects the electrode-skin interface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Miniature FM radio transmitter used to obtain electromyographic signals by complete implantation. The signals are received externally and, after processing, can be used as control inputs in a control system. The transmitter shown will be encapsulated in epoxy and coated with medical grade silicone rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Transmitters implanted in a human and attached to the trapezius muscles. The electromyographic signal obtained by lifting the shoulder ( a motion possessed by many quadriplegics) was used to drive a variable-speed motor, a bidirectional prehensile hand splint, and a multilevel selector. The transmitter was turned on by changing the state of a magnetic switch influenced by an external magnetic field. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Many other sources for voluntary signals from the human being have been suggested from time to time. The electroencephalogram (EEG) signal is often mentioned, but, to date, it has been used only as an on-off switch responding to the presence or absence of the alpha rhythm <i>. </i><a></a> Enticing as the idea may be, many years must pass before thoughts will will be transformed directly into meaningful electrical signals.</p> <p>The human voice, including whistles and the like, has been proposed and used as a signal source. Much research at present is devoted to machine recognition of human speech for voice-operated typewriters and for speaking directly to a computer <i>. </i><a></a> These efforts show promise, but they are probably far too complicated at present to be considered for use in a prosthetics or an orthotics system. The human eye has also been used to switch devices by means of ultrasonic and infrared reflections <i>. </i><a></a> Unfortunately, many such promising sources of control signals are involved in the normal activities of living, such as eating, looking around, speaking, and the like. This could be a disadvantage when the patient desired to control his orthotics or prosthetics system with a signal such as sound while he was talking or eating <i>.</i><a></a> </p> <h4>II. Transducers</h4> <p>Transducers are the devices used to change physiological phenomena into engineering signals that provide inputs to signal processors and output systems. A transducer may be as simple as an on-off switch or as complicated as an implantable FM radio transmitter. Some elements of orthotics and prosthetics systems are difficult to classify. Bowden cables used to transmit shoulder movements to an amputee's terminal device are an example. More recently, hydraulic systems which function as a wire cable have been demonstrated <i>. </i><a></a> Such systems combine the roles of transducer and actuator in a single unit.</p> <p>Electric switches and pneumatic-hydraulic control valves which convert body movements into changes in electric current or fluid flow are highly developed. Many types of reliable, very small electric switches have been easily adapted to prosthetics and orthotics systems, but, in the case of hydraulic and pneumatic control valves, it has been necessary to develop a number of appropriate special valves.</p> <p>Not so widely used in prosthetics and orthotics systems, but highly developed for general instrumentation purposes, is a wide range of proportional analog and digital transducers capable of converting pressure or movement into voltage or current changes. These devices range from analog potentiometers and capacitive and inductive devices which convert motion to smooth voltage changes, to linear transducers which produce pulse-coded signals proportional to incremental changes or absolute position. Also available are the very ingenious accelerometers and other motion transducers developed for space research and guidance control systems. Accelerometers have been used in at least one head-motion-activated control system <i>.</i><a></a> </p> <p>Generally speaking, the mechanical-to-electric transducers have been highly developed, but only limited use has been made of their capabilities in prosthetics and orthotics systems. This does not imply, however, that a number of mechanical - to - electric transducers are immediately available for use in prosthetics and orthotics systems. An actual application often requires either a major redesign or a new design to take into account the unique problems inherent in physiological-data transduction. It is appropriate to mention here the National Aeronautics and Space Administration's Space Technology Utilization Program, in which NASA is actively searching for ways to apply transducers developed for space applications in orthotics and prosthetics systems.</p> <p>The recent interest in electrophysiological signals for control of orthotics and prosthetics systems has focused attention on the development of electrodes. A large variety of surface electrodes used in electrocardiographic diagnosis and long-term monitoring systems is already available. From space technology come the "spray-on" electrodes and other surface electrodes used in telemetry and in obtaining physiological data from astronauts.</p> <p>Two main approaches exist for obtaining EMG signals from within a muscle, namely: percutaneous wires inserted by means of hypodermic needles; and surgically implanted radio-transmitting devices. In the first method, wires leading through the surface of the skin from inside the muscle must be capable of flexing as the muscle moves and maintaining contact with motor units for many months. Present indications are that tissue-reaction and infection at the point of exit from the skin are minimal. Some newly developed silastic-im-pregnated spiral electrodes show promise of solving the problem of mechanical reliability <i>. </i><a></a> Similar problems exist for the electrodes of surgically implanted devices. In fact, the electrodes may well prove to be the weakest link in a biotransmitting system. It is well known that electrode failures in heart pacers continue to be a vexing problem. Research will continue to find ways to prevent metal fatigue and to discover contact materials which produce no body-tissue reaction, and which do not corrode and weaken.</p> <p>In the foregoing paragraph, electrodes were discussed in the context of signal-sensing devices. Their importance is much more critical in transducers used for the electrical stimulation of muscle, as in the case of functional electrical stimulation to be described later on in this article, and in heart pacemakers and bladder stimulators, which have been excluded from this discussion of orthotics and prosthetics systems. The relatively higher currents associated with electrical stimulation, as compared with detection of electrophysiological signals, create problems. It is believed that the material, corrosion, and tissue-reaction problems associated with electrodes for picking up signals are not severe and can be easily overcome through present technology.</p> <p>Electrical powering, long-term body acceptance, and sealing of the package are the issues around the active transmitters used for detecting electrophysiological signals from within the body and the passive and active implantable transducers for electrical stimulation of muscles. At present, all such experimental devices are powered by mercury cell batteries. Much effort is being devoted to minimize total electrical power requirements and to obtain electrical energy from within the body through mechanical and chemical transformers.<a></a> Battery-powered biotransmitters of a total size of 0.1 cu. in. have operated continuously for 200 hr. and, intermittently, over a three-month period in dogs. An EMG transmitter was first implanted in a human being in Sweden in 1966 <i>. </i><a></a> More recently, one was implanted in a subject in Cleveland, Ohio <i>. </i><a></a> Many problems remain to be overcome before such transmitters can be used routinely in the clinical situation, but progress with packaging techniques which produce no tissue-reaction in animals over long periods of time, and with electrode designs which can survive mechanical and electrolytic effects, indicates that prototype systems will be evaluated in human subjects within the year.</p> <h4>III. Signal Processors</h4> <p>This discussion of signal processors is concerned primarily with the special electronic and computer-type systems used for converting low-level control signals containing noise and artifacts to useful, high-level input for orthotic or prosthetic devices.</p> <p>Although not specifically designed for signal processing, the mechanical and hydraulic characteristics of many systems may be viewed as signal processors. For example, the speed of response of a gas-powered orthotics or prosthetics system is often limited by the size of the valve openings and tubing used in the system. In this way, the on-off characteristic of the valve is converted inherently into a velocity output and is so observed by the patient. In fact, subjects are often very much aware of the noises and speeds of response associated with their control devices, and improve their skills with practice and knowledge of how the system will perform for given input operations.</p> <p>Signal processors designed specifically to alter electrical wave forms include a wide range of circuits used for processing EMG information. Most such circuits involve rectification, integration, and various nonlinear components used to reject noise and provide the smoothest possible electrical systems for operating the orthotic or prosthetic device. Since the EMG signal, especially when detected from within the muscle, consists of an asynchronous train of pulses, signal conditioners based upon digital - signal - handling theory are being developed. Some of these systems would "clean up" the pulse signals from within a muscle to the point where they might be used as direct signals into a digital computer.</p> <p>Under another kind of theory for signal processing, combined or patterned functions are produced from one or more inputs. Among body-powered orthotic devices, the linkage feeders widely used by quadriplegics are an example.<a></a> These mechanical linkage systems support the forearm and allow the patient to convert shoulder and trunk movement into controlled movement of his hand. When given a controlled prehensile function, patients often learn to feed themselves and perform many other useful tasks. Externally powered arm prostheses have been designed for children, with coupled movements such that the programmed movement of an eating implement is obtained by the child through a single input action.<a></a> The conversion of a single input action to interrelated movements of each part of the prosthesis may be regarded as a type of signal processing, especially when one considers the possibility of using an elecrical computer to do the same sort of thing. The sophisticated prosthetic hands built in France and, more recently, in Yugoslavia and Japan,<a></a> in which a simple set of input signals is mechanically converted to a smoothly closing movement of all fingers, constitute a type of signal processing.</p> <p>Another type of signal processing is found in the automatic control systems used in some orthotic and prosthetic devices (<b>Fig. 6</b>). Recently, interest has developed in systems possessing automatic proportional and velocity control. Such systems differ from so-called "open-loop" systems in that feedback position or force signals are fed back to the control system itself rather than the patient. The patient provides command signals, such as a new position, to which the control system automatically responds. Such techniques have not been widely used in orthotics and prosthetics systems to date, but they have been demonstrated in research prototypes and will probably find increasing application <i>.</i><a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. A prototype automatic prehension system developed at the Army Medical Biomechanical Research Laboratory. It includes miniaturized electronics, a motor-driven No. 4 hand, and a thumb sensor. A cosmetic glove is worn over the assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Most human motor activity is a combination of direct conscious control and patterned movements which are coordinated at levels below the conscious nervous system. Many research projects are now concerned with using computers or high-speed data processors to perform for an advanced prosthetics or orthotics system what the lower motor neuron system does for the human being. The problem is essentially one of information-channel capacity, wherein much information may be required to control a complex device but only limited channels are available for converting the desires of the patient into electrical command signals.<a></a> </p> <p>One approach to this problem was the Case Research Arm Aid, Mark I (<b>Fig. 7</b>), <a></a> which used a computer with pre-programmed tapes for a number of activities of daily living. The quadriplegic patient was required to select the portion of tape appropriate for the action he wished to accomplish, but he did not need to be actively involved once the action had started. More recently, proposals have been made for using computers adaptively to learn to provide patterned functions. The idea would be to store within the computer patterns or subroutines for elementary body movements which combine to produce walking or upper-extremity movement. The subject would then provide only "coarse" information about where he wanted his limb to go, and the computer would calculate according to some pre-programmed strategy how best to move his limb most efficiently from one place to another. The tremendous progress in machine computation has opened unlimited possibilities for research in such systems which can be reduced practically to patient needs. One can visualize, for example, a paralyzed leg being electrically stimulated according to a patterned program stored in a solid-state, micrologic computer worn on the belt. Although such a system can be imagined, it will be many years before it is technically and economically feasible.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The Case Research Arm Aid, Mark I. The pneumatic system shown allowed five degrees of freedom through the shoulder, arm, and wrist. Modifications being made include conversion from a pre-programmed tape control to computer-calculated trajectories by means of myoelectric input control signals. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>IV. Output Systems</h4> <p>In the past, most of the research, development, and clinical application of orthotics and prosthetics systems has been concerned with the output systems, for these are the hardware devices which perform the functions required by the handicapped person. Through intuition, designers have shown awareness of control and feedback, but their attention has been primarily directed toward the powering and fitting of devices to improve the function of the handicapped.</p> <p>Almost all the elements in the man-machine systems are applicable to both orthotics and prosthetics; but, when output systems are considered, it is necessary to discuss orthoses and prostheses independently, except for certain communication devices which apply to both. For example, much effort has been devoted to modifying telephone, recorder, typewriter, radio and television equipment for easier use by handicapped persons. Touch dialing, alone, is an important asset. Tape-recording and typewriters operated through coded signals from the tongue or voice make it possible for the paralyzed person to carry on a business and communicate with friends.</p> <p>In addition to communication devices, attention has also been given to the development of special tools and machines so that the handicapped can perform useful work. Interestingly, much of the philosophy in the development of such tools is common with the development of special tools for astronauts to use in space. This occurs because the normal man in an alien environment is similar in many respects to the handicapped man in a normal environment. Vehicles for the transportation of handicapped persons, including powered wheelchairs (<b>Fig. 8</b>) and modified automobiles, must also be included in output systems for the handicapped.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Ampersand Research, Highland View Hospital, three-level electromyographic control of wheelchair and flexorhinge splint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prosthetics</i></p> <p>The term "prosthesis" brings to mind artificial hands, arms, and legs. The historical development of these artificial limbs is an extensive and fascinating study in itself. Although seemingly simple and perhaps crude, the cable-controlled, rubber-band hooks commonly used by below-elbow amputees are, in fact, quite sophisticated, and many amputees have developed remarkable dexterity with them. Probably many years will elapse before the users of EMG-controlled, electrically powered hands achieve the same level of reliability and dexterity now found in thousands of skilled hook-users around the world.</p> <p>The problem is much more severe for the above - elbow and shoulder - disarticulation amputee, especially the bilateral case. It is a fact that when a patient has one good arm the margin of increase in function provided by a prosthetic second arm is often too small to make it worth his while to learn to use it. Much effort is now under way to provide improved functions for high-level amputees, especially bilateral cases. The most successful systems to date are powered by gas or electricity.<a></a> Each clinical application represents a major engineering achievement, and each one is usually somewhat different from all others. This is the real limitation in the development of sophisticated upper-extremity systems, for the problem of fitting and the nature of disability are so different among the relatively limited numbers of amputee patients and congenitally deformed children that the sophisticated engineering required is often economically unjustified. However, the obvious challenge presented by the creation of an artificial human limb continues to fire the imagination of engineers throughout the world, and one may expect continued progress.</p> <p>The case for the lower-extremity prostheses is somewhat different, because a man cannot walk with just one leg. Much effort has been devoted to developing lower-extremity prostheses for both above-knee and below-knee amputees. A successful prosthetic application requires close collaboration between the orthopaedic surgeon and the prosthetist. Thoughtful planning concerning the nature of the stump to be produced can make a great difference in the effectiveness of the final prosthesis. Walking is one of the most sophisticated patterned functions in man. Many muscles are interrelated in producing a gait of minimum energy expenditure. One area of intensive research has been the study of human gait in order to improve the design of lower-extremity prosthetic and orthotic devices. Although considerable data have been gained through cinematography and EMG studies, there is still much to be learned, and one can expect continuing research in this area.<a></a> </p> <p>Lower-extremity prostheses are more complicated than one might imagine. The acceleration sequences required for normal human gait are not produced by a simple pendulum swing. Instead, one must build nonlinear damping devices into a lower-extremity prosthesis to control the swing phase so that it will approximate that of a normal human being. In the simplest versions, disks of leather are used to provide this friction. Recently, nonlinear and hydraulic devices have been built into artificial limbs. These hydraulic devices still suffer occasionally from seal and other failures, but they have been successfully used by amputees under a Veterans Administration evaluation program.</p> <p>The problem of socket design and fitting is still under investigation, for one must transfer considerable forces to the limb, both in direct compression and in torsion. Sockets providing total-surface contact, air cushions, "breathing effect" and special types of support have been developed. For a number of years, researchers have attempted to measure the pressure distributions occurring under dynamic conditions within lower-extremity sockets. In general, these attempts have not been successful, and this remains a challenging area for future research. Such pressure-distribution data are urgently needed for the intelligent design of lower-extremity prostheses and, in some cases, for upper-extremity devices.</p> <p><i>Orthotics</i></p> <p>The first orthoses were the splints used to support a fractured limb and the canes and crutches used by early man. Bracing of weakened limbs due to neurological disorders and the therapeutic appliances used to overcome deformities have been widely applied by the orthopaedic surgeon and his collaborating orthotist. Through surgical reconstruction and tendon transplants, the orthopaedic surgeon can provide concepts for rehabilitation which complement improved engineering systems.<a></a> The future possibilities of such combined surgical intervention and engineering systems development have been only hinted at and much research undoubtedly will be carried on between the engineer and the surgeon in this area.</p> <p>A number of new, externally powered, and controlled splint systems are being made available to paralyzed patients. A kind of race is now occurring between the proponents of gas-powered orthotics systems and electrically powered systems. Actually, these systems are highly competitive when one considers the energy-storage capacity and weight of motors and batteries as compared to gas actuators and storage containers. The gas-powered systems still provide the best force-to-weight capability, but electric motors are being improved continuously and the overall simplicity of an all-electric system has many advantages.<a></a> </p> <p>A number of prehensile splints to provide grasp to paralyzed patients have been applied routinely, and many new multiaxis powered splints are being applied.<a></a> As in the case of the complex prosthesis, the need for many different approaches to meet the many different types of disability in paralysis or neurological disorders has slowed down the broad development of externally powered orthotic systems. We believe, however, that engineering developments will soon reach the point where such systems will be widely applied to the very large number of patients who can benefit from increased functions, especially in old age. Expanded research and development in externally powered orthoses for both upper and lower extremities is certainly going to occur.</p> <p>A promising new approach is being investigated throughout the world. This approach suggests the use of electrical stimulation of muscles for functional activity. <a></a> While electrical stimulation of muscles has been used extensively for a number of years in diagnosis and in therapy, its use for functional action has only recently been studied. The increased sophistication of electronic systems and the possibility of passive and active implants suggest the realization of controlled muscle activity. Such systems would certainly operate in parallel with some sort of external functional bracing, for in the foreseeable future one can imagine only a limited number of agonist and antagonist muscles being functionally stimulated.</p> <p>There is much to be learned about whether denervated muscles can be kept in an active stimulatable condition for long periods of time and whether intact lower motor systems will respond to controlled stimulation without inducing spasticity and other aberrations. The progress to date, however, is exciting and it is urged that serious consideration be given to programs of electrical stimulation of the muscles of recent victims of neuron lesions so that the atrophy of involved muscles can be retarded awaiting the day that functional stimulation can be made available.</p> <p>Expanded research around the understanding of the process of functional stimulation and physiologic factors in muscle stimulation, both from a physiological and an engineering point of view, is to be expected.</p> <h4>V. and VI. Feedback Receptors and Local Feedback</h4> <p>A human being controlling either the most simple or the most complex assistive device must have feedback information. In normal human motor activity, feedback comes via sight, sound, touch (pressure), and proprioceptive senses. These normal feedback channels are always impaired to some degree in handicapped persons and may be altogether missing. The visual path is still the most important for control in most orthotics and prosthetics systems, but much research has been undertaken recently to relieve the patient of the need to keep his eyes consciously fastened on each part of an output task. The sounds of electric motors and gas-operated systems provide many cues for feedback control, some of which may not be consciously appreciated by the subject. Many amputees learn to interpret reflected forces and motions through Bowden cables and other body-powered components.</p> <p>Much interest in sensory feedback research has been shown throughout the world, but only minimal progress has been made to date. Stereo effects are also being investigated, including transducers which produce vibration of varying phase and intensity at two points on the surface of the skin from which a sensation of spatial position proportional to an actual position can be produced <i>. </i><a></a> The possibility of producing a similar spatial position sense through "stereo" electrical stimulation at two different points on the surface of the skin is also being investigated.</p> <p>Recently proposed orthotics and prosthetics systems, using data processes, may require local feedback which is not processed by the human. <b>Fig. 1</b> indicates some paths which are analogous to some afferent paths in lower motor neuron systems in the human. Systems to select the grasping pressure in terminal devices have been developed. A recent approach to the problem at the Army Medical Biomechanical Research Laboratory uses a sound pickup to detect incipient slip in lieu of pressure to modulate the force applied in an artificial hand <i>.</i><a></a> </p> <p>To date, feedback control of orthotics and prosthetics systems has been severely limited by the inability to provide effective artificial sensory feedback, and will constitute a major barrier to overall system effectiveness for some years to come. It seems clear that a maximum research effort should be made to develop effective pseudosensory feedback signals, not only for orthotics and prosthetics systems, but also for sensory aids to the blind and deaf- areas which are, of course, closely related.</p> <h4>VII. Adaptive Learning</h4> <p>The success of any orthotics or prosthetics system or device must depend on acceptance by a patient and his abilty to learn to use it effectively. If the device proves to be more trouble than it is worth, it will be rejected. Thousands of rejected devices now rest in closets and dark corners.</p> <p>An important element of an orthotics or prosthetics system is the capability of a patient, whether young or old, to learn to employ his device skillfully <i>.</i><a></a> </p> <p>As new systems become ever more complex with many degrees of freedom (moving elements), the problem of control becomes more difficult.<a></a> One may visualize a multi-axis orthosis controlled by EMG signals from six or more voluntarily excited muscles (<b>Fig. 9</b>). An unanswered question remains as to how well the patient can train the six or more muscles to perform the functions required, especially when the functions may be very different from those for which the muscle was naturally used. The authors have discussed this difference between so-called naturally conditioned communication channels (NCCC) and operant-conditioned communication channels (OCCC) (<b>Fig. 10</b>) <i>. </i><a></a> It appears intuitively correct to use the naturally conditioned channels wherever possible as signal sources for natural functions. The EMG-controlled artificial hands previously referred to use signals obtained from the prehensile extensors and flexors so that the amputee may open and close his artificial hand with the same muscles he would have used prior to the amputation. However, as degrees of freedom increase and the nature of the disability precludes naturally conditioned sources, one is forced to employ other muscles, such as the auriculares muscles behind the ears<a></a> or the trapezius muscles in the shoulders, as signal sources.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. A test of the feasibility of exercising three degrees of freedom by means of myoelectric control. Six muscle sites received percutaneous electrodes, all in the forearm. The six sites were then connected to a model hand trainer possessing three degrees of freedom. The motions of the trainer could be controlled to correspond with those of the control muscles. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Schematic representation of naturally conditioned communication channels (NCCC) and operant-conditioned communication channels (OCCC). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is clear that much research on these issues remains to be done. Age is certainly an important factor, for it is known that young children adapt very much more easily to orthotic and prosthetic devices than do older persons. Learning capability is closely related to the amount of information being received by the patient through his feedback channels and to the amount of patterning and programming that can be done at the signal-processing level. No doubt the future will bring clarification of these matters.</p> <h3>Evaluation</h3> <p>Before closing, a major problem which continues to face the American orthotics and proshetics research, development, and clinical application program should be mentioned. This is the important issue of effective <i>evaluation. </i>Evaluation does not stand alone as a specific activity. The theory that a prototype developed by one group can be taken over by a separate evaluation agency to determine if it "works," and if it works can then be taken over by a manufacturer for production, just does not often succeed in practice. Problems in the medical engineering field of prosthetics and orthotics development are immensely complicated, and often the true nature of the problem to be solved is not undertood until one or two attempts have been made at solution. A constant interplay between the needs of the patient, the requirements of the physician, and the technical development by the engineer must be maintained. It is the rule, rather than the exception, that most new developments brought to the prototype stage require continued research and redesign. It seldom happens that a first-prototype development can be picked up and replicated in quantity for the field.</p> <p>The implication of the foregoing remarks is that the evaluation process is a continuing and integral part of the overall design-development process and is perhaps the hardest and most expensive part. To date, inadequate funds have been allocated for its accomplishment in grant programs. The result has been that not nearly so many fruits have accrued from the research and development programs as might otherwise have been the case.</p> <p>The specific need could be met by providing an overall systems-management function for the broad spectrum of activities throughout the nation. This systems-management function would be a cooperative effort authorized by federal government agencies and their advising groups. The lessons learned by the National Aeronautics and Space Administration in the management of the space effort seem applicable here, and it is the strong recommendation of these authors that the need for systems management in the broad field of orthotics and prosthetics research and development be recognized.</p> <p><b>References:</b></p> <ol> <li>Alldredge, R. H., and E. F. Murphy, Prostheticsresearch and the amputation surgeon, Artificial Limbs, pp. 4-46, September 1954.</li> <li>Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</li> <li>Alter, R., Bioelectric control of prostheses, MITechnical Report 446, Cambridge, Mass., December 1966.</li> <li>Basmajian, J. V., M. Baeza, and C. Fabrigar,Conscious control and training of individual spinal motor neurons in normal human subjects, J. of New Drugs, 5(2):78-85, March-April 1965.</li> <li>Battye, C. K., A. Nightingale, and J. Whillis,The use of myoelectric currents in the operation of prosthesis, J. Bone and Joint Surg., 37B:506, 1955.</li> <li>Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</li> <li>Bontrager, E., M.Sc. thesis, Case Institute ofechnology, Cleveland, 1965.</li> <li>Bottomley, A. H., Myoelectric control of poweredprostheses, J. Bone and Joint Surg., 47B:411-415, 1965.</li> <li>Bottomley, A. H., and T. K. Cowell, An artificialhand controlled by the nerves, New Scientist, pp. 668-671, March 12, 1964.</li> <li>Bottomley, A. H., A. B. Kinnier Wilson, and A.ightingale, Muscle substitutes and myoelectric control, J. Brit. Institution of Radio Engineers, 26(6), December 1963.</li> <li>Brejdo, M. G., V. S. Gurfinkle, A. Ye. Kobrinskii,. A. Sysiu, M. L. Celtin, and A. S. Jakobson, O biolektricskoj sisteme upravlenija, Problemy kybernetiki, Gs. izd., fizikomatematiceskoj, literatury, Moscow, 1959.</li> <li>Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</li> <li>Close, J. R., E. D. Nickel, and F. N. Todd, Singlemotor unit action potentials, Clinical Orthopaedics, 42:171-190, 1965.</li> <li>Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 1964.</li> <li>Crochetiere, W. J., L. Vodovnik, and J. B. Reswick,Electrical stimulation of skeletal muscle: a study of muscle as an actuator, Med. and Biol. Eng., 5:111-125, 1967.</li> <li>Dewan, E. M., Communication by electroencephalog-raphy, Special Report No. 12, Air Force Research Laboratory, Cambridge, Mass., November 1964.</li> <li>Dimitrijevic, M. R., Use of physiological mechanismsin the electrical control of paralyzed extremities, International Symposium on External Control of Human Extremities, Dubrovnik, 1966.</li> <li>Dorcas, D. S., and R. N. Scott, A three-state myo-electric control, Med. and Biol. Eng., 4:367-370, Pergamon Press, 1966.</li> <li>Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</li> <li>Freedy, A., and J. Lyman, An information theoryapproach to control of externally powered artificial arms, Paper read at combined meeting of Panel on Control of External Power and Panel on Upper-Extremity Orthotics, Subcommittee on Design and Development, Committee on Prosthetics Research and Development, New York, May 1967.</li> <li>Gracanin, F., and M. R. Dimitrijevic, Applicationof functional stimulation in rehabilitation of neurological patients, International Symposium on Rehabilitation in Neurology, Prague, September 1966.</li> <li>Grahn, E. C, Electrical actuators in prosthetics andorthotics, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 172-185, 1966.</li> <li>Groth, H., and J. Lyman, A functional evaluationof several surgical techniques for establishing prosthetic control sites, Biotechnology Laboratory Technical Report No. 2, University of California (Los Angeles), June 1959.</li> <li>Highland View Hospital, Ampersand report, Cleve-and, September 1966.</li> <li>Hirsch, C, E. Kaiser, and I. Petersen, Telemetry ofmyopotentials, Acta Orthop. Scand., 37:156-165, 1966.</li> <li>Horn, G. W., Muscle voltage moves artificial hand,lectronics, October 11, 1963.</li> <li>Inman, V. T., Human locomotion, Can. Med. Ass.., 94:1047-1054, 1966.</li> <li>Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</li> <li>Kay, Hector W. Conclusions of a conference onlinkage feeders, Artificial Limbs, Spring 1966.</li> <li>Kay, Hector W., and Nancy V. Appoldt, Prelimi-nary design analysis of linkage feeders, Artificial Limbs, Spring 1966.</li> <li>Kestenback, H. J., A feasibility study of smallradioisotopic batteries for medical implants, Report SSG-67-32, Case Institute of Technology, 1967.</li> <li>Kiessling, E. A., Carbon dioxide as a source of ex-ternal power for prosthetic devices, The application of external power in prosthetics and orthotics, National Academy of Sciences-National Research Council, Publication 874, pp. 79-87, 1961.</li> <li>Kiessling, E. A., Pneumatic prosthetic components:rigid servo mechanisms and their control valves, The application of external power in prosthetics and orthotics, National Academy of Sciences- National Research Council, Publication 874, pp. 116-131, 1961.</li> <li>Kinnier Wilson, A. B., Design of a motorized elbowsplint, Proc. Int. Symposium on the Application of Automatic Control in Prosthetic Design, pp. 6-9, Belgrade, 1962.</li> <li>Ko, W., Progress in miniaturized biotelemetry, Bio-cience, 15(2):118-120, 1966.</li> <li>Ko, W., Piezoelectric energy converter for electronicimplants, Proc. 19th Conference on Engineering in Medicine and Biology, San Francisco, p. 67, 1966.</li> <li>Ko, W., and M. R. Neuman, Implant biotelemetryand microelectronics, Science, 156:351-360, April 21, 1967.</li> <li>Kobrinskii, A. Ye., Bioelectric control of prostheticdevices, Herald of the Academy of Sciences, USSR, 30(7):58-61, July 1960.</li> <li>Kralj, A., L. Vodovnik, and M. Borovsak, Elec-tronic circuits used to obtain some functional movements by means of electrical stimulation, 2nd European Symposium on Medical Electronics, London, 1967.</li> <li>Litton Systems (Canada) Ltd., Research on myo-electric devices, D.I.R. Project No. E-74, DRB 9301-02, Toronto, 1967.</li> <li>Long, C, and B. Ebskov, Research applications ofmyoelectric control, presented at the 43rd Annual Session of the American Congress of Physical Medicine and Rehabilitation, 1965.</li> <li>Long, C, and V. Masciarelli, An electrophysiologicsplint for the hand, Arch. Phys. Med. and Rehab., 44:499, 1963.</li> <li>Lucaccini, L., A. Freedy, and J. Lyman, Externallypowered upper extremity prosthetic systems: studies of sensory motor control, Dept. of Eng. Report 67-12, University of California (Los Angeles), March 1967.</li> <li>Lucaccini, L. F., P. K. Kaiser, and J. Lyman, TheFrench electric hand: some observations and conclusions, Bull, of Prosth. Research, Veterans Administration, BPR 10-6, pp. 30-51, Fall 1966.</li> <li>Lyman, J., Biotechnology Laboratory Progress Re-ort No. 61-76, University of California (Los Angeles), September 1961.</li> <li>Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</li> <li>McGhee, R. B., Finite state control of quadrupedlocomotion, Report USCE 186, University of Southern California, December 1966.</li> <li>McLaurin, C. A., Control of externally poweredprosthetic and orthotic devices by musculoskeletal movement, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 10-19, 1966.</li> <li>McLaurin, C. A., On the use of electricity in upperextremity prostheses, J. Bone and Joint Surg., <b>47B: </b>448, 1965.</li> <li>Marquardt, E., Biomechanical control of pneumaticprostheses with special consideration of the sequential control, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 20-31, 1966.</li> <li>Massie, H., Cardiac pacemaker without batteries, 18th Conference on Engineering in Medicine and Biology, Philadelphia, 1965.</li> <li>Mott, W. E., and L. Sagan, Bioengineering problemsof implantable radioisotopic powered heart devices, San Diego Biomedical Engineering Symposium, 1967.</li> <li>Murphy, E. F., The swing phase of walking withabove-knee prosthesis, Bull, of Prosth. Research, Veterans Administration, BPR 10-1, pp. 5-39, Spring 1964.</li> <li>National Academy of Sciences-National Researchouncil, The application of external power in prosthetics and orthotics, Publication 874, 1961.</li> <li>National Academy of Sciences-National Researchouncil, The control of external power in upper-extremity rehabilitation, Publication 1352, 1966.</li> <li>Olson, H. F., Speech processing systems, IEEEpectrum, pp. 90-102, February 1964.</li> <li>Pearson, J. R., Gas-power sources and actuators forprosthetic and orthotic devices, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 186-201, 1966.</li> <li>Rakic, M., An automatic hand prosthesis, Med.lectron. Biol. Eng., 2:47, 1964.</li> <li>Reynolds, L. W., Utilization of bioelectricity aspower supply, Aerospace Med., February 1964.</li> <li>Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 1966.</li> <li>Scott, R. N., A method for inserting wire electrodesfor electromyography, IEEE Transactions on Bio-Medical Engineering, BME-12(l):46-47, January 1965.</li> <li>Scott, R. N., Myo-electric control, Science J., pp. 2-8, March 1966.</li> <li>Scott, R. N., Myoelectric control of prostheses, Arch. Phys. Med. and Rehab., 47:174-181, March 1966.</li> <li>Scott, R. N., Myo-electric control systems, Reporto. 5, University of New Brunswick Bio-Engineering Institute, December 1965; No. 6, January 1967.</li> <li>Selwyn, D., Head-mounted inertial servo control forhandicapped, 6th Annual Symposium of the Professional Group on Human Factors in Electronics, Boston, May 1965.</li> <li>Sherman, E. D., A. L. Lippay, and G. Gingras,Prosthesis given new perspectives by external power, Hospital Management, pp. 44-49, November 1965.</li> <li>Spaco, Inc., The sight switch, Huntsville, Ala.,pril 1965.</li> <li>Stanford Research Institute, Experiments in tactualperception, Technical Report AFAL-TR-65-75_rJuly 1965.</li> <li>Suzuki, R., An automatic hand prosthesis, Jap,lectron. Eng., 2(1):39-41, January 1965.</li> <li>Tomovic, R., and G. Boni, An adaptive artificialhand, IRE Trans. Auto. Control, pp. 3-10^ April 1962.</li> <li>Tomovic, R., and R. B. McGhee, A finite stateapproach to the synthesis of bioengineering control-systems, IEEE Trans. Human Factors, HFE-7,. No. 2, June 1966.</li> <li>Trombly, C. A., Principles of operant conditioningrelated to orthotic training of quadriplegic patients, Amer. J. Occup. Ther., 20:217-220, September-October 1966.</li> <li>Vodovnik, L., W. J. Crochetiere, and J. B. Reswick,Control of a skeletal joint by electrical stimulation of antagonists, Med. and Biol. Eng., 5:97-109,1967.</li> <li>Vodovnik, L., C. Long, J. B. Reswick, A. Lippay,nd D. Starbuck, Myoelectric control of paralyzed muscles, IEEE Trans., BME-12, pp. 169-172, 1965.</li> <li>Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 1967.</li> <li>Waring, W., and V. L. Nickel, Powered braces withmyoelectric controls, Orthop. and Prosth. Appliance J., pp. 228-230, September 1965.</li> <li>Wasserman, W. L., Human amplifiers, Sci. and Technol., October 1964.</li> <li>Weltman, G., H. Groth, and J. Lyman, An analysisof bioelectrical prosthesis control, Biotechnology Laboratory Technical Report No. 1, Dept. of Eng. Report No. 59-49, University of California (Los Angeles), July 1959.</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>7.</b> </td><td class="clsTextSmall">Bontrager, E., M.Sc. thesis, Case Institute ofechnology, Cleveland, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progress Re-ort No. 61-76, University of California (Los Angeles), September 1961.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Weltman, G., H. Groth, and J. Lyman, An analysisof bioelectrical prosthesis control, Biotechnology Laboratory Technical Report No. 1, Dept. of Eng. Report No. 59-49, University of California (Los Angeles), July 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Trombly, C. A., Principles of operant conditioningrelated to orthotic training of quadriplegic patients, Amer. J. Occup. Ther., 20:217-220, 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>60.</b> </td><td class="clsTextSmall">Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 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>68.</b> </td><td class="clsTextSmall">Stanford Research Institute, Experiments in tactualperception, Technical Report AFAL-TR-65-75r July 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Crochetiere, W. J., L. Vodovnik, and J. B. Reswick,Electrical stimulation of skeletal muscle: a study of muscle as an actuator, Med. and Biol. Eng., 5:111-125, 1967.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Dimitrijevic, M. R., Use of physiological mechanismsin the electrical control of paralyzed extremities, International Symposium on External Control of Human Extremities, Dubrovnik, 1966.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Gracanin, F., and M. R. Dimitrijevic, Applicationof functional stimulation in rehabilitation of neurological patients, International Symposium on Rehabilitation in Neurology, Prague, September 1966.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Kralj, A., L. Vodovnik, and M. Borovsak, Elec-tronic circuits used to obtain some functional movements by means of electrical stimulation, 2nd European Symposium on Medical Electronics, London, 1967.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Long, C, and V. Masciarelli, An electrophysiologicsplint for the hand, Arch. Phys. Med. and Rehab., 44:499, 1963.</td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Vodovnik, L., W. J. Crochetiere, and J. B. Reswick,Control of a skeletal joint by electrical stimulation of antagonists, Med. and Biol. Eng., 5:97-109,1967.</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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Grahn, E. C, Electrical actuators in prosthetics andorthotics, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 172-185, 1966.</td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Pearson, J. R., Gas-power sources and actuators forprosthetic and orthotic devices, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 186-201, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, R. H., and E. F. Murphy, Prostheticsresearch and the amputation surgeon, Artificial Limbs, pp. 4-46, September 1954.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Groth, H., and J. Lyman, A functional evaluationof several surgical techniques for establishing prosthetic control sites, Biotechnology Laboratory Technical Report No. 2, University of California (Los Angeles), June 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Inman, V. T., Human locomotion, Can. Med. Ass.., 94:1047-1054, 1966.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking withabove-knee prosthesis, Bull, of Prosth. Research, Veterans Administration, BPR 10-1, pp. 5-39, Spring 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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Kiessling, E. A., Carbon dioxide as a source of ex-ternal power for prosthetic devices, The application of external power in prosthetics and orthotics, National Academy of Sciences-National Research Council, Publication 874, pp. 79-87, 1961.</td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Kiessling, E. A., Pneumatic prosthetic components:rigid servo mechanisms and their control valves, The application of external power in prosthetics and orthotics, National Academy of Sciences- National Research Council, Publication 874, pp. 116-131, 1961.</td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Kinnier Wilson, A. B., Design of a motorized elbowsplint, Proc. Int. Symposium on the Application of Automatic Control in Prosthetic Design, pp. 6-9, Belgrade, 1962.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Marquardt, E., Biomechanical control of pneumaticprostheses with special consideration of the sequential control, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 20-31, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">McGhee, R. B., Finite state control of quadrupedlocomotion, Report USCE 186, University of Southern California, December 1966.</td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Tomovic, R., and R. B. McGhee, A finite stateapproach to the synthesis of bioengineering control-systems, IEEE Trans. Human Factors, HFE-7,. No. 2, June 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>14.</b> </td><td class="clsTextSmall">Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Freedy, A., and J. Lyman, An information theoryapproach to control of externally powered artificial arms, Paper read at combined meeting of Panel on Control of External Power and Panel on Upper-Extremity Orthotics, Subcommittee on Design and Development, Committee on Prosthetics Research and Development, New York, May 1967.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Lucaccini, L., A. Freedy, and J. Lyman, Externallypowered upper extremity prosthetic systems: studies of sensory motor control, Dept. of Eng. Report 67-12, University of California (Los Angeles), March 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>60.</b> </td><td class="clsTextSmall">Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 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>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Lucaccini, L. F., P. K. Kaiser, and J. Lyman, TheFrench electric hand: some observations and conclusions, Bull, of Prosth. Research, Veterans Administration, BPR 10-6, pp. 30-51, Fall 1966.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Rakic, M., An automatic hand prosthesis, Med.lectron. Biol. Eng., 2:47, 1964.</td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Suzuki, R., An automatic hand prosthesis, Jap,lectron. Eng., 2(1):39-41, January 1965.</td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Tomovic, R., and G. Boni, An adaptive artificialhand, IRE Trans. Auto. Control, pp. 3-10^ April 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>References</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">McLaurin, C. A., Control of externally poweredprosthetic and orthotic devices by musculoskeletal movement, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 10-19, 1966.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">McLaurin, C. A., On the use of electricity in upperextremity prostheses, J. Bone and Joint Surg., 47B: 448, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Kay, Hector W. Conclusions of a conference onlinkage feeders, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Kay, Hector W., and Nancy V. Appoldt, Prelimi-nary design analysis of linkage feeders, Artificial Limbs, Spring 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>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 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>25.</b> </td><td class="clsTextSmall">Hirsch, C, E. Kaiser, and I. Petersen, Telemetry ofmyopotentials, Acta Orthop. Scand., 37:156-165, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Kestenback, H. J., A feasibility study of smallradioisotopic batteries for medical implants, Report SSG-67-32, Case Institute of Technology, 1967.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Ko, W., Piezoelectric energy converter for electronicimplants, Proc. 19th Conference on Engineering in Medicine and Biology, San Francisco, p. 67, 1966.</td></tr><tr><td class="clsTextSmall"><b> 51.</b> </td><td class="clsTextSmall">Massie, H., Cardiac pacemaker without batteries, 18th Conference on Engineering in Medicine and Biology, Philadelphia, 1965.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Mott, W. E., and L. Sagan, Bioengineering problemsof implantable radioisotopic powered heart devices, San Diego Biomedical Engineering Symposium, 1967.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Reynolds, L. W., Utilization of bioelectricity aspower supply, Aerospace Med., February 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>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 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>65.</b> </td><td class="clsTextSmall">Selwyn, D., Head-mounted inertial servo control forhandicapped, 6th Annual Symposium of the Professional Group on Human Factors in Electronics, Boston, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Researchouncil, The application of external power in prosthetics and orthotics, Publication 874, 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>14.</b> </td><td class="clsTextSmall">Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 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>67.</b> </td><td class="clsTextSmall">Spaco, Inc., The sight switch, Huntsville, Ala.,pril 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Olson, H. F., Speech processing systems, IEEEpectrum, pp. 90-102, February 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>16.</b> </td><td class="clsTextSmall">Dewan, E. M., Communication by electroencephalog-raphy, Special Report No. 12, Air Force Research Laboratory, Cambridge, Mass., 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>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Basmajian, J. V., M. Baeza, and C. Fabrigar,Conscious control and training of individual spinal motor neurons in normal human subjects, J. of New Drugs, 5(2):78-85, March-April 1965.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Singlemotor unit action potentials, Clinical Orthopaedics, 42:171-190, 1965.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Highland View Hospital, Ampersand report, Cleve-and, September 1966.</td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Scott, R. N., A method for inserting wire electrodesfor electromyography, IEEE Transactions on Bio-Medical Engineering, BME-12(l):46-47, January 1965.</td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Scott, R. N., Myo-electric control, Science J., pp. 2-8, March 1966.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Scott, R. N., Myoelectric control of prostheses, Arch. Phys. Med. and Rehab., 47:174-181, March 1966.</td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Scott, R. N., Myo-electric control systems, Reporto. 5, University of New Brunswick Bio-Engineering Institute, December 1965; No. 6, January 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>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Battye, C. K., A. Nightingale, and J. Whillis,The use of myoelectric currents in the operation of prosthesis, J. Bone and Joint Surg., 37B:506, 1955.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Bottomley, A. H., Myoelectric control of poweredprostheses, J. Bone and Joint Surg., 47B:411-415, 1965.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Bottomley, A. H., and T. K. Cowell, An artificialhand controlled by the nerves, New Scientist, pp. 668-671, March 12, 1964.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Bottomley, A. H., A. B. Kinnier Wilson, and A.ightingale, Muscle substitutes and myoelectric control, J. Brit. Institution of Radio Engineers, 26(6), December 1963.</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Brejdo, M. G., V. S. Gurfinkle, A. Ye. Kobrinskii,. A. Sysiu, M. L. Celtin, and A. S. Jakobson, O biolektricskoj sisteme upravlenija, Problemy kybernetiki, Gs. izd., fizikomatematiceskoj, literatury, Moscow, 1959.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Dorcas, D. S., and R. N. Scott, A three-state myo-electric control, Med. and Biol. Eng., 4:367-370, Pergamon Press, 1966.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Horn, G. W., Muscle voltage moves artificial hand,lectronics, October 11, 1963.</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Kobrinskii, A. Ye., Bioelectric control of prostheticdevices, Herald of the Academy of Sciences, USSR, 30(7):58-61, July 1960.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Litton Systems (Canada) Ltd., Research on myo-electric devices, D.I.R. Project No. E-74, DRB 9301-02, Toronto, 1967.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Long, C, and B. Ebskov, Research applications ofmyoelectric control, presented at the 43rd Annual Session of the American Congress of Physical Medicine and Rehabilitation, 1965.</td></tr><tr><td class="clsTextSmall"><b> 66.</b> </td><td class="clsTextSmall">Sherman, E. D., A. L. Lippay, and G. Gingras,Prosthesis given new perspectives by external power, Hospital Management, pp. 44-49, November 1965.</td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Waring, W., and V. L. Nickel, Powered braces withmyoelectric controls, Orthop. and Prosth. Appliance J., pp. 228-230, September 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alter, R., Bioelectric control of prostheses, MITechnical Report 446, Cambridge, Mass., December 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Instructor in Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Mo. Data has estimated the numbers of patients in the United States with presented at combined meeting of the Panel on Control of External Power and the Panel on Upper-Extremity Orthotics of the Subcommittee on Design and Development, Committee on Prosthetics Research and Development, in New York, N.Y., May 15-17, 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>Lojze Vodovnik, D.Sc. </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Engineering, Engineering Design Center, Case Western Reserve University, University Circle, Cleveland, Ohio 44106, and Associate Professor of Electrical Engineering, University of Ljubljana, Yugoslavia.</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>James B. Reswick, Sc.D. </b></td></tr><tr><td class="clsTextSmall">Leonard Case Professor of Engineering and Director of the Engineering Design Center, Case Western Reserve University, University Circle, Cleveland, Ohio 44106.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_02_005/aut67t-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_02_005/aut67-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_02_005/aut67-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_02_005/aut67-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_02_005/aut67-04.jpg Figure 6 http://www.oandplibrary.org/al/images/1967_02_005/aut67-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1967_02_005/aut67-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1967_02_005/aut67-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1967_02_005/aut67-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1967_02_005/aut67-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1967_02_005/aut67-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource External Power in Prosthetics and Orthotics, an Overview Creator An entity primarily responsible for making the resource James B. Reswick, Sc.D. * Lojze Vodovnik, D.Sc. * https://staging.drfop.org/files/original/00aef4cd6df4fe2afbe93e23bb1aa9a0.pdf 27266064d8bfe3c96f4086c7204d1b26 https://staging.drfop.org/files/original/08880a20a3c0f8fd3794a62b5e39233d.jpg 79a06756e4f898cff5eebb111185d355 https://staging.drfop.org/files/original/f314fd85de1bb9acb2edfc3629026582.jpg 38d5c67d49c718680e501e2c20e483ff https://staging.drfop.org/files/original/56dbb5a30ba120dc374233660a6d08f2.jpg 66064d3a55ad5117af2b25623bc9cc92 https://staging.drfop.org/files/original/2d2151c41c8d769207ce1150be49de3c.jpg a9ad2494375193603f1088dc4f80b52f https://staging.drfop.org/files/original/35ce4605762acb542ff3e5cfb0953f88.jpg 338a3e36c40cb57d3a465aa7b51a0fed https://staging.drfop.org/files/original/1a6880facfd5db40696e5d6d3e54f5c7.jpg 9f7281a6ee94e4e07aa0cb3a096b65a9 https://staging.drfop.org/files/original/0cb44f1af50f82e37a10bcf6655eef8f.jpg d39462496db66313910dd49940ae4454 https://staging.drfop.org/files/original/1568f3bda968608839fa654316c6fcdf.jpg 751c90e73f3344c1b5bd104bcd06bcde 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_04_235.pdf Text Any textual data included in the document <h2>Mechanical Comparison of Terminal Devices</h2> <h5>James D. Corin, M.S.&nbsp;<a style="text-decoration: none;">*</a><br />Teresa M. Holley, CP.&nbsp;<a style="text-decoration: none;">*</a><br />Rodney A. Hasler, M.E.&nbsp;<a style="text-decoration: none;">*</a><br />Richard B. Ashman, Ph.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Considerable controversy has developed over the appropriateness of fitting "functional hand" prostheses to juvenile and adolescent amputees. This controversy is further enhanced by the cosmetic advantages of functional hands over the more traditional hook terminal devices. Conversely, experience has shown the hook terminal devices to offer greater functional control. Prosthetists often feel obliged to fit the amputee with a more functional terminal device, while the amputee often wishes to relinquish some function for cosmesis. Because the functional hands available today do not approach the necessary control, and because hooks are so uncosmetic, a significant percentage of upper limb amputees tend not to wear their prosthesis. The fundamental question presented to the prosthetist in fitting an amputee is how much function can be gained with a particular device. If function is defined simply as prehension grip force and grip width, the next question is whether an amputee can fully operate the particular device completely and comfortably.</p> <p>To date, very little objective data has been available on the comparison of terminal devices. Hence, prescription principles on the part of most prosthetists have been somewhat subjective. Quantitative force and excursion are not usually critical in fitting low level amputees; but the strength adolescents, juveniles, and higher level adult amputees can induce, becomes quite variable. The study presented here is an objective comparison of several terminal devices for mechanical function. The measured parameters were prehension grip force, grip width at full open, excursion range, and the excursion force required to fully open the terminal devices.</p> <h3>Methods</h3> <p><i>Test Protocol</i></p> <p>All test data presented here was accomplished on a MTS-858 universal materials testing machine. With this hydraulically powered machine, a piston-like cross-head can be positioned accurately, while loads created on the test specimens are monitored. The degree of sophistication of this machine is not critical to the test protocol. Any testing apparatus can be used as long as displacement and created force can be measured accurately.</p> <p>Two different tests were performed on each terminal device at each of the different tension settings available. The first test will be referred to as the excursion test. Here, the cross head and load cell of the test machine were attached to the cable actuator of the terminal device (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-01.jpg"><b>Fig. 1</b></a>). The terminal device itself was mounted rigidly to the machine base. The result of this test was a plot of excursion of the cable actuator against the tensile force generated in pulling the cable (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-02.jpg"><b>Fig. 2</b></a>). The rate of pull was constant at 4" per minute and, because of this slow rate, loading was considered to be static. The plots of excursion force verses excursion of the cable actuator were all of the same general form. <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg"><b>Fig. 3</b></a> shows generalized force versus excursion plot. To present the actual loading curves for each device tested would have taken considerable space, therefore, for each device the only parameters that were tabulated are "A," "B," "C," "D," and "E." The portion of the curve up to "A," "C," represents the pre-loading of the terminal device. Excursion of the cable up to this point does not significantly move the appendages of the terminal device and is primarily due to slack in the system. The pre-load force "C," is the force necessary to overcome preloading of the spring or bands. The force constant "D," of a particular terminal device is the slope of the loading curve between the end of preloading and full open excursion of the cable. The full open excursion of the cable actuator is the distance "B," while the force required to fully open the device is labeled "E." It should be noted that with the five parameters, an estimation of the excursion-load curve of a particular device can be reconstructed. It should also be noted that the tabulated excursion parameters were measured by pulling the terminal devices open. If one was to continue to plot force versus excursion while the device was allowed to close, one would find much lower forces for a given excursion. This hysterisis in the loading curve is due primarily to friction. The loading curves are presented, rather than the unloading curves, because this is the manner in which the devices are operated.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-01.jpg"><strong>Figure 1. A 2.5" U.N.B. STEEPER set up for excursion testing on the MTS-858 universal machine.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-02.jpg"><strong>Figure 2. Experimental plot of excursion force vs. excursion travel on a 2.5" U.N.B. STEEPER terminal device. Notice that at 0.45" the characteristics of the curve changes. This is the point (A,C) at which the hand just begins to open.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg"><strong>Figure 3. Generalized version of excursion force vs. excursion with parameters indicated.</strong></a><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg"><strong>A-Pre-load excursion (inches)</strong></a><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg"><strong>B-Full opening excursion (inches)</strong></a><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg"><strong>C-Pre-loading force (lb.)</strong></a><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg"><strong>D-Force constant in loading (lb./in.)</strong></a><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg"><strong>E-Total excursion force at full open (lb.)</strong></a><br /> <p>The second test performed was to assess the prehension gripping forces that are created with each device. With the hand in a horizontal position, the base of the test machine was attached to the thumb, or one hook half, with a cable. The phalanges, or other hook half, were attached to the cross head and load cell of the test machine via a cable (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-04.jpg"><b>Fig. 4</b></a>). The prosthesis was started in the full open position. A plot of grip force verses grip width was created by allowing the device to close at a constant rate of 4" per minute (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-05.jpg"><b>Fig. 5</b></a>). From these plots, the parameters "G," "H," and "I," were calculated for use with the generalized graph (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg"><b>Fig. 6</b></a>). It should be noted that the plotting direction of these curves was opposite to those discussed in Figures 2 and 3. Since the hand was started full open, maximum prehension grip force "I" and the full open grip width "F" are plotted first. The force plotted here represents the force created by the device upon its own closing. The force necessary to pull the appendages open would be greater than this force, due to friction. In <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg"><b>Fig. 6</b></a>, "G" is referred to as the initial prehension force. This is the force created just prior to the grip closing completely. Also, the prehension grip force constant, "H" is the slope of the unloading curve between fully open and closed positions of the terminal device. With the parameters "F," "G," "H," and "I," an approximate reproduction of prehension grip force verses grip width can be created.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-04.jpg"><strong>Figure 4. A 2.5" U.N.B. STEEPER set up for prehension grip testing on the MTS-858 universal machine.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-05.jpg"><strong>Figure 5. Experimental plot of prehension grip force vs. grip width for a 2.5" U.N.B. STEEPER. This plot was started with the hand full open, a 2.25" grip width, and 2.5 lb. grip force. The steep slope at approximately 0.4" is where the inner locking mechanism activates. The hand is essentially closed at this time.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg"><strong>Figure 6. Generalized version of prehension grip force vs. grip width, with parameters listed.</strong></a><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg"><strong>F-Full opening grip width (inches)</strong></a><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg"><strong>G-Initial prehension grip force (lb.)</strong></a><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg"><strong>H-Prehension grip force constant (lb./in.)</strong></a><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">I-Total prehension grip force (lb.)</a><br /></strong><br /> <h3>Results</h3> <p>Table I lists the measured parameters derived from the two tests of 33 terminal devices. Of the 12 parameters listed, the first nine were described previously in the test protocol section. The J-th parameter is the number of different devices tested of each type. When more than one device was tested of a particular type, results were averaged. The criteria for testing most of the devices was based on local availability. The ratio of maximum prehension grip force to excursion force is often called the efficiency of a terminal device. The K-th parameter is the measured efficiency. The last parameter, listed as "L," is that of the work required to open the terminal device by pulling the actuator cable. Work is defined as the excursion force times excursion length and is measured by calculating the area under the force-excursion curve. This parameter can be estimated to reasonable accuracy by considering the area under the generalized force-excursion curve (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg"><b>Fig. 3</b></a>). The work, or area under this curve can be calculated as:</p> <p>work = (1/2)*(A*C) + (B-A)*C + (1/2)*(E-C)*(B-A)</p> <p class="clsTextCaption"><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-08.jpg"><strong>Table I. Values measured from hook and hand type terminal devices.</strong></a></p> <h3>Description of Terminal Devices Tested</h3> <p>The following list of terminal devices corresponds to the device number of Table I.</p> <ol> <li> <p>CAPP regular spring, center pull, nylon cabled</p> </li> <li> <p>CAPP soft spring, center pull, nylon cabled</p> </li> <li> <p>HOSMER SSS-555, 1 band, steel cabled</p> </li> <li> <p>HOSMER SSS-555, 2 bands, steel cabled</p> </li> <li> <p>HOSMER SSS-555, 3 bands, steel cabled</p> </li> <li> <p>HOSMER 10P, 1 band, steel cabled</p> </li> <li> <p>HOSMER 10P, 2 bands, steel cabled</p> </li> <li> <p>HOSMER 10P, 3 bands, steel cabled</p> </li> <li> <p>HOSMER 10X, 1 band, steel cabled</p> </li> <li> <p>HOSMER 10X, 2 bands, steel cabled</p> </li> <li> <p>HOSMER 10X, 3 bands, steel cabled</p> </li> <li> <p>HOSMER 12P, 1 band, steel cabled</p> </li> <li> <p>HOSMER 12P, 2 bands, steel cabled</p> </li> <li> <p>HOSMER 88X, 1 band, steel cabled</p> </li> <li> <p>HOSMER 88X, 2 bands, steel cabled</p> </li> <li> <p>HOSMER 88X, 3 bands, steel cabled</p> </li> <li> <p>HOSMER 99X, 1 band, steel cabled</p> </li> <li> <p>HOSMER 99X, 2 bands, steel cabled</p> </li> <li> <p>HOSMER 99X, 3 bands, steel cabled</p> </li> <li> <p>U.N.B. STEEPER, 2.0" w/glove, nylon pull</p> </li> <li> <p>U.N.B. STEEPER, 2.25" w/glove, tension #1 (softest), nylon pull</p> </li> <li> <p>U.N.B. STEEPER, 2.25" w/glove, tension #2, nylon pull</p> </li> <li> <p>U.N.B. STEEPER, 2.25" w/glove, tension #3, nylon pull</p> </li> <li> <p>U.N.B. STEEPER, 2.50" w/glove, steel cabled</p> </li> <li> <p>U.N.B. STEEPER, 2.75" w/glove, steel cabled</p> </li> <li> <p>HOSMER SIERRA, gloved, steel cabled</p> </li> <li> <p>HOSMER ROBINS-AIDS, soft-mechanical, gloved, steel cabled</p> </li> <li> <p>HOSMER BECKER-IMPERIAL, gloved, steel cabled</p> </li> <li> <p>HOSMER, #201 gloved, steel cabled</p> </li> <li> <p>HOSMER, #301 gloved, steel cabled</p> </li> <li> <p>HOSMER, #401 gloved, steel cabled</p> </li> <li> <p>OTTO-BOCK, 6.75", gloved, steel cabled</p> </li> <li> <p>OTTO-BOCK, 7.75" gloved, steel cabled</p> </li> </ol> <h3>Discussion</h3> <p>General trends in the measured parameters become evident on closer examination of <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-08.jpg"><b>Table I</b></a>. Organization of these tables is such that devices with numbers less than 20 were hook type terminal devices, while those with numbers 20 and over were functional hands. Preload excursion, parameter "A," can be thought of as the excursion necessary to take up slack in the system. Some functional hand units require as much as 1/2" of excursion before any opening occurs. Full opening excursion, parameter "B," and the total excursion force necessary to open the terminal device, parameter "E," are self explanatory. If an amputee cannot generate either the excursion or the necessary force, a different terminal device should be considered. It should be noted that children usually have trouble operating a device with an excursion force greater than ten pounds.</p> <p>The pre-loading force "C" and the force constant "D" are useful parameters in assessing the function of a terminal device when the amputee can marginally create the forces and excursion necessary for full opening. In marginal cases, large pre-loading forces will limit the function of a device. For example, although the UCLA CAPP, device number one, only takes eight pounds to open fully, a patient must be able to create at least 4.5 pounds to start the device in motion. Without regard for the pre-load, one might incorrectly think that four pounds of excursion force would open the device halfway. A terminal device with a high pre-opening excursion (more prominent in hands) could be used on an amputee with good strength initially, but might have weakness toward the end of the excursion range. This is particularly true for higher levels of amputation which rely more on scapular abduction and less humeral flexion. Another important factor to note is the grip performance of the terminal devices. Here the full open grip width "F" and maximum prehension grip force "I" are the important notable values.</p> <p>The parameter that includes both grip and excursion is "K," the ratio of maximum grip force to excursion force. This term was measured to be greater than 0.40 for all of the hook type devices examined, and less than 0.40 for the functional hands. Some hooks revealed efficiencies as high as 0.70. It should be noted that the ratio of maximum grip force to excursion force can be calculated from the geometry of a particular device and is independent of the spring or rubber band tension. The measured results show this to be the case, in that parameter "K" did not significantly vary when spring tensions or the number of rubber bands were changed. Measured efficiencies for the functional hands were, in general, less than hook terminal devices. This consistent discrepancy is due largely to friction in the mechanics of the internal hinges within the hands in addition to glove attachments.</p> <p>The final parameter "L" which is the total amount of work required to operate the terminal device is also of extreme importance. Hands compare more favorably to hooks because on a general basis hands require less excursion than hooks for full opening. This is an important factor for children as well as higher levels of amputation, because of less available excursion.</p> <p>Plotting maximum prehension grip force against total excursion force, the relative performance between hooks and hands can be compared (<b>Fig. 7</b>). For clarity, the hand device numbers were plotted with a preceding dash. For any particular excursion force, it can be easily seen that grip force is greater for the hook devices. The devices 7, 8, 10, 11, and 19, were particularly good performers, which required excursion forces less than 15 pounds, and created prehension grip forces greater than seven pounds. In light of this comparison, it should be challenging for terminal device designers to come up with functional hand devices that approach the efficiencies of hooks.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-07.jpg">Figure 7. Graph of prehension grip force vs. excursion force for all terminal devices. Note that all hand terminal devices have a preceding dash.</a><br /></strong><br /> <h3>Conclusions</h3> <p>This comparison of terminal devices is only preliminary in that many more terminal devices have yet to be analyzed. Furthermore, the number of devices tested was very small. In spite of these limitations, the best protocol allowing comparisons between the different terminal devices was felt to be objective and reflect the relative performance of different devices.</p> <h3>Acknowledgments</h3> <p>This research was funded by the King Foundation, Dallas, Texas and the Research Fund of Texas Scottish Rite Hospital for Crippled Children.</p> <p>We wish to also thank Hosmer Dorrance and Liberty Mutual for the donation of their terminal devices.</p> <p><em><b>*Richard B. Ashman, Ph.D. </b> Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219.</em></p> <p><em><b>*Rodney A. Hasler, M.E. </b> Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219.</em></p> <p><em><b>*Teresa M. Holley, CP. </b> Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219.</em></p> <p><em><b>*James D. Corin, M.S. </b> Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219.<br /><br /><br /></em></p> Page Number(s) 235 - 244 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-01.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-05.jpg Figure 7 TABLE I http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-08.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-07.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-02.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.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 Mechanical Comparison of Terminal Devices Creator An entity primarily responsible for making the resource James D. Corin, M.S. * Teresa M. Holley, CP. * Rodney A. Hasler, M.E. * Richard B. Ashman, Ph.D. * https://staging.drfop.org/files/original/b49a7d60a8722dcfdaf97025e92ca74f.pdf 5e63ea89230fc95a4cad21e843a948ef 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_001.pdf Text Any textual data included in the document <h2>The Canons of Ethics and Professionalism</h2> <h5>James Fenton, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Every society must have a set of rules or laws by which it governs itself. Without laws, society does not exist. The American Board for Certification in Orthotics and Prosthetics, Inc. is a society of sorts. It has a governing body, it has several different departments (committees), with department heads (committee chairmen), and it has citizens (certifees). It has laws by which it governs. It also has a department of justice in the form of the character and fitness committee. The one thing that our society does not have is a police department.</p> <p>If there is no police department, how effective can our society be? The answer to that question is at the very heart of the word professionalism. There are several dictionary definitions of professionalism. However, I have a very strong inner feeling that professionalism is not defined by words alone. I believe that professionalism in our society is a commitment to do the very best job that you are capable of doing on each and every case. This is not to say that you have to live up to any individual standard, but you must live up to the standards of practice in your community. If you're capable of doing better, then you should commit yourself to that level of excellence to which you're capable. I also believe that professionalism involves a commitment to your community: being an active participant in community affairs, being cognizant of the needs of the underprivileged of your community, and doing your fair share to alleviate their suffering.</p> <p>Professionalism demands that a practitioner keep current of the knowledge of his profession by continued reading of technical manuscripts and attendance at seminars.</p> <p>Professionalism is wanting to help in the day-to-day activities of the society by committee membership, by helping in the examination procedure, and by doing site evaluations.</p> <p>All of these are ways in which I believe we can define professionalism in an idealistic way. The Canons of Ethics of the American Board of Certification does not really attempt to set standards of professionalism but it does set standards of conduct that, if breached, can lead to punitive action being taken.</p> <p>Each and every certifee has received at least one copy of the Canons and if we all try to live up to the standards set forth in them, our patients will receive a better quality of care.</p> <p>These standards are directed to the way in which we conduct ourselves in the day-to-day management of our patients as well as the manner in which we conduct our businesses and ourselves in general.</p> <p>Rather than being idealistic, these standards are real. They were always meant to be the absolute minimum that our profession expects from us. Anyone who cannot live up to these standards should not receive the respect and recognition of his peers or the community.</p> <em><b>*James Fenton, CPO </b> President, American Board for Certification in Orthotics and Prosthetics, Inc. Fenton Brace and Limb Co., Inc. Miami, Florida<br /><br /><br /></em> Page Number(s) 1 - 1 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 The Canons of Ethics and Professionalism Creator An entity primarily responsible for making the resource James Fenton, CPO * https://staging.drfop.org/files/original/c8a6de84d03266c8bc9f6d6fbbd73688.pdf d1910921582f687b0864172e72031731 https://staging.drfop.org/files/original/1485e4d578f1b428ab1272868a562fc9.jpg 7f8190e7460853fcb6038029386ab1b8 https://staging.drfop.org/files/original/50626bc64a6c233af5c84abb7e6df06f.jpg cc5e165fe7160341865c6791ffbdf829 https://staging.drfop.org/files/original/a164e3f6134e5ced2d7e9cbcdad0579e.jpg 5901261c3142163ed97b63077e119af1 https://staging.drfop.org/files/original/3eb28fac21b5adb765e964436bd2f075.jpg aa6fff355b3e7a00e8413bfd9665f54c https://staging.drfop.org/files/original/f0969d5ad22c3d7d3386e1840992de54.jpg 40d2b29106fe4f7b4648d916a305851e https://staging.drfop.org/files/original/b8a15397236070a1928f734b01eb7ada.jpg aa0f0ea19415d3b62b627c9f367e717a https://staging.drfop.org/files/original/cb45f9034e87770a17262895139a95e2.jpg 0a2949048e4a5d562595657a3d9747e4 https://staging.drfop.org/files/original/ddfff8a45792bdbaff35b784cf009351.jpg ba30758487795821efba0587640fe3a8 https://staging.drfop.org/files/original/07ffd06b6d225ed567e2848bba985e83.jpg e3b152af1db7fd6c4894d6db133288ad https://staging.drfop.org/files/original/97f84bc7e3ced60be18d3ffe0df9cdca.jpg 2040d3bd5e41d0d2959bed152fa4c1cc https://staging.drfop.org/files/original/e57ff3235c3552832ed937f2e20f0f02.jpg 866160e477f752c327061c13dc0be413 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_004.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 4 - 13 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/1965_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Patellar-Tendon-Bearing Prosthesis for Below-Knee Amputees, a Review of Technique and Criteria</h2> <h5>James Foort, M.A.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p><i>At a recent meeting of the Workshop Panel on Lower-Extremity Fitting <a></a>, which is sponsored by the Subcommittee on Design and Development of the Committee on Prosthetics Research and Development, there was prolonged discussion of below-knee prostheses. Questions were raised concerning the adequacy of the PTB design for many patients, especially patients who were longtime users of the joint-corset, below-knee limb. The view was expressed that the expenditures of time and money in achieving a successful PTB fit did not justify the selection of the PTB prosthesis or a conversion to it, and that the use of a joint-corset prosthesis initially would shorten the prosthetic restoration process for most patients.</i></p> <p><i>It was recognized that the private practitioner is often forced to elect the simplest and least expensive procedure for his patient. Institutional facilities, on the other hand, can take more of the patient's time, without having the often-required succession of visits reflected in direct cost to the patient or to the sponsor. Yet, the panel was of the opinion that some prosthetists probably are still committing errors in fitting PTB prostheses, resulting in deterioration of the stump, excessive shrinkage, or edema. Moreover, criteria for use of the joint-corset prosthesis are still misunderstood.</i></p> <p><i>Fortunately, the Workshop Panel on Lower-Extremity Fitting had the benefit of the counsel of James Foort, formerly of the University of California (Berkeley) but now of the Prosthetics-Orthotics Research and Development Unit at Manitoba Rehabilitation Hospital, Winnipeg, Canada Mr. Fool spoke at length on the PTB design and then agreed to put his comments in writing for the benefit of clinicians the world over. Presented below is his helpful review of the subject.</i></p> <p><i>We are indeed indebted to Mr. Foort for his contribution. The clear expression of certain axioms will, hopefully, solve some of the problems experienced in the fitting of this very important prosthetic appliance.</i></p> <p><i>Anthony Staros <a style="text-decoration:none;">*</a> - Chairman, Workshop Panel on Lower-Extremity Fitting</i></p> <p>The patellar-tendon-bearing (PTB) prosthesis has been in use for more than five years. It was fully discussed in the June 1962 issue of <i>Artificial Limbs <a></a>. </i>Although experience suggests that approximately 90 per cent of all below-knee amputees can benefit from the use of the PTB prosthesis, a substantial number of prosthetists continue to fit joint-corset prostheses to a large proportion of their patients. Apparently, these prosthetists and their clients have found that maintenance and replacement costs outweighed the fabrication and functional advantages of PTB prostheses. Difficulties developing from the use of the PTB prosthesis are said to be edema, stump breakdown, and stump shrinkage. With these difficulties in mind, the purpose of this review is to examine the fitting technique for PTB's, emphasizing factors to be considered in avoiding or overcoming the difficulties and outlining criteria for use of joint-corset prostheses.</p> <h3>PTB Fitting Technique</h3> <p>The most common error made with a PTB socket is an excessively tight fit in the popliteal area of the stump. Too large a bulge in the popliteal area can be constrictive, affecting circulation, causing edema, and in turn leading to deterioration of the stump end. <i>Posterior pressure needed to balance the posteriorly directed force against the patellar tendon by the weight-bearing bar of the socket must be provided by the posterior and posteromedial aspects of the tibial condyles and the overlying tendonous structures, as well as by the popliteal area of the stump. (First factor.)</i></p> <p>Emphasis on the patellar tendon as a weight-bearing structure has contributed to constriction of the stump in the popliteal area. <i>The posterior and posteromedial aspects of the tibial condyles and the overlying tendonous structures are important weight-bearing surfaces of the stump. (Second factor.)</i></p> <p>In order to make the area for pressure against the popliteal surface of the stump larger, many prosthetists have extended the back of the socket up into the space between the hamstring tendons, cutting grooves to relieve the tendons during knee flexion. This design can contribute to constriction of circulation in the popliteal area when the amputee stands or sits. <i>The back brim of the socket should be formed into a broad, flared surface against which the hamstring tendons can rest when the amputee sits. (Third factor.) </i>So shaped, the back brim of the socket can be made sufficiently high to provide the large support area needed to minimize pressure while holding the patellar tendon in position on the weight-bearing bar and still ensure sitting comfort (<b>Fig. 1</b>). When the back brim is made higher, as for a short stump, the flare also lifts the stump out of the socket and supports it when the amputee sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Two views of a temporary plastic PTB socket showing the flared posterior brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Edema is also caused by constriction at the mid-stump level, and such constriction can result from the cumulative effects of modifying the plaster stump model. The least desirable modification is that made in the lateral fibula area. This modification is meant to help stabilize the stump mediolaterally in the socket, but the fibula is a poor structure against which to stabilize. <i>To achieve mediolateral stability of the stump in the socket, the socket should fit securely against either side of the tibial crest and against the medial and lateral surfaces of the knee joint. (Fourth factor.) </i>Mediolateral stability is a problem only if the foot is set in or out too far. <i>The socket should be placed over the foot so that there is little tendency for the prosthesis to tilt medially or laterally on the slump as the amputee walks. (Fifth factor)</i></p> <p>Although breakdown at the end of the stump is sometimes attributed to pressure on the end, a more likely cause is constriction at the mid-stump level. Tightness around the middle third of the stump gives the amputee the feeling that the end is contacting the bottom of the socket or that the tissues are being pulled up against the end of the bone. There are, however, circumstances in which end pressure is damaging and painful. <i>The socket should support distal tissues with sufficient pressure to aid venous and lymphatic return without pressing against the bone ends. (Sixth factor.) </i>If the stump has been amputated through cancellous bone, however, the bone end may be an important weight-bearing surface (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A very short stump which is capable of bearing considerable weight on the end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Frequently, the anterodistal tibia area is painful because of the thin cutaneous covering; it is also vulnerable to excessive pressure because of poor circulation. Hollowing out the socket in this region usually does not give the expected relief. Foot alignment, as viewed from the side, and a stiff heel action can be the causes of difficulty. <i>The foot should be pliant and aligned to give a smooth rolling action as the amputee walks, as though the foot were a segment of a wheel run. (Seventh factor.) </i>If, so to speak, the "hub of the wheel" is too far back, the end of the stump is forced forward painfully against the socket as the amputee attempts to control the prosthesis at heel contact by active extension of the knee. This problem is especially pronounced with recent amputees who have not become skilled at regulating the forces against the stump by appropriate coordination of knee and body actions. A softer heel wedge, increased plantar-flexion of the foot (or extension of the socket), or moving the foot forward (least likely) can reduce discomfort at the anterodistal end of the stump resulting from these causes.</p> <p>General tightness is sometimes considered a source of trouble-and may be initially. But a socket should fit snugly, especially for a recent amputee or one who has not worn a PTB prosthesis before. The newly fitted amputee may have to remove the insert from the socket shell, put it on the stump, powder it, and force it back into the socket shell, even when he is wearing only a cast sock over the stump. One should be sure, however, that the socket bears weight evenly on the main support areas and that it also supports the distal tissues. If the socket does provide proper support, the imprint of the stump sock on the skin will be even in appearance, with the important support areas on the stump somewhat reddened. During the early phases of walking, the amputee should not use the prosthesis excessively. Soon his stump will become accommodated, and then he will be able to use a wool sock. <i>Tissues which are snugly pressed in a socket will shrink until pressures are reduced to suitable levels. (Eighth factor.) </i>Sometimes when the stump is fitted snugly, a vacuum develops during the swing phase and has a tendency to produce edema. To correct this problem, holes -sufficiently large to prevent hissing noises- may be drilled into the prosthesis, or the suspension system should be made more effective.</p> <p>All these factors must be kept in mind when an impression is made over the stump and the plaster model of the stump is shaped for use as a socket mold.</p> <h4>Taking The Plaster Impression</h4> <p>It is not easy to outline a specific procedure for taking a plaster cast of an amputee's stump. Stumps vary in the amount and resiliency of tissue covering the skeletal frame to be fitted. Moreover, the size, strength, and shape of prosthetists' hands and their sense of pressure-all unique to the individual-vary considerably. But if the impression is made tightly over the weight-bearing areas of the stump, these areas will be better defined than if the cast is made looser, regardless of these other differences.</p> <ol> <li>The impression should be started at the knee. The plaster-of-Paris bandage is wrapped tight, starting at the superior edge of the patella. As each pass is made around the knee, the plaster is formed up higher on either side of the knee by guiding it upward with the fingers of the left hand (<b>Fig. 3</b>). At the back, the cast should cover the knee crease by about two finger widths. Wrapping continues in this manner down to the level of the tibial tubercle.</li><li>Next, an effort must be made to obtain an accurate imprint of the medial flare of the tibia (<b>Fig. 4</b>). The plaster-of-Paris bandage is pulled up against the medial flare with even tension, and each turn is anchored to the lateral surface of the knee. Thus tissue tension is prevented from driving the plaster away from this important support area.</li><li>The rest of the stump is wrapped with less tension.</li><li>The plaster is smoothed over the entire stump and worked around the bony areas. As the plaster is worked, the stump is palpated to determine how it should be held for shaping.</li><li>Just before the plaster begins to set, the thumbtips are positioned on either side of the patellar tendon, close to its edges, so that the plaster-of-Paris bandage is pulled in against the tendon as pressure is applied. This position of the thumbs precludes intrusion into the spaces under the edge of the patella medially and laterally. The fingers are placed around the media] flare of the tibia and held flat against the back of the stump. It is important <i>not </i>to push into the popliteal space with the fingertips. Where the fingers encircle the lateral side of the stump, they are not in contact, Across the back of the stump, they are straight and exert pressure against the posterior aspects of the lateral tibial condyle and the popliteal area. Very little force should be used. The cast has been wrapped tight at the top to obtain an imprint of the stump close to the required shape, and the cast is held to ensure that the required support areas will be well defined when it sets (<b>Fig. 5</b>).</li><li>When the plaster impression can hold its shape, the thumbs are used to obtain a clear imprint of the anterior crest of the tibia by moderately caving in the semi-set plaster along a 3/4-in. strip on each side of the tibia to within an inch of the end (<b>Fig. 6</b>). The impression will now be wedge-shaped in front. Just before the plaster sets firmly, the hands are returned to the holding position, and the cast is held until it can be taken from the stump. This holding-squeezing action flattens the back and ensures retention of the required anteroposterior width.</li></ol> <p><b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Starting the plaster impression and guiding the plaster upward along the sides of the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Pulling the plaster-of-Paris bandage against the medial flare of the tibia to obtain an accurate impression of this important support area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Holding the cast with moderate pressure and with the fingers flat across the back. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Caving in the plaster on either side of the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Modifying The Model</h4> <p>It is desirable to modify the plaster stump model as soon as possible after the impression is taken, while the recollection of details is still strong.</p> <ol> <li>A groove is carved in the patellar-tendon ridge with a 1/2-in. self-cleaning rasp to a depth of about 1/2 in. The groove is made halfway between the inferior edge of the patella and the tibial tubercle. The groove should be about 3/4-in. wide between the upper and lower edge, and the edges should be smoothly curved toward the patella and toward the tibial tubercle (see <b>Fig. 7</b>).</li><li>Modifications on either side of the crest of the tibia are made in the usual way. <a></a></li><li>The medial flare area is smoothed first with a curved self-cleaning rasp to make the flare blend in with lower sections of the model and then with wire screening, which should be swept around the natural contours of the flare extending into the posterior area and even over the hamstring tendons (see <b>Fig. 8</b>).</li><li>The back of the model is flattened and smoothed over the popliteal area; care must be taken <i>not </i>to indent this area.</li><li>The flattened surface at the back of the model is extended downward and blended in with the more distal parts of the model by shaving off small amounts of plaster.</li><li>The model is smoothed on either side of the knee. If necessary, material is carved away to reduce the model to the measured width of the knee. This area is important, because it contributes to stabilization of the stump in the socket. The lateral side of the socket stabilizes the medial flare of the tibia against its weight-bearing surface in the socket. Sometimes a very slender amputee will find that when he sits, the wide part of his femoral condyles binds against the socket at the top. To correct this, the socket should be heated in that area and forced outward to give relief.</li><li>Plaster is added to the model in bony areas such as the head of the fibula, the crest of the tibia (especially toward the distal end), and the ends of the fibula and tibia. If the crests of the tibial condyles are prominent, extra space should be provided for them in the socket. They and the tibial tubercle seldom present problems if the patellar-tendon shelf has the proper dimensions, because then the socket is forced away from those prominences.</li><li>Before constructing the posterior flare on the plaster model, it is necessary to mark the socket trim lines on the model. First, a line is drawn circumscribing the model at the mid-patellar-tendon level and perpendicular to the long axis of the model. This line defines the back brim for the average type of stump. <i>A </i>shorter stump will be fitted higher at the back, depending on how short it is. Next, a line drawn through the middle of the patella and upward on either side gives the shape of the medial and lateral extensions of the socket. On the lateral side, the line will pass straight down through the posterolateral corner of the model to cross the posterior reference line. The corner can be rounded so that the lines join with a 1/2-in. radius. On the medial side, the trim line should be further in from the side so that the posteromedial curve is retained in the socket to help provide posterior support to the stump. This is possible because the medial hamstring tendons are toward the midline of the stump. After the model has been secured in a vise with the popliteal area up and the long axis of the model horizontal, plaster is poured above the trim line at the back (<b>Fig. 9</b>). When the plaster has set slightly, a 3/4-in. flare is formed by smoothing the plaster with wet fingers and thumb. It is seldom necessary to adjust the fit of the flare for relief of the low-set medial hamstring tendons, even though the socket curves around to the back on that side, because the flare allows the tendons to support considerable pressure comfortably. (For a medial view of the modified model, see <b>Fig. 10</b>.)</li></ol> <p><b>Fig. 7</b>, <b>Fig. 8</b>, <b>Fig. 9</b>, <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The patellar-tenclon groove. A, Carving the groove in the patellar-tendon ridge on the plaster model; B, the finished form of the groove. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The finished form of the medial flare area on the plaster model. A, An anterior view; B, a posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Marking and forming the posterior flare on the plaster model, which has been secured in a vise with the popliteal area up. Top, the line circumscribing the model at mid-patellar-tendon level defines the level of the back brim of the socket. Center, plaster is poured onto the model above the trim line and allowed to set slightly. Bottom, wet fingers and thumb are used to form the posterior flare. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Medial view of the modified model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Stump Shrinkage</h4> <p>Even the seasoned stump can shrink. To the prosthetist this is a problem of economic significance, because his guarantee provides for repair or replacement. The worst of it is that when the socket of a PTB prosthesis is no longer satisfactory and must be replaced, there is little the prosthetist can do but rebuild the prosthesis completely. The least that can be done is to lay in material between the socket shell and the insert or to cast RTV Silastic resin under the stump. This sometimes affects alignment, which then must be adjusted. If the weight-bearing area can be modified easily, it is good practice to take a new cast of the stump, prepare a new model, and make a new insert over it. The new insert will support the stump distally, while the modified brim area gives satisfactory weight support and stabilization.</p> <p>Actually, what is needed is a different approach to the provision of prostheses. The recent amputee should be provided with a well-fitted limb to which a series of sockets can be easily attached until the stump has become stable. Then a final fitting can be made. At present, the permanent limb is often fitted as soon as the shrinker bandage treatment has been completed. The forces imposed on the stump by the prosthesis are much greater than can be developed by the shrinker bandage. Also, the socket forces are different in location. In addition to the loss of control and harmful forces that develop between the stump and the prosthesis, the reduced bulk of distal tissues leaves them unsupported and prone to edema.</p> <p>When the stump is fitted tightly, as recommended here, the initial discomfort will diminish as the stump shrinks and molds into shape. Finally, the amputee will be able to don his prosthesis while wearing a wool stump sock.</p> <h4>Perspiration and Maceration of the Stump</h4> <p>There have always been amputees who have suffered maceration of the stump end as a result of accumulation of perspiration in their sockets. Contributing to the heat in a PTB prosthesis are the rubber-leather insert, the thick plastic shell and surrounding materials, the closed end of the socket, and the tightness of fit. Ventilation is poor, even when holes are drilled through the walls of the socket. Use of a valve system, such as that designed at the Navy Prosthetics Research Laboratory, which allows air to enter slowly and forces it to escape up through the sock, could be helpful provided noise is avoided; and porous plastic laminates, such as have been developed at the Army Medical Biomechanical Research Laboratory, may be of some use as a solution to the problem. The most likely immediate solution is to make the socket thin, somewhat pliable, perforated, and without an insert. Such a socket must be titled with care, since there is no soft insert to provide a margin for error and to permit easy modification of the socket. A socket constructed of four to six layers of stockinet laminated with two turns of glass-cloth covering from the top to the tibial tubercle will serve. The socket, supported in a plastic receptacle (<b>Fig. 11</b>), can easily be replaced without seriously affecting the entire prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Temporary plastic socket and the receptacle into which it fits. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Use of Joint-Corset Prostheses</h3> <p>Under ideal conditions, the percentage of amputees who use joint-corset prostheses might be as low as 10 per cent. There is no doubt that the joint-corset system can make up for deficiencies in the fit of the socket and thereby serve as a safety factor when the proper lit of a PTB prosthesis is not achieved or maintained. Hut there are definite criteria which can be used for the prescription of a joint-corset prosthesis.</p> <p>Sometimes the amputee's occupatjon requires him to use his prosthesis under heavy-duty conditions; he may be required to pry up or lift heavy objects. <i>When the amputee must place a force on his prosthesis which is considerably greater than the weight of his body, a joint-corset prosthesis aids him by permitting part of the weight to be borne on the thigh. (First criterion </i>) The joint-corset system is especially effective when the knee is slightly flexed so that forces are borne by the back of the thigh and are transmitted to the shank through the side joints. When the thrust on the prosthesis is along its axis, the amputee can prepare for it by temporarily tightening his thigh corset.</p> <p>Many amputees kneel, climb ladders, or climb stairs frequently. Such activities may be especially difficult or troublesome to the bilateral amputee because of rotation of the PTB prosthesis on the stump. <i>The joint-corset system prevents the prosthesis from rotating about the amputated leg when the joints are flexed. (Second criterion.)</i></p> <p>There is the rare amputee whose knee is unstable, or whose musculature is so weak that the joint-corset system is required. <i>The joint-corset system can stabilize an unstable knee against extreme mediolateral motions; against dislocations; and, when a back-check is used, against hyperextension of the knee. (Third criterion.)</i></p> <p>For the amputee with a stable knee, however, the corset is functionally limited as a mediolateral stabilizer because of the thinness of the joints, the fleshy nature of the thigh, and the pliability of the leather corset. Only if the amputee also bears weight on the corset", or has an extremely atrophied thigh against which he laces the corset tightly, or the corset extends to the peroneal level with cross braces between the side joints, will the corset be of much value as a mediolateral stabilizer.</p> <p>Also rare are amputees who cannot bear weight effectively either on the stump or through the femur. <i>An amputee who cannot bear weight on the stump should be fitted with a quadrilateral ischial-gluteal weight-bearing support and have straps connecting the thigh to the side joints above the knee for control of flexion and extension and for suspension of the prosthesis. (Fourth criterion.)</i></p> <p>Sometimes an amputee is mentally retarded or senile. In such an event, especially if there are no qualified helpers to ensure that the prosthesis is donned correctly, the joint-corset system should be used. <i>The joint-corset system is an aid in ensuring that a prosthesis is correctly placed on the amputated limb when the amputee's judgment is questionable. (Fifth criterion.)</i></p> <p>A problem often faced by the prosthetist fitting a PTB prosthesis to an experienced wearer of a joint-corset prosthesis is that the amputee is not prepared to make the change, either because he doubts that he can do so successfully or easily, or because he has a definite bias toward the joint-corset prosthesis. <i>The joint-corset system should be used when there are definite psychological pressures favoring it. (Sixth criterion.)</i></p> <h3>Conclusions</h3> <p>Probably many prosthetists who fit the PTB prosthesis successfully have discovered for themselves, or have learned from previous experience with other prostheses, how to deviate from established procedures. For those who have difficulties, this review may be of assistance. But it may be necessary to have those who are successful demonstrate to those who are not. Short-term or immediate success should not mislead those who are trying to establish improvements. Often it is only after a year or so that results can be judged. Meanwhile, encouragement should be given to those who seek to develop devices and techniques which will eliminate as many as possible of the craft-oriented tasks needed to fit amputees, thereby increasing reliability and uniformity.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, June 1962.</li> <li>National Academy of Sciences-National Research Council, Committee on Prosthetics Research and Development, <i>Report of third workshop panel on lower-extremity fitting, November 4-6, 1964.</i></li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-bearing below-knee prosthesis, </i>Biomechanics Laboratory, University of California (Berkeley and San Francisco), 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California (Berkeley and San Francisco), 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs, June 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Director, Veterans Administration Prosthetics Center, 252 Seventh Avenue, New York, N. Y. 10001.</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">National Academy of Sciences-National Research Council, Committee on Prosthetics Research and Development, Report of third workshop panel on lower-extremity fitting, November 4-6, 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>James Foort, M.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Technical Director, Prosthetics-Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, 800 Sherbrook St., Winnipeg 2, Man.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Patellar-Tendon-Bearing Prosthesis for Below-Knee Amputees, a Review of Technique and Criteria Creator An entity primarily responsible for making the resource James Foort, M.A.Sc. * https://staging.drfop.org/files/original/897efa93c8f0f30a250eccc724813589.pdf e53c2e6eef7da7fdb79521021433f7d8 https://staging.drfop.org/files/original/c6c0a9c17de4d27109310814707b7ea9.jpg a92870c95ef82139b0b52a743706a5d4 https://staging.drfop.org/files/original/29c0d4894d9c12cab8e7e6de799c2eed.jpg 5aae8022f80eabcc317cdfc744911e6b https://staging.drfop.org/files/original/6ef64458260bc2d1bde1e86f529b05fd.jpg 059fabe5ce19ca7120b4dca37de6a827 https://staging.drfop.org/files/original/3ffdcbb4b21055eba4533c885af8d30e.jpg bf323b08ef78be03b4cdd81505b1117f https://staging.drfop.org/files/original/570c0db690f8d4929a4e24a544499f04.jpg a75a3433b11e417be3aaf5931af55647 https://staging.drfop.org/files/original/25ba53d34e86878d89a422613a423219.jpg 49d279d5f622a33f7bab7e9a13941475 https://staging.drfop.org/files/original/86c9a5fc2e2c6424943c5d82967bca6b.jpg df44bcb9079a48fad702bd6ce8cbd7c2 https://staging.drfop.org/files/original/7f22825f726c7c3cd036fdc490fc0311.jpg 49b270cdb8ab4bf273e44b7ff0d6adcd https://staging.drfop.org/files/original/d7e9a11114bd8cf398078615dc266ef0.jpg effa0ef8f6e071995f4db91e16956da6 https://staging.drfop.org/files/original/c791f2953272b15882d258981a1009c6.jpg 63e16f08b2372dab80ba402c7ec179da https://staging.drfop.org/files/original/b4e99d6ae2d85be6de0ebef5d20927f6.jpg 2764e06e43929f9813a2330db858522a https://staging.drfop.org/files/original/c90405176cc45ad9822c08f2c83403fc.jpg fb0324acf3b3efcca91cc33616b2ac93 https://staging.drfop.org/files/original/78a8fc8bb5859084900fc76a87459fec.jpg 39d5fd4f9942eeadc11787a402d0ee30 https://staging.drfop.org/files/original/3b8caa354bfe35ea776768597c689ace.jpg 3f44ac3f0d0fede052be1900dd619aa4 https://staging.drfop.org/files/original/234a59503cb92f7f867861e34588d1de.jpg be8cf73cabbf52ac504564063d5273ab https://staging.drfop.org/files/original/2c09290f6e88d7d02270ca5e0c495f52.jpg 0e05933eba5072a94777c38b2af8a9ba https://staging.drfop.org/files/original/9ebc06a2cd39befeb223452a2fce202d.jpg b4d10db15d99610189bd994126d8059a https://staging.drfop.org/files/original/e68efc6c51e5847738a124ba8c0650bd.jpg 3ca5390d466efbb2cefeaa72e57341c0 https://staging.drfop.org/files/original/72a98fe700fcf3286ffce2026dbfe490.jpg 926e883f350b7cc4cc2ca3e4da92e8d4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_039.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 39 - 51 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_02_039.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_039.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>Construction and Fitting of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>James Foort, MASc. <a style="text-decoration:none;">*</a><br /></h5> <p>True hip disarticulation connotes removal of the femur at the acetabulum. But loosely within the hip-disarticulation category a residual length of femur, too short to control a prosthesis effectively, may be left. A much more drastic operation, the hemipelvectomy, removes all of the ischium, all of the pubis, and most or all of the ilium on the side of the amputation. In this discussion, a classical and idealized hip-disarticulation amputee is considered in outlining a method for making the Canadian-type hip-disarticulation prosthesis. Certain adaptations have been found suitable for the short-stump above-knee amputee and for the hemipelvectomy.</p> <p>Consider the remaining functions of the hip-disarticulation amputee. The gluteal muscles have been pulled anterior and fastened at the suture line to form a rugged pad which supports the body's weight. Support forces are transmitted through this gluteal musculature and the ischial tuberosity to the stable pelvic base. Movement of the pelvis relative to the normal leg permits the amputee to position the artificial foot at the beginning of the stance phase of walking and aids in flexing the knee at the end of the stance phase and in sitting down. Pelvic movement relative to the rest of the body enables him to secure balance on and to control the prosthesis. The tuberosity on the side of the amputation, the iliac crests, and the sacrum provide excellent keying points for securing the body in the socket. To minimize movement between the body and the socket for the most efficient transmission of forces, the socket must snugly enclose those areas providing support, suspension, and stabilization and must give relief for any sensitive areas or bony prominences.</p> <p>The socketmaking technique, as worked out by the Prosthetics Research Group at the University of California, Berkeley, is described in detail in the report by Foort and Radcliffe<a></a>. The socket is made by taking a female impression of the pelvis with plaster bandage, forming it into a check socket and making the necessary modifications, making a male model from the check socket, and using the model as a mold for the plastic-laminate socket to which the rest of the prosthesis is attached.</p> <h4>Taking the Cast</h4> <p>To provide relief pockets for the anterior-superior spines, the posterior-superior spines, the spinous processes of the vertebral column, and any other sensitive areas, patches of 1/4-in. skived felt are attached to the body with adhesive tape (<b>Fig. 1</b>). To protect the body from plaster, a covering of cotton stockinet is pulled up over the lower part of the torso and extended well beyond the area where the socket is to be shaped (<b>Fig. 2</b>). In order to define accurately the areas which may require modification, the iliac crests and those areas which have been covered with felt are marked on the stockinet covering with indelible pencil. A mark around the waist, marks on the front and back mid-lines, and a mark extending from mid-line to mid-line around the normal leg at the level of the inguinal crease will define the approximate trim lines of the plaster cast (<b>Fig. 3</b>). Metal strips may be placed over the mid-line marks to facilitate subsequent cutting of the wrap cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Application of skived felt patches over pressure-sensitive areas of the stump and torso. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stockinet pulled over lower part of the torso well above the waist, tied at waist and around proximal end of sound thigh. Waist, mid-line, and bony prominences marked with indelible pencil. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Waist, mid-line, and bony prominences marked in the rear. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One way to get a good, snug fit for the socket is to take the wrapping of the upper part of the pelvis with the subject lying on his back on a cast table (<b>Fig. 4</b>, <i>A). </i>This position causes the viscera to move upward and backward and flattens the abdomen, thus reducing the distance from the anterior to the posterior wall of the cast and more sharply defining the iliac crests (<b>Fig. 4</b>, <i>B </i>and <i>C). </i>The cast of the lower pelvis is taken as a second step (<b>Fig. 4</b>, <i>D). </i>Snug fit is achieved by having the amputee bear weight on the stump as the cast hardens (<b>Fig. 4</b>, <i>E). </i>Three or four layers of plaster bandage are wrapped firmly around the upper part of the pelvis <i>{i.e., </i>from about 2 in. above the iliac crests to just above the pubic symphysis) and then, with tension, diagonally over the iliac crest on the amputated side and under the crest on the normal side (<b>Fig. 4</b>, <i>A </i>and <i>B). </i>After the wrap is complete, a block of firm sponge rubber 2 in. thick is placed under the patient's lumbosacral region to force the back portion of the cast against the body (<b>Fig. 4</b>C). By molding over the iliac crests with the hands while the cast is setting, and by pressing in firmly while the cast hardens, the operator obtains good suspension hooks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Taking the cast. <i>A, </i>Wrapping the waistband area of the pelvis, patient supine on cast table, cast table set apart to facilitate wrapping; <i>B, </i>diagonal wrapping for distortion of the cast over the iliac crest on the side of the amputation; C, rubber pad under patient's lumbosacral region to give firm fit in that area, cast table closed; <i>D, </i>wrapping the stump area, a separate operation, patient standing; <i>E, </i>patient "sitting" on rubber pad to give weight-bearing impression. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the upper portion of the cast has set, the amputee stands, and the stump area is wrapped with plaster bandage. To unite the two portions completely, the bandage is applied back and forth over the stump with several turns around the upper section of the cast (<b>Fig. 4</b>, <i>D). </i>While the cast is setting, the amputee bears full weight on the sponge-rubber pad now placed under the stump area (<b>Fig. 4</b>, <i>E). </i>Weight-bearing at this time keys the body within the socket between the weight-bearing platform and the suspension hook over the iliac crest on the side of the amputation. Up-and-down motion of the body within the socket is thus minimized. There may be some gapping of the cast in the gluteal area and lateral to the pubic area, but such gapping will be closed with plaster when the cast is modified.</p> <p>When the cast has set, it is removed from the torso by cutting at the approximate midlines, front and back (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cutting and removing the cast. <i>A, </i>Cast marked on mid-line, front view; <i>B, </i>cast cut along anterior and posterior mid-lines, rear view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Check Prosthesis</h4> <p>The cast is rejoined, reinforced, split again, hinged posteriorly, provided with a buckled closure anteriorly, and attached to a pylon base (<b>Fig. 6</b>). To rejoin the two sections, they are aligned in their original position, and plaster bandage is wrapped around the outside. Plastic laminate, consisting of polyester resin, stockinet, and glass cloth, is applied over the plaster cast to strengthen it. Two layers of glass cloth about 4 in. wide are laid over the outside on the posterior mid-line. One layer of 8- to 10-in. stockinet is then pulled over the cast and tied at the opening for the normal leg. Polyester resin is painted over the fabric and allowed to cure, after which excess material is trimmed away.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The check prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is now sawed along the posterior mid-line, and a hinge is fastened over the cut. When the hinge is secured, the cast is sawed along the front mid-line, and a buckle-and-strap arrangement is attached. A block of wood about 4x4x4 in., scooped out to fit the bottom of the cast roughly, is attached to the cast with "gunk," a mixture of resin and sawdust, to serve as the base for the pylon.</p> <p>The pylon must now be attached to the wood block in the proper alignment and the socket tried on the amputee for any necessary modifications. With the plaster socket on the amputee, marks are made on the side and front of the block to indicate the inclination of the peg. It should be so set that it will make the same angle with the floor at the beginning and end of the stance phase of walking and so that it will clear the normal leg in the swing phase. Typically, this will mean that the distal end of the pylon will be set somewhat forward as viewed from the side and somewhat lateral as viewed from the front. A hole is drilled in the middle of the block at the required angles, and a length of crutch-tipped dowelling is inserted.</p> <p>To test for discomfort, excursion, and restriction of body motion, the amputee now performs on the check prosthesis. He is asked to bend his body and normal leg in every direction, and the cast is cut down until there is complete freedom of motion. Taking care to leave the ischial seat intact, the medial side is cut away to relieve rubbing against the normal leg and the genitalia. The edges of the cast are then smoothed and flared with plaster, and gapping in the areas of the gluteus and pubis is similarly closed.</p> <p>If there is ramus contact, the amputee usually will complain of it. This detail can be checked by locating the ramus with a finger and having the amputee put full weight on the socket while dropping his pelvis on the normal side. If there is contact, the ischial seat and other weight-bearing areas should be built up with 1/8-in. layers of plaster until the ramus is sufficiently cleared. Fore-and-aft excursion can be detected by placing a finger alongside the tuberosity while the amputee steps back and forth on the prosthesis. Any fore-aft excursion will be reduced if the prosthetist slips a hand between the torso and either the anterior or the posterior wall of the socket. If the amputee then feels more secure, the anterior and posterior walls should be built up appropriately with plaster so laid that the forces are evenly distributed.</p> <p>If the body has not been sufficiently stabilized in the socket in the up-and-down direction, the prominences will move along and out of the relief pockets established for them, and chaffing and painful pressures will occur. As a final check on excursion, therefore, the amputee should be walked in the check socket. Two hours of walking is usually enough to prove any discomfort. Further refinements may then be necessary:</p> <ol> <li>If the musculature in the area of the iliac crest on the side of the amputation has atrophied, the extent of the hook in this region may need to be increased. An increase is indicated if a hand placed inside the socket under the hook makes the socket seem more secure on the amputee.</li><li>If, without causing discomfort, security is increased by inserting 1/8-in. pads between the stump and the weight-bearing area of the socket, the weight-bearing area should be built up accordingly.</li><li>If the body seems stabilized in the up-and-down direction but there is still pressure on the prominences, either the areas around the relief pockets must be built up with plaster, 1/8-in. at a time, or material must be sanded out of the pockets.</li></ol> <h4>The Male Model</h4> <p>A hollow model is now made in the check socket. After the inside of the cast has been coated with petroleum jelly, a section of 8-in. stockinet is pulled over the check socket and tied closed around the pylon base. Sufficient thin plaster is then poured into the cast through the waist opening to coat lightly both the check socket and the stockinet closing the end (<b>Fig. 7</b>). When the first layer of plaster has set, successive layers of somewhat thicker plaster are added until the model is approximately 1 in. to l 1/2 in. thick. When the shell has hardened, a quart more of plaster is poured in, the stockinet is pulled across the opening, and the cast is inverted and placed on a table so that the plaster seals the end. The completed male model is removed from the check socket and dried.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Making the male model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Plastic Socket</h4> <p>To prepare the model as a mold for construction of the plastic socket, a hole is cut in the top (the waist), and a mandrel of 1-in. pipe about 2 ft. long is inserted and fastened with "gunk." The edges of the mold are trimmed so that the flares are not more than 1/4 in., and the whole is smoothed with fine sandpaper. To the surfaces which will become the open ends of the completed socket wooden blocks approximately 1/2 to 1 in. are attached with "gunk" (<b>Fig. 8</b>). They will later be used to secure the layers of fabric to the mold. A 1/4-in. pad of dense sponge rubber is placed over what will be the weight-bearing area of the socket. This pad will later be transferred to the corresponding area of the completed socket. A truncated cone of polyvinyl alcohol film is then pulled over the cast and tied to the mandrel at one end and to the leg-opening surface at the other (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Wooden blocks bonded to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Truncated cone of polyvinyl alcohol film drawn over the model and fastened top and bottom. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 44--> <p>To reinforce the polyester resin, da-cron tricot (a very strong fabric with one-way stretch) and glass cloth are used in construction of the socket. The dacron waistband will be limber enough to allow the socket to open, while areas of force concentration, reinforced with the glass cloth, will be strong and rigid.</p> <p>Six layers of dacron tricot are used, each layer being stapled into place individually. The six layers of dacron are cut with enough material to wrap around the cast horizontally and with an overlap great enough to span the distance between the crests. These are fitted and seamed to pocket the stump area (<b>Fig. 10</b>). Beginning at the vertical line of the normal iliac crest, the end of the material is stapled to the wooden blocks at either end of the model. As it is brought across the abdominal area, then around the back, continuing to its starting point, the dacron is stapled to the blocks (<b>Fig. 11</b>), the excess length of material being allowed to hang free. Alternating with the dacron, four layers of glass cloth are laid up over the stump area, extending upward to the crest (<b>Fig. 12</b>), and the lay-up is finished off with the final two layers of dacron tricot (<b>Fig. 13</b>). When all the fabric has been applied in this way, the loose sections of dacron are brought across the front and stapled into position over a sheet of polyvinyl alcohol film (<b>Fig. 14</b> and <b>Fig. 15</b>). The film separator prevents the overlap from bonding to the underlying section.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Dacron tricot tailored to fit the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Securing the fabric to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Glass cloth applied over the stump area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Final lay-up of dacron fabric. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Application of PVA funnel and film separator under overlap of waistband. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Film separator and overlapping fabric stapled into position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In order to get resin to the fabric under the film separator, it is helpful to place a polyvinyl alcohol funnel, approximately 2 to 3 in. wide and 2 ft. long, under the film separator before it is stapled into position (<b>Fig. 14</b>). The mouth of the funnel will be at the mandrel. After the film separator and the overlapping material have been stapled to the wooden blocks in final position, two similar funnels are placed over the front and back surfaces of the lay-up with the mouths at the mandrel (<b>Fig. 16</b>). A final truncated cone of polyvinyl alcohol film is pulled over the entire mold and tied in the area of the wooden blocks at the stump end (<b>Fig. 17</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. PVA funnels applied to front and back of lay-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Truncated PVA cone placed over entire lay-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The required quantity of resin is weighed, mixed with catalyst, promoter, and pigments, and introduced into the fabric through the funnels, after which the funnels are removed (<b>Fig. 18</b>). The polyvinyl alcohol bag is tied closed at the mandrel, and the resin is squeezed through the fabric. When the fabric is completely saturated, excess resin and air bubbles are worked out toward both ends by "roping" (<b>Fig. 19</b>). Sponge-rubber pads are then bound over the undercut areas with Ace bandage in order to guarantee close adherence of the lay-up to the mold (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Resin introduced through the funnels, funnels ready to be removed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Saturation of the fabric and removal of air bubbles by "roping." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Sponge-rubber pads applied to undercut areas to guarantee adherence to mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is released from the mold by cutting around the waist and around the opening for the normal leg approximately 1/2 in. from the final trim lines (<b>Fig. 21</b>). Care should be taken not to cut the hands on the sharp edges of the overlapping sections (<b>Fig. 22</b>). After the socket has been removed from the mold, the edges are trimmed on a sanding drum.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Cutting the socket free of the mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Removing the socket from the mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 46--> <h4>The Trial Leg</h4> <p>The fixtures are attached to the socket, the socket is attached to a thigh section through the hip-joint assembly, and the thigh section is attached to the adjustable leg and the foot (<b>Fig. 23</b>, <b>Fig. 24</b>, <b>Fig. 25</b>, and <b>Fig. 26</b>). Attachments for the socket are the weight-bearing pad (<b>Fig. 23</b>), the belt-and-buckle arrangement, and the wooden base for the hip joint (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Finished socket with weight-bearing pad installed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Socket with wood block attached. Dotted lines indicate the saw lines. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Hip-joint assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Trial prosthesis set up on the UC adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Wooden Base</h4> <p>A block of wood 4 x 4 x 4 in. for the base, hollowed out to fit the front-bottom corner of the socket, is bonded in place with "gunk." When the resin has cured, the front-bottom corner of the block is cut off as close to the socket as possible to provide a surface to which to attach the hip - joint bearing. When the socket is in its normal position, this attachment surface will face downward and forward at a 45-deg. angle to the floor, so that when the hip-joint bearing is attached its axis will be approximately perpendicular to the line of progression and parallel to the floor (<b>Fig. 25</b>).</p> <h4>Hip-Joint Assembly</h4> <p>The hip-joint assembly (<b>Fig. 25</b>) consists of a special bearing, a shaft, and two metal side-straps. The bearing, which is lined with a bronze bushing, is machined out of a block of aluminum and includes four tabs with screw holes for attachment to the base of the socket. The shaft and sidestraps of the hip-joint assembly are from a 3 1/2-in. standard prosthetic-knee assembly.</p> <h4>Thigh Section</h4> <p>The thigh section is made from a 6- x 6-in. block of wood 12 in. long, with a core drilled from the middle at the edge of one end through the center of the block at the other. This hole facilitates pulling out wood from the interior of the thigh section later. A line is marked off 2 in. from the cored edge at one end, and, starting at this line, a diagonal cut is made to the opposite corner at the other end. The 6- x 6-in. face becomes the knee end, the 2- x 6-in. surface the hip end, and the vertical surface (6 x 12 in.) the front face of the thigh.</p> <p>The sidestraps of the assembled hip joint are traced on the front face of the block equidistant from the sides, and the block is cut along these lines to extend somewhat beyond the side-straps and to flare out toward the end. The straps are then attached to the cut sides flush with the front of the block at the bolt end and so that the axis of the bolt will be approximately 3/4 in. above the top surface of the thigh block. The portion of the block which extends behind the axis of the hip joint is sawed as necessary to provide the platform for the hip-stop bumper (<b>Fig. 24</b>). To position the hip joint on the base, the amputee dons the socket and sits down.</p> <p>Viewed from the front, the prosthetic thigh should be approximately parallel to the normal thigh and as close to the mid-line as possible, and the hip joint should be parallel to the floor and high enough on the base so that the back edge of the hip-stop platform is flush with the chair. The position of the bearing is traced on the block, and the free end of the thigh section is marked 2 in. back from the normal knee axis.</p> <h4>Trial-Leg Assembly</h4> <p>The socket is removed from the patient, the thigh section is cut where it was marked, and the components of the trial leg are assembled. The adjustable leg is attached to the knee end of the thigh piece, and the socket is attached to the thigh with screws through the hip-joint bearing. To prepare the trial leg for alignment checks, a temporary hip-stop bumper, a temporary hip-flexion control <!--Page 48--> strap, and a kick strap are attached to the leg, and the knee joint is located in a stable position (<b>Fig. 26</b>).</p> <h4>Temporary Bumper</h4> <p>A bumper of foam-crepe shoe-sole material is tacked temporarily to the hip-stop platform in such a manner that when the socket is against the bumper the vertebral spine will be in its natural position.</p> <h4>Hip-Flexion Control Strap</h4> <p>One end of the hip-flexion control strap is attached laterally to the socket 2 in. behind the hip joint; the other is attached to the shank 3 in. below and 1/2 to 1 in. ahead of the knee joint.<a style="text-decoration:none;">*</a> The distance between these attachments is adjusted to provide the correct stride length.</p> <h4>Kick Strap</h4> <p>The temporary kick strap is attached to the front of the shank at the same level as the hip-flexion control strap, passes over the knee in front, and attaches to the front of the socket 3 in. above the hip joint. The length of the strap is adjusted to provide the correct balance between heel rise and knee extension. Knee stability will be satisfactory if, when the knee is in full extension, the knee joint falls behind the line projected from the hip joint to the back of the heel.</p> <h4>Adjustments</h4> <p>The prosthesis is now ready for sitting, standing, and walking adjustments. When the amputee is sitting, the prosthetic shank should be vertical, the knee axis approximately level with the normal knee center and the toe-out equivalent to that on the normal side. In the standing position, with a 2- to 3-in. standing base, the length of the leg should be such that the hips are level. The thickness of the hip bumper is adjusted to eliminate humping or arching of the spine. The patient now walks on the trial leg, and checks are made of knee stability, width of walking base, stride length, toe clearance, whip in the swing phase, and swing-phase control.</p> <h4>Knee Stability</h4> <p>Although the knee has been stabilized on the bench, a number of factors may affect it in action. If the knee buckles, it may be that the hip bumper is contacting too soon and that its thickness needs to be reduced. A knee axis too far forward also will cause buckling.</p> <h4>Walking Base</h4> <p>With the toe-out of the prosthesis consistent with the natural toe-out, the medial distance between the heels is the walking base. If this base is found to be over 2 to 3 in., it should be made narrower by moving the foot in. If the feet are not clearing each other sufficiently, the base should be increased to 2 to 3 in.</p> <!--Page 49--> <h4>Stride Length</h4> <p>The distance between toe-off and heel strike should be approximately the same for the two legs. Stride length is adjusted by shortening or lengthening the hip-flexion control strap.</p> <p>The thickness of the hip-stop bumper affects stride length. If the thickness of the bumper is increased, the angle at which the leg inclines forward at the end of the stance phase is reduced, and the stride is shortened. But bumper thickness should never be changed to improve control and stride length at the expense of comfort.</p> <h4>Toe Clearance</h4> <p>A number of factors are involved in toe clearance-the length of the leg, the inclination of the foot, the amount of knee flexion in the swing phase, and suspension. Leg length is first adjusted, but the limb should not be shortened more than an inch. If scuffing persists, it is due to other factors. If the knee is not bending sufficiently, the toe will drag, and kick-strap tension should be reduced. If drop-off is causing the toe to scuff, a hand placed between the socket and the crest of the ilium on the side of the amputation should eliminate it. In this case, either the suspension hook over the crest should be enlarged or the weight-bearing area should be built up with pads and the length of the leg reduced equiva-lently. Correction of scuffing may make the clearance too great, in which case leg length must be readjusted.</p> <h4>Whip</h4> <p>Whip in the Canadian-type hip-disarticula-tion prosthesis typically takes a form comparable to circumduction in the above-knee prosthesis. Circumduction can be reduced by rotating the knee bolt externally. The degree to which the knee axis can be rotated is limited by the extent the foot will move medially in the sitting position. It may thus be necessary to effect at least some external rotation at the hip joint by cutting a wedge (with the apex medially) from the hip-joint base.</p> <h4>Swing-Phase Control</h4> <p>With alignment established, refinements can be made in swing-phase control. Heel rise at the beginning of the swing phase should be limited through adjustment of the kick strap rather than of the knee-friction units. The compound-pendulum system of the prosthesis does not allow the hip-disarticulation amputee to walk as fast as he would like, and it has been found that tensing the kick strap increases his speed more effectively than does increasing knee friction. This may mean that there will be some impact at the end of the swing phase, but it usually is quite tolerable because the hip joint flexes as soon as the knee comes against the extension stop, and the energy which would otherwise lead to impact is thus absorbed. Stride length may require periodic adjustment as changes are made in swing-phase control.</p> <h4>Finishing the Prosthesis</h4> <p>The leg is now ready to be used either as a training leg, or, after sufficient attention has been given to fit and alignment, to be duplicated.<a></a> The only difference between duplicating the Canadian-type hip-disarticulation prosthesis and a standard above-knee prosthesis is that in the case of the former the thigh section rather than the socket is clamped in the jig.</p> <!--Page 50--> <p>The thigh section, shank, and foot are shaped and reinforced according to standard techniques<a></a>. Weight of the thigh section is reduced by pulling wood from the inside. The hip joint is faired to the wooden base on the socket with "gunk" and tied to the base with three layers of resin-impregnated glass cloth extending about an inch beyond the wooden block. This reinforcement is smoothed and finished with a light coat of lacquer. For ventilation, the socket is perforated with 1/8-in. holes at 1-in. intervals, and padded areas are covered with nylon-coated leather or leather substitutes. The permanent kick strap and hip-flexion control strap are installed, their connections to the limb being such as to allow the straps to rotate about the points of attachment. The hip-flexion control strap (<b>Fig. 27</b>) is made of 1-in. vinyon or dacron webbing sewed on either end of a 4-in. section of heavy elastic webbing. For attachment to the prosthesis, a piece of leather large enough to include a 1/4-in. metal grommet (such as is used in below-knee corsets) is sewed at each end of the hip-flexion control strap, and a clamping arrangement is installed on the webbing to permit length adjustment. The conventional kick strap is used, with the exception that it is attached proximally to the socket instead of to the thigh. Final adjustments are made to socket edges and to the permanent swing-phase controls.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Hip-flexion control strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The last step in the construction and fitting of the Canadian-type hip-disarticulation prosthesis is to provide a cosmetic fairing for the thigh section. A truncated cone of sponge rubber is made to fit over the thigh section so that it extends from just above the knee to the socket. The rubber cone is in turn covered with leather or a leather substitute extending beyond the rubber fairing at both ends, so that the covering can be attached to the thigh at the bottom and to the front and side of the socket with snap fasteners (<b>Fig. 28</b>). In order to make the fairing neat in both the sitting and the standing positions, a triangle with a 3-in. side and with the apex on the hip-joint axis may be cut from the lateral side of the covering and a piece of light elastic webbing substituted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Cosmetic fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The procedures outlined for checking the prosthesis during construction and fitting can be applied equally well to the evaluation of hip-disarticulation prostheses.</p> <h4>Acknowledgment</h4> <p> The line drawings which accompany this article were prepared by Frank N. Todd, illustrator with the Biomechanics Laboratory at <!--Page 51--> the University of California at Berkeley. The halftones are by George Rybczynski, free-lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Foort, J., <i>Fiberglas laminate reinforcement of wooden prostheses, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report tohe] Advisory Committee on Artificial Limbs, National Research Council, February 1956.</li> <li>Foort, J., and C. W. Radcliffe, <i>The Canadian typehip disarticulation prosthesis, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Prosthetics Research Board, National Research Council, March 1956.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignmentof lower-extremity prostheses, </i>Artificial Limbs, May 1954. p. 23.</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">Foort, J., Fiberglas laminate reinforcement of wooden prostheses, Prosthetic Devices Research Project, University of California (Berkeley), [Report tohe] Advisory Committee on Artificial Limbs, National Research Council, February 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignmentof lower-extremity prostheses, Artificial Limbs, May 1954. p. 23.</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">If the amputee is well adjusted to using a prosthesis and does not need the added stability offered by attaching the hip-flexion control strap below the knee, the distal end of the strap may be attached to the thigh section.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Foort, J., and C. W. Radcliffe, The Canadian typehip disarticulation prosthesis, Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Prosthetics Research Board, National Research Council, March 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James Foort, MASc. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Engineer, University of California Prosthetics Laboratory, U. S. Naval Hospital, Oakland, Calif.; formerly Research Engineer, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-012.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-013.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-014.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-015.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-016.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-017.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-018.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-019.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 Construction and Fitting of the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource James Foort, MASc. * https://staging.drfop.org/files/original/6390d2b802a51debf473b9656b992a03.pdf 5239891523840188e87e90863af212cf Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_002.pdf Text Any textual data included in the document <h2>The Parents Experience</h2> <h5>James R. Cuchna&nbsp;<a style="text-decoration: none;">*</a><br />Anna Mae Cuchna&nbsp;<a style="text-decoration: none;">*</a></h5> <p>A new birth . . . another miracle . . . a baby is born . . . but why is our baby not made perfect like our friends and relatives? Life began, but it was not surrounded by complete joy. We were confronted with the inevitable—"Your child was born with spina bifida. She will, probably, live no longer than a week." We were asked, "Do you want to put her in an institution or leave her in the hospital?" Try to imagine the feeling that would rush through your mind at the onset of this occasion. It is unbelievable.</p> <p>Our immediate and only reaction was to take this child and love her just as if she were born "perfect." We accepted our daughter and were determined to treat her as if nothing was wrong. We had faith that God would help us through the problems we might encounter. This happened on March 21, 1966.</p> <p>Today, Cindy is 18 years old and is entering her first year of college. We also have a 17 year old daughter and a 9 year old daughter. We feel we have been richly blessed.</p> <p>Even though our first child was the one born with a physical problem, spina bifida, we really don't feel she has ever been "the problem." Society in general . . . everyone else's opinion, the medical profession, the people in government passing legislature, etc. are "the problems." Everyone thinks they know what "life is going to be like" for these children, what a "burden" they will be on the family. These statements infuriate us.</p> <p>Having had other children helped us substantiate our thoughts and feelings that a child born with a physical problem is "no different" than a child born "normal." We have had to deal with medical problems, hospital stays, doctors visits, etc. with all our children—maybe not as many problems as with Cindy, but, all have been traumatic for us. We have also had parents inflicted with cancer and have cared for them. To us, life is what a person makes of it. It is the positive attitude that surrounds any child or person that is so important. One can only try to make the best of things and live each day to the fullest.</p> <p>We are concerned for the babies that have doctors who perceive spina bifida as a dreadful defect/disability and make the decision of whether to treat or not. Cindy was not treated at birth but survived. Thoughts arise as to what more she could do had she been treated. Would her degree of paralysis and the kidney damage be less severe? We'll never know. Some doctors hesitate on treating babies born with spina bifida, but wouldn't give a second thought to treating victims of automobile, industrial or other accidents even though the outlook may be very bleak. An example of this is the president's aide, James Brady. What makes the difference?</p> <p>Another concern lies in the high cost of the medical supplies and equipment she will need the rest of her life. It doesn't seem fair that urostomy bags bought 11 years ago cost $13.95 and today are $42.50, that a set of full braces is $5,000 or more, that a wheelchair is over $1,000, that vans with lifts are $20,000, or that urine analysis that were $2.00 are now $10.00. Most of the people with physical problems have limitations in job opportunities. Very few will be able to hold high paying jobs. Where will the money come from to pay for their needs?</p> <p>Some places now want the money first and then they will bill your insurance. Where will she get the start to save money when she needs something? What happens when our 80 percent group insurance coverage lapses because she is an adult and then she cannot get insurance of her own because of her medical/physical involvement?</p> <p>Cindy feels good about herself and has accepted her handicap. She realizes that she has limitations but that these should not preclude her from being able to achieve the goals she sets. The fact she is paralyzed from the waist down and requires orthopedic bracing brought Cindy to the realization that she would have to work very hard for what she wants very early in life. She knows that nothing is going to be handed to her on a silver platter and does not think that she deserves special treatment because she is "physically challenged." All she wants is an equal opportunity to contribute to society and earn her way.</p> <p>Cindy has been a constant source of strength, love, and courage for us. As we watch her grow and see her achieve, our admiration for the child/young lady/soon-to-be woman grows. We truly believe that we have been more dependent on Cindy than she has been, or ever will be, upon us.</p> <p>We have been very fortunate in having benefitted from the professional services of very dedicated, talented, competent, and caring people in the areas of medicine, education, and orthotics. Yes, there have been differences of opinions between themselves as well as with us. There were goals that took longer than anticipated to be reached. But, can't we all say this happened to us also in our "normal" lives.</p> <p>It is one of our dreams and goals to see more medical professionals get involved with the National Spina Bifida Associaion of America and its local chapters. We don't need people to be afraid of spina bifida. We need help to spread a positive image, to achieve the establishment of a hospital for research and for the needs of all people with spina bifida. People need to know that children who are physically challenged don't need sympathy and things done for them. What they need is the opportunity to live, learn, grow in love and be loved—just as we all do.</p> <em><b>*Anna Mae Cuchna </b> Mr. and Mrs. Cuchna reside in Ohio and are the parents of Cynthia Cuchna.</em><br /><br /><em><b>*James R. Cuchna </b> Mr. and Mrs. Cuchna reside in Ohio and are the parents of Cynthia Cuchna.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 2 - 3 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Parents Experience Creator An entity primarily responsible for making the resource James R. Cuchna * Anna Mae Cuchna * https://staging.drfop.org/files/original/681729931d4cfc067bfb635d350a0038.pdf 08c883182b90889c54a46553cb7eb012 https://staging.drfop.org/files/original/e3d52b0be7f8bf314487219accc7c636.jpg 533dd7911eac0f2103f63f55a2974f2e https://staging.drfop.org/files/original/88d35e0e098d1d592a33914182995d15.jpg 01b25278628c187bfd931c739f3f8d09 https://staging.drfop.org/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg 0e95b44fd8762f309bc14b7344472c45 https://staging.drfop.org/files/original/504357506176edb60a65b7ae82059220.jpg 0a53764bf308ba3a7a6cb38844c982d5 https://staging.drfop.org/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg d6f074b0d9ad6cb75e44c3c67e36f961 https://staging.drfop.org/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg 79827f16dc5d8ac8a0d99d9def75de42 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_018.pdf Text Any textual data included in the document <h2>Gait Analysis in Prosthetics</h2> <h5>James R. Gage, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Ramona Hicks, R.P.T., M.A.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Review</h3> <p>Objective measurement systems which quantify locomotion have been in use for the past century. But not until World War II, when thousands of men returned home to the United States with amputations, was technology really applied to the understanding of prosthetic gait.</p> <p>Inman and colleagues<a></a> founded the Biomechanics Laboratory at the University of California to establish fundamental principles of human walking, particularly in relation to problems faced by lower limb amputees. Inman's measurement techniques included motion pictures of coronal and sagittal views, as well as transverse rotations from below using a glass walkway. Using interrupted light photography, the Biomechanics Laboratory team studied the motion of body segments during gait. Force plates measured the subject's ground reaction forces, and muscle activity was recorded using electromyography (EMG), which measures the electrical signals associated with contraction of a muscle. Prior to Inman's fundamental studies prostheses were customized for the individual amputee, without any particular regard to rational structural design. Inman's goal was to provide fundamental data essential for the design of prosthetic limbs. By analyzing normal human walking, he and his colleagues laid the groundwork for biomechanical analysis of amputee gait.<a></a> Since that time, numerous techniques have been developed to study human locomotion,<a></a> and numerous studies have been undertaken to evaluate prosthetic gait.</p> <h3>Research Applications</h3> <p>Eberhart, et al.<a></a> described the locomotor mechanism of the above-knee amputee from kinematic and kinetic data. They compared lateral stick figures of amputees to normal subjects as a means to objectively identify gait deviations in the sagittal plane. Force plate data were used to compare the weight-bearing characteristics of the prosthetic limb and the sound limb. From these comparisons, the authors identified amputees who walked well with their prostheses and those who were less adept. Eberhart believed that ultimately "optimal" patterns of gait could be determined for amputees and used as a reference for evaluating prosthetic gait.</p> <p>Zuniga, et al.<a></a> studied gait in 20 above-knee amputees by using electrogoniometers attached to the knee and foot switches. Their data documented asymmetry in the stance and swing phase times between the prosthetic and sound limb.</p> <p>In similar investigations, James and Oberg<a></a> and Murray, et al.<a></a> studied temporal stride parameters and knee flexion-extension angles, and also examined above-knee gait at various speeds. They confirmed the stance and swing phase asymmetry between the prosthetic and sound limb. They also showed that the asymmetry was present regardless of the speed of walking.</p> <p>The collection of baseline data in above-knee amputees clearly demonstrated some shortcomings in prosthetic gait. One of these, the longer swing time which is required on the prosthetic side, has led to the development of dozens of prosthetic knees. Gait analysis laboratories have been used to evaluate some of these prosthetic designs. Godfrey, et al.,<a></a> in a limited study that compared gait with six cadence-responsive knee units, found no significant differences among them. Murray, et al.<a></a> compared the gait of above-knee amputees with hydraulic knee units versus constant friction knee units. Temporal and kinematic data, which were collected at slow, free, and fast speeds, showed that the hydraulic knees improved the symmetry between the prosthetic limb and the sound limb, especially at the fast and free speeds. This finding was true for both cadence and the amount of knee-flexion at swing phase.</p> <p>Hoy and colleagues,<a></a> in one of the few studies on gait in juvenile amputees, collected kinematic data at various speeds to compare the solid ankle cushioned heel (SACH) foot to a Child Amputee Prosthetic Project (CAPP) experimental foot. The authors found hip range of motion to be closer to normal and significantly less with the CAPP foot than the SACH foot.</p> <p>Hannah and Morrison<a></a> studied the effect of alignment of the below-knee prosthesis on gait. Using electrogoniometers to measure hip and knee joint rotations in the coronal, sagittal, and transverse planes, they found that malalignment of the prosthetic foot was the most crucial for gait symmetry.</p> <p>Grevsten and Stalberg<a></a> used electromyography to compare muscle activity in below-knee amputees walking with patellar tendon-bearing (PTB) and PTB-suction prostheses. Surface electrodes were placed over the tibialis anterior and gastrocnemius muscles which, in normal gait, usually fire at opposite phases. The data showed that these muscles contracted for longer periods when the PTB prosthesis was used than with the PTB-suction prosthesis, suggesting that the suction mechanism improved the adaptation to the prosthesis.</p> <p>Thiele, et al.<a></a> investigated possible neuro-physiological reasons for weakness in above-knee amputees by recording electromyographic activity of the quadriceps during gait. They did not find abnormal recordings and concluded that muscle weakness was secondary to biomechanical, rather than neurophysiological, factors.</p> <h3>Clinical Applications</h3> <p>Until the present, gait analysis has been applied to prosthetics only for research purposes. Routine prosthetic fitting and checkout are still done by means of observational gait analysis. However, observational gait analysis has many disadvantages.</p> <p>In the first place, even normal human walking is extremely complex. With each step, more than 30 major muscles have to contract and/or relax synchronously in each lower extremity. Also, normal human gait is rapid (approximately 105 steps per minute), and the human eye is not fast enough to separate the various components of gait at this speed. Krebs, et al.<a></a> have shown that data vary widely when different examiners have observed a person's gait and that observational analysis is only a moderately reliable technique. The variations between observers may be due to the preconceptions of individual observers, to limitations of human perception, or to problems in transmitting the information or data to colleagues. In light of these findings, it is not surprising that the fit and quality of the limbs fabricated by different prosthetists vary greatly.</p> <p>Technology has now progressed to the point where automated gait laboratories can be built. Their capabilities vary, but most labs monitor one or more of the following parameters:</p> <ol> <li> <p>kinematics or movement measurements through a motion analysis system,</p> </li> <li> <p>evaluation of ground reaction forces via force plates or pressure sensitive switches, and</p> </li> <li> <p>dynamic electromyography (monitoring the electrical activity of contracting muscles).</p> </li> </ol> <p>The advantage of an automated motion measurement system is that automated data entry and rapid processing allow routine clinical use at a reasonable cost. Since the sampling rate of most automated motion systems is in excess of 50 Hz (50 samples/second), all movement in the lower extremities during walking can be examined in detail and with excellent reproducibility.</p> <p>Thus, the analysis of walking becomes objective, rather than subjective, and a record of this objective analysis is produced by the computer in such a fashion that preconceived biases and communication errors between observers are minimized. Furthermore, some of the more modern gait analysis facilities have the ability to compare records, for example, of a patient's gait pre- and post-operatively, or of an amputee's gait with two different prosthetic devices or components. Through comparisons like these, the presence or absence of benefit can be determined objectively.</p> <h3>Kinesiology</h3> <p>The field of prosthetics can make use of the new science of kinesiology, or the study of movement. Kinesiology consists of two major fields:</p> <ol> <li> <p>kinematics, the study of motion exclusive of the influences of mass or forces, i.e., without regard to the underlying cause of the motion; and</p> </li> <li> <p>kinetics, which deals with the forces that produce motion.</p> </li> </ol> <p><i>Kinematic Data</i></p> <p>Kinematic data can be gathered in a variety of ways—through interrupted light photography, cinefilm, video systems, and/or electro-goniometers—and it can be displayed in many ways. Stick figures provide a visual display of the subject walking.</p> <p><a href="/files/original/e3d52b0be7f8bf314487219accc7c636.jpg"><b>Fig. 1</b></a> is a stick figure representation of an 11 year old girl with a right knee disarticulation. The stick figures facilitate the identification of gait deviations, e.g., knee hyperextension on the prosthetic side at stance phase. With observational gait analysis, this gait deviation might be missed, or two examiners might argue about its presence. With objective gait analysis, we can prove the deviation's existence by viewing the stick figures, and we can identify the cause of the deviation by reviewing the graphs that depict motion. These graphs display motions of each joint of the lower extremities in all three planes during a representative gait cycle.</p> <strong><a href="/files/original/e3d52b0be7f8bf314487219accc7c636.jpg">Figure 1.</a> Lateral stick figures of the right gait cycle of an 11-year-old-girl with a right knee disarticulation.</strong><br /> <p><a href="/files/original/88d35e0e098d1d592a33914182995d15.jpg"><b>Fig. 2</b></a> is a graph showing knee flexion-extension of the same child with a knee disarticulation. The child's sagittal knee motion is compared with the mean or average flexion-extension of seven other above-knee amputees.</p> <strong><a href="/files/original/88d35e0e098d1d592a33914182995d15.jpg">Figure 2</a>. Comparison of knee flexion-extension motion in one above-knee amputee with an average composite of knee flexion-extension in seven above-knee amputees.</strong><br /> <p>Although all above-knee amputees hyperextend their knees slightly during stance phase, this patient has 10 degrees more hyperextension than average. Following the gait analysis, it was discovered that the knee extension bumper was too soft, and it was replaced with a suffer one.</p> <p>Kinematic data can also be used to compute temporal data, such as stride length, cadence, and walking velocity. <a href="/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg"><b>Fig. 3</b></a> compares the temporal data of the child with knee disarticulation with "normal" children the same age. Notice that the stride length is normal but that the walking velocity and cadence are less than normal.</p> <strong><a href="/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg">Figure 3.</a> Linear measurements of an 11-year-old girl with a knee disarticulation compared with a composite of linear measurements of normal children.</strong><br /> <p><i>Kinetic Data</i></p> <p>The forces that cause movement are usually collected through pressure sensitive switches or paper, or with commercial force plates, which are designed to break down the ground reaction forces into their components (X,Y,Z force, and X,Y,Z moment). The software of a modern gait analysis laboratory is able to combine force plate data with motion analysis data to produce meaningful graphic outputs.</p> <p><a href="/files/original/504357506176edb60a65b7ae82059220.jpg"><b>Fig. 4</b></a> shows the vertical ground reaction force (Z force) for walking barefoot compared with walking with shoes in a 9 year old boy with a Symes prosthesis. Notice the improved symmetry at push-off between the prosthetic and sound limb when shoes are worn.</p> <strong><a href="/files/original/504357506176edb60a65b7ae82059220.jpg">Figure 4.</a> Graphic display of the vertical ground reaction forces in a 9-year-old boy with and without shoes.</strong><br /> <p>Force plates can also be used to compute the location of the center of pressure on the foot. <a href="/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg"><b>Fig. 5</b></a> compares the foot force progression pattern of a SACH foot to a multi-axis foot in a 27 year old male with a below-knee amputation. From these data, one can see that the foot force progression pattern is more lateral with the multi-axis foot than with the SACH foot. Also, notice with the SACH foot how the initial forces move from an anterior to posterior direction as the heel compresses. This pattern is not seen in the multi-axis foot.</p> <strong><a href="/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg">Figure 5</a>. Path of the center of pressure on the foot in a 27-year-old below-knee amputee with a SACH foot and with a multi-axis foot.</strong><br /> <h3>Dynamic Electromyography</h3> <p>Dynamic electromyography is a valuable tool for measuring the time duration of muscle activity, which is recorded through electrodes, either surface or indwelling. However, since voluntary muscle activity results in an electromyographic recording that increases in magnitude with the tension, other variables can also influence the signal, limiting the accuracy of EMG as a predictor of muscle tension.</p> <p>Electromyographic data can be displayed in several ways. When used to analyze a gait cycle, the data show which muscles are active during each phase of gait. <a href="/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg"><b>Fig. 6</b></a> compares muscle activity during gait of the subject walking with the SACH foot compared with the multi-axis foot. The hamstrings and quadriceps muscle groups were sampled and show the same firing patterns regardless of the type of foot that is worn. What is interesting is that the hamstrings are firing just before toe-off when they are usually silent and the quadriceps are inactive at this time when normally they fire to restrain knee flexion and prevent excessive heel rise. As might be expected, this patient walks with exaggerated knee flexion at swing phase.</p> <strong><a href="/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg">Figure 6.</a> EMG activity of the hamstrings and quadriceps muscles during gait in a 27-year-old patient with a SACH foot and with a multi-axis foot.<br /></strong><br /> <h3>Summary</h3> <p>Gait analysis is useful in evaluating an amputee's prosthesis by providing objective measurements and a permanent record of the patient's status. Kinematic, kinetic, and EMG data assist the clinician and prosthetist in identifying specific problems encountered by the amputee and in identifying the causes. Gait analysis also allows comparison of different prosthetic designs or different alignments of the same prothesis. Most importantly, however, the record provided allows examiners to objectively discuss the problems and their potential solutions.</p> <h3>Future Applications</h3> <p>The field of prosthetics will begin to change rapidly with the application of kinesiology. Soon, optimal standards of gait will be established for each prosthetic level. With the widespread availability of low-cost motion analysis, kinematic analysis will be routinely incorporated into dynamic alignment of each new prosthesis, helping to insure appropriate alignment and fit. Finally, prosthetic research, using both kinematics and kinetics, will continue as we seek to identify and rectify the problems created by loss of the body's normal limb. The ultimate outcome of this research will be the development of components that will be stronger, lighter in weight, and much more functional than those used now.</p> <div style="width: 400px;"> <div style="width: 400px;"><em><b>*Ramona Hicks, R.P.T., M.A. </b> Kinesiology Laboratory at Newington Children's Hospital in Newington, Connecticut 06111.</em><br /><br /><em><b>*James R. Gage, M.D. </b> Kinesiology Laboratory at Newington Children's Hospital in Newington, Connecticut 06111.</em></div> </div> <div style="width: 400px;"></div> <p><b>References:</b></p> <ol> <li><i>Fundamental Studies of Human Locomotion and Other Information Relating to Design of Artificial Limbs</i>. Subcontractor's Report to the Committee on Artificial Limbs. National Research Council. Prosthetic Devices Research Project, College of Engineering, University of California, Berkeley. Serial No. CAL 5. 2 vols. The Project, Berkeley, 1947.</li> <li>Radcliffe, C.W., "Functional considerations in the fitting of above-knee prostheses," <i>Selected Articles From Artificial Limbs</i>, Huntington, NY, Kreiger Publishing Co, Inc, 1970, p.p. 5-30.</li> <li>Winter, D.A., <i>Biomechanics of Human Movement</i>, New York, John Wiley &amp; Sons, 1979, p.p. 9-46.</li> <li>Eberhart, H.D.; Elftman, H.; and Inman, V.T., "The locomotor mechanism of the amputee," <i>Klopsteg PE, Wilson PD, et al (eds): Human Limbs and Their Substitutes</i>, New York, Hafner Publishing Co, 1968, p.p. 472-480.</li> <li>Zuniga, E.N.; Leavitt, L.A.; Calvert, J.C.; Canzoneri, J.; and Peterson, C.R., "Gait patterns in above-knee amputees," <i>Arch Phys Med Rehabilitation</i>, 53:373-382, 1972.</li> <li>James, U. and Oberg, K., "Prosthetic gait pattern in unilateral above-knee amputees," <i>Scand J Rehabil Med</i>, 5:35-50, 1973.</li> <li>Murrary, M.P.; Sepic, S.B.; Gardner, G.M.; and Mollinger, L.A., "Gait patterns of above-knee amputees using constant-friction knee components," <i>Bull Prosthet Res</i>, 17(2):35-45, 1980.</li> <li>Godfrey, C.M.; Jousse, A.T.; Brett, R.; and Butler, J.F., "A comparison of some gait characteristics with six knee joints," <i>Orthotics and Prosthetics</i>, 29(3):33-38, 1975.</li> <li>Murray, M.P.; Mollinger, L.A.; Sepic, S.B.; Gardner, G.M.; and Linder, M.T., "Gait patterns in above-knee amputee patients: Hydraulic swing control vs constant-friction knee components," <i>Arch Phys Med Rehabil</i>, 64:339-345, 1983.</li> <li>Hoy, M.G.; Whiting, W.C.; and Zernicke, R.F., "Stride kinematics and knee joint kinetics of child amputee gait," <i>Arch Phys Med Rehabilitation</i>, 63:74-82, 1982.</li> <li>Hannah, R.E. and Morrison, J.B., "Prostheses alignment: Effect on gait of persons with below-knee amputations," <i>Arch Phys Med Rehabil</i> 65:159-162, 1984.</li> <li>Grevsten, S. and Stalberg, E., "Electromyographic study of muscular activity in the amputation stump while walking with PTB- and PTB-suction prosthesis," <i>Ups J Med Sci</i>, 80:103-112, 1975.</li> <li>Thiele, B.; James, U.; and Stalberg, E., "Neuro-physiological studies on muscle function in the stump of above-knee amputees," <i>Scand J Rehabil Med</i>, 5:67-70, 1973.</li> <li>Krebs, D.E.; Edelstein, J.E.; and Fishman, S., "Reliability of observational kinematic gait analysis," Accepted for publication in <i>J Phys Ther</i>, 1985.</li> </ol> <div style="width: 400px;"></div> Page Number(s) 18 - 23 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-5.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/1985_03_018/1985_03_017-6.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 Gait Analysis in Prosthetics Creator An entity primarily responsible for making the resource James R. Gage, M.D. * Ramona Hicks, R.P.T., M.A. * https://staging.drfop.org/files/original/e9f6b0ca0af8a979b6d3b20f2d9bf767.pdf 1bf7ecb945d70a0277568f72c0dd60e4 https://staging.drfop.org/files/original/e15daffdfb1ccd3c85ae31f758316228.jpg c7dc78f031800bd557e5e56886799610 https://staging.drfop.org/files/original/d7ecccb8dead833240dffb959177354c.jpg c31f94bc12db418af7fb09b67b391776 https://staging.drfop.org/files/original/443471c199b97e3910f5097fdeb8663e.jpg 4d1970fb7af2dcebb6d5aab2f7a0cf6c https://staging.drfop.org/files/original/8dbf7c64f23ae2955b3479bbb5fb302b.jpg 6b10e90231ab54505b1f29f0b21d1b18 https://staging.drfop.org/files/original/3a7c493869b8831afd00e9855e6c13ed.jpg f1fadc470bf7c0e5e704d5a587bda07f https://staging.drfop.org/files/original/eafcf91b4f973afa24add247a75817cf.jpg ea25252f54c00432d4ae8cdacd36ceb0 https://staging.drfop.org/files/original/eaea3592bc911874251c428e1ed0160b.jpg c21941b7ba4a91a5aa35d3e543daa7b1 https://staging.drfop.org/files/original/c585a3d3e836903584dba11878c0eac4.jpg 27ffd0226c847cdedb8ccf353f198219 https://staging.drfop.org/files/original/d7bd659b04aae888f075c506f9f1384c.jpg 53058ebbcd650e261bf37943275d6def https://staging.drfop.org/files/original/c54a555fdecec535e9a9d65b05a7edad.jpg bb55f6b1b0e326f1b85948db260a2740 https://staging.drfop.org/files/original/8cd98250a947dc0e83ffe62feb4ce885.jpg 88a53d4cfc08a94c502625bde4132277 https://staging.drfop.org/files/original/df58327f0134c1887a1fbe9da76db215.jpg a1bcc591f0218b53b85af82918d4d5a3 https://staging.drfop.org/files/original/abfc8d66ef593ba1303fdceca612b1f7.jpg 3ab086cb4672a061b9c84c4f105a6734 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_017.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 17 - 30 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_017.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_017.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>Porous Plastic Laminates for Upper-Extremity Prostheses</h2> <h5>James T. Hill, C.E., B.S. <a style="text-decoration:none;">*</a><br />Fred Leonard, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p> The problem of perspiration and its removal from the amputee's arm and leg stumps encased in sockets has engaged the attention of the doctor and limb fitter for as long as limbs have been fitted. </p> <p> In the early days of leather prostheses, a few months of wear during the summer were sufficient to cause the leather to rot and degrade because of perspiration. Since it was not possible to wash leather prostheses easily, severe hygienic problems were created. Efforts to coat leather with plastic films to overcome this difficulty were only partially successful for, in many instances, the adhesion of the coating was poor and frequent re-coatings were necessary. With the development of the all-plastic arm, it became possible to wash the socket thoroughly and virtually eliminate the hygienic problem. However, because the plastic did not permit diffusion of water vapor, sweat gathered profusely in the socket and became a source of discomfort and irritation. Efforts to permit diffusion of sweat by drilling gross holes in the plastic socket were not very successful. Although this practice permitted greater removal of sweat than in undrilled prostheses, the strength characteristics were seriously affected when a sufficient number of holes were cut to permit adequate removal. In addition, there still remained between the holes impervious plastic which could block large numbers of sweat pores-approximately 155 per square centimeter on the forearm<a></a>-and permit puddling between the plastic and the stump. </p> <p> It appeared that for optimum socket ventilation a porous-plastic socket should be developed which contained a large number of interconnnected pores. Such a socket should permit rapid diffusion of sweat with minimal blocking of sweat pores. The porous laminate envisioned would consist of a layered fabric resin composite with unbridged voids between the filler strands. Such material should be easily cleaned by soaking in detergent, followed by flushing with water. The following design criteria were outlined for the desired socket material: </p> <ol> <li>The socket material should have a uniform distribution of minute pores which would result in high porosity without blockage of sweat pores. </li><li>It should be easily cleaned.</li><li>Porous socket fabrication should conform as closely as possible with well-known fabrication techniques current in the practice of upper-extremity prosthetics.</li></ol> <p> Procedures for preparing porous upper-extremity prostheses were developed, utilizing the design criteria as a guide. In general, the method comprised the use of a solvent or diluent with an epoxy resin. After initial cure had occurred, the solvent was permitted to evaporate by removal of the outer polyvinyl-alcohol (PVA) bag. </p> <p> A series of experiments determined the combination of diluent, curing rate, and other factors necessary to produce a laminate with the optimum ratio between porosity and strength.<a></a> Evaluation at New York University indicated that the procedure initiallv developed by the Army Prosthetics Research Laboratory produced a satisfactory material insofar as porosity and strength were concerned but that use of the conventional stockinet as filler produced rough surfaces that made cleaning difficult. Subsequent experiments at the Army Prosthetics Research Laboratory showed that this problem could be overcome by using a nylon stockinet of 200-denier Banlon knit (<b>Fig. 1</b>) for the outer and inner layers of the laminate and by the reapplication of a PVA bag at a critical time in the curing process. Further testing and development resulted in a practical technique which is described in detail in a manual prepared by the Army Prosthetics Research Laboratory.<a></a> Sockets fabricated in accordance with this manual have smooth surfaces and high porosities. Patients fitted with porous sockets have reported a definite increase in comfort as a result of improved ventilation.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Porous epoxy laminate made in accordance with the procedure developed at the Army Prosthetics Re search Laboratory. Magnification approximately 21X. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Laboratory tests have shown that porous epoxy laminates are not as strong in compression and tension as nonporous laminates, but that resistance to impact loads appears to increase with the porosity and reach a maximum at approximately 17 per cent of effective porosity.<a style="text-decoration:none;">*</a> In practice, the combination of physical properties possessed by the porous laminate which has been developed is satisfactory for use in arm prostheses. Experiments in the use of porous laminates for lower-extremity prostheses are under way. </p> <p> If actual prosthetist working time is considered, the man-hours required for fabrication of porous laminates are somewhat longer than those required for the conventional plastic laminates. Depending on the technique employed, the porous laminating process may take up to one-and-one-half times as long as the conventional technique. </p> <p> The components of the liquid resin system may elicit allergic reactions in certain sensitive individuals. Therefore, fabrication should take place in a well-ventilated area and protective gloves should be used in preparing the layup. </p> <p> No stump dermatitis or other adverse reactions have been reported from the use of the porous laminates to date. </p> <p> Because the socket is porous, it is necessary that it be cleaned thoroughly and often in order to preclude an accumulation of foreign matter in the pores of the wall. It is recommended that ordinary soap and water be used for this cleaning. </p> <p> Porous laminates may be considered for application to all upper-extremity amputation levels from below-elbow to shoulder-disarticu-lation. The technique is of particular value whenever perspiration presents a significant problem. </p> <h4> Epoxy-Resin Mixture </h4> <p>The following epoxy-resin system has been found to produce a satisfactory porous laminate:</p> <table> <tbody><tr> <td> </td> <td> </td> <td>parts by weight</td> </tr> <tr> <td>Epoxy resin    </td> <td>ERL 2795<a style="text-decoration:none;">*</a>or Epon 815<a style="text-decoration:none;">*</a>    </td> <td>65</td> </tr> <tr> <td>Curing agent</td> <td>Versamid 140<a style="text-decoration:none;">*</a></td> <td>35</td> </tr> <tr> <td>Solvent</td> <td>Trichloroethylene</td> <td>43</td> </tr> </tbody></table> <p> The "pot life" of the liquid resin mixture resulting from this formulation is never less than 30 minutes and usually considerably longer. </p> <p> The individual limb fitter can best determine the actual amount of resin mixture required for a particular lamination. Appendix A (page 29) contains a table which may serve as a guide in determining the correct amounts of materials for various applications. </p> <h4> Fabrication </h4> <p> Briefly described here is the fabrication of a double-wall, below-elbow, porous prosthesis, utilizing a plaster-of-Paris (or wax) buildup; this account is followed by a brief description of the fabrication of a single-wall, below-elbow, porous prosthesis, based on the Mylar<a style="text-decoration:none;">*</a> cone method.<a style="text-decoration:none;">*</a> </p> <h4> Double-Wall, Below-Elbow, Porous Prosthesis </h4> <p> For the fabrication of a double-wall, below-elbow, porous prosthesis, the stump model is prepared in accordance with common practice<a></a>. As shown in (<b>Fig. 2A</b>), the model is then placed in a vise, distal end up, and coated with a lacquer such as Hi-Glo.<a style="text-decoration:none;">*</a> When this coating has dried, a moistened sheet of PVA is stretched over the model and tied at the base (<b>Fig. 2B</b>). The next step in preparing the layup is to cut one length of tubular Banlon stockinet with a 200-denier weave<a style="text-decoration:none;">*</a> and three lengths of tubular orthopedic stockinet so that each is at least 6 inches longer than the stump model (<b>Fig. 2C</b>). The end of each piece of stockinet is sewed in a curve to match the distal end of the model, and the excess stockinet is trimmed at the sewed end. The Banlon stockinet is turned inside out and pulled down over the model (<b>Fig. 2D</b>). Two of the orthopedic stockinets are pulled down over this. Then the remaining piece of stockinet is turned inside out and pulled down over the layup. The stockinet is smoothed, pulled down tightly, and tied at the base. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Preparing the layup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A PVA pressure sleeve is now prepared in the usual manner, pulled down snugly over the layup, and tied at the base rod (<b>Fig. 3A</b>). The layup is ready for impregnation, and it is time to mix the resin. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Applying the resin mixture. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To measure the ingredients for the resin mixture, it is well to balance a disposable container, such as a paper cup, on a scale. The resin, curing agent, and solvent are then put in the cup in the proper amounts by weight. By referring to the table contained in Appendix A (page 29), it can be seen that the following quantities should be sufficient for a short below-elbow socket: </p> <table> <tbody><tr> <td>ERL 2795 (resin).................</td><td>45.5 grams</td> </tr> <tr> <td>Versamid 140 (curing agent)......</td> <td>24.5 grams</td> </tr> <tr> <td>Trichloroethylene (solvent)......</td> <td>30.0 grams</td> </tr> </tbody></table> <p>To this resin mixture should be added an appropriate pigment; for example, 2.5 grams of Caucasian epoxy pigment or 3.5 grams of Negroid epoxy pigment (Appendix A, page 29). The pigment is stirred into the mixture until it is uniformly blended. </p> <p> The resin mixture is poured into the open end of the PVA sleeve and worked down into the stockinet. Twisting the end of the sleeve (<b>Fig. 3B</b>) develops considerable force and aids in the impregnation. </p> <p> When the stockinet is fully impregnated, the PVA sleeve is pulled down, and the excess resin is "strung" down to the proximal end of the layup (<b>Fig. 3C</b>). Next, the PVA sleeve is cut and removed from the layup. Care should be exercised not to spill the excess resin contained in the bottom of the sleeve. The sleeve and the excess resin are discarded. Spilled resin may be cleaned off with isopropyl alcohol or trichloroethylene. The layup is "strung" with a heavy string until no further excess resin appears (<b>Fig. 3D</b>). </p> <p> The layup is now placed for 30 minutes in a pre-heated oven set at 115 deg. F (47 deg. C), for what is known as the pre-cure. During this stage, the solvent evaporates from the layup, leaving it porous. </p> <p> Upon completion of the pre-cure, the layup is removed from the oven, and the oven is set at 212 deg. F (100 deg. C) for the cure. At this step in the procedure, the solvent has evaporated and the resin has gelled slightly. If any areas of the laminate contain excess resin, the excess is "strung" to the proximal end. When the oven has reached a temperature of 212 deg. F (100 deg. C), the laminate is placed back in the oven for one hour. During this hour, the laminate will be cured sufficiently to permit the buildup for the outer socket. </p> <p> At the end of the hour, the laminate is removed from the oven, and the oven is set at 115 deg. F (47 deg. C). </p> <p> As soon as the laminate is cool enough to handle, a sheet of Saran-Wrap or rubber sheeting is placed over the laminate as a separating medium. This sheet will facilitate the release of the outer socket which is to be laminated over the inner shell. </p> <p> For the forearm buildup, plaster of Paris is considered preferable rather than wax, for the reason that wax may enter the pores of the prosthesis. The buildup is done in the usual manner (<b>Fig. 4A</b>). After the plaster has hardened, the paper cone is removed and the plaster of Paris is shaped to the desired contour. Any plaster on the knurled surface of the wrist unit is removed. The plaster is coated with Hi-Glo or some similar lacquer. A PVA sleeve is prepared, moistened, pulled down over the buildup, and trimmed at the wrist unit (<b>Fig. 4B</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The forearm buildup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Next, a piece of Banlon stockinet and a piece of orthopedic stockinet are cut, each about 3 to 5 inches longer than the layup. Another piece of orthopedic stockinet is cut, a little more than double the length of the layup. (Additional lengths of stockinet may be used if additional strength is desired.) </p> <p> The Banlon stockinet is turned inside out, pulled 1 to 2 inches over the distal end, and tied at the wrist unit (<b>Fig. 4C</b>). Excess stockinet that is proximal to the wrist unit is trimmed off. </p> <p> The short piece of orthopedic stockinet is pulled over the longer piece so that both pieces meet at one end. The other end of the short piece should extend just past the middle of the longer piece. </p> <p> These pieces of stockinet are extended and slipped, double end first, down over the wrist unit until the double thickness covers the entire layup (<b>Fig. 4D</b>). The double thickness of stockinet is tied at the wrist unit and pulled down and tied at the proximal end. The Banlon stockinet should be on the inside. Two PVA pressure sleeves are now prepared in the usual manner, with the shiny surface of the material on the inside. One sleeve is set aside to be used later. The other is pulled down snugly over the layup and tied to the base rod at the proximal end. </p> <p> Resin and pigment are mixed in the manner described previously. For a short or medium below-elbow forearm, the following quantities should be sufficient: </p> <table> <tbody><tr> <td>ERL 2795............</td> <td>68 grams</td> </tr> <tr> <td>Versamid 140........</td> <td>37 grams</td> </tr> <tr> <td>Trichloroethylene...</td> <td>45 grams</td> </tr> <tr> <td>Pigment..................</td> <td>As required to match previous mix</td> </tr> </tbody></table> <p> The resin is poured into the pressure sleeve (<b>Fig. 5</b>) and worked into the stockinet. When the stockinet is fully impregnated, the pressure sleeve is pulled down as far as possible, and the excess resin is "strung" down from the layup. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Impregnating the forearm layup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the layup has been thoroughly "strung" down, the PYA sleeve is stripped off and discarded. The layup is "strung" once more to remove all excess resin. </p> <p> There may be considerable resin in the stockinet around the base rod. This excess resin should be absorbed in the scrap stockinet wrapped around the base, so that it will not be drawn back into the laminate during the cure. </p> <p> For the pre-cure, the layup is now placed for 30 minutes in a pre-heated oven set at 115 deg. F (47 deg. C), allowing the solvent to evaporate. </p> <p> While the pre-cure is taking place, the second PVA pressure sleeve previously prepared should be moistened by wrapping it in a damp towel for 10 to 15 minutes. The next step in the procedure gives the prosthesis a smooth surface, and it is essential that the PYA sleeve be thoroughly moistened. </p> <p> Upon completion of the pre-cure, the layup is removed from the oven. The moistened PVA sleeve is pulled down until the entire layup is in contact with the sleeve. Light contact pressure is most desirable, for this will result in a smooth surface without reducing the porosity. It is important that the sleeve slide easily over the layup; otherwise, the force and pressure may cause pooling of the resin. At this point in the procedure, there should be no pools of resin on the stockinet. If there are, they should be "strung" out. </p> <p> The PVA sleeve is taped around the wrist unit (<b>Fig. 6</b>); any severely undercut areas should also be taped. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Molding the surface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The layup is now placed for one hour in an oven pre-set at 212 deg. F (100 deg. C). During this period the PVA sleeve shrinks around the layup, giving the surface a smooth gloss and aiding in molding the undercuts. At the end of the hour, the laminate is removed from the oven and the PVA sleeve is stripped off. At this point the laminate should be firm and free from tackiness. </p> <p> The laminate is now ready for the final cure. It is replaced in the oven, set at 212 deg. F (100 deg. C), for 75 minutes to complete the final cure. </p> <p> While the plastic is still warm, the layup is cut to the desired length. The outer socket will separate easily from the inner socket. The plaster may be removed by striking the socket with a rubber mallet. If necessary, a chisel may be used to dig the plaster out of the distal end of the socket. Remaining PVA film can be stripped off by hand or dissolved with hot water. </p> <p> The prosthesis is held firmly on the amputee's stump, and the trim line is marked, after which the socket is removed and trimmed in the usual manner. After the socket and the forearm have been properly aligned, the edges are sanded and bonded together with liquid epoxy resin (ERL 2795, 65 parts; Versamid 140, 35 parts) (<b>Fig. 7</b>). The bond may be cured with a heat gun, or the prosthesis may be placed for one hour in an oven set at 212 deg. F (100 deg. C). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Bonding the socket and forearm </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The porosity of the finished prosthesis can be tested by holding it under a water tap and allowing the water to run through the prosthesis (<b>Fig. 8</b>). If the prosthesis has been prepared properly, the laminate should show a uniform porosity. The prosthesis is now ready to be harnessed in the usual manner. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Testing the porosity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Single-wall, Below-Elbow, Porous Prosthesis (Mylar Cone Method) </h4> <p> For the fabrication of a single-wall, below-elbow, porous prosthesis, the stump model is prepared in the usual manner,<a></a> placed in a vise, distal end up, and coated with lacquer. When the lacquer has dried, a moistened PVA sheet is pulled down over the stump model and tied at the base. </p> <p> The stockinet layup, consisting of one length of tubular Banlon stockinet and three lengths of tubular orthopedic stockinet, is prepared in the same manner as the stockinet layup for the socket of the double-wall prosthesis previously described. </p> <p> When the stockinet layup is completed (<b>Fig. 9</b>), a sheet of PVA is pulled down over the layup and tied at the base rod. This PVA cover will protect the layup during subsequent steps. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The stockinet layup on the model. A PVA sheet is pulled down and tied at the base rod. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Next, on an 8 in. X 12 in. sheet of Mylar (5-10 mils), a crayon mark is made halfway along one of the sides, about one-quarter in. from the edge. A second mark is made one-half in. inside the first mark. Then two final marks are made; one 3 in. above the first mark, the other 3 in. below the first mark. A curve is drawn from the edge of the Mylar sheet through the upper mark, through the inside mark, through the lower mark, and thence to the edge of the sheet. A cut is made along the curve. This cut side will permit the standard adult wrist unit to fit squarely to the Mylar sheet when it is fitted into a cone (<b>Fig. 10A</b>). The wrist unit should be fitted a minimum distance into the cone. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The Mylar cone buildup and impregnation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The cone is placed over the stump model and adjusted so that the desired contour of the finished prosthesis will be obtained. Next, the prosthetist holds the cone and wrist unit in one hand, placing the unit flat on a table. With the other hand, he positions the stump model in the cone so that the distance between the elbow axis and the table surface corresponds to the required forearm length. The cone is adjusted at the proximal end, and the excess is trimmed off. The shortest cone that will give a desirable final shape to the forearm should be used, since it will provide the greatest bond area between the forearm and the socket. When the correct conical shape is obtained, the cone is closed with transparent tape, the proximal end of the cone is taped to the socket with transparent tape, the wrist unit is taped in place, all holes in the unit are closed with a sealer, and all seams are taped. </p> <p> Next, a piece of orthopedic stockinet is cut so that it is at least 10 in. longer than twice the length of the layup. The stockinet is pulled down over the entire layup in such a manner that half of the stockinet extends above the wrist unit. The stockinet is tied at the wrist unit, and the extended half of the stockinet is pulled back down over the layup. The stockinet is pulled smooth and tied at the base rod. </p> <p> The proximal edge of the Mylar is found by palpation, and a light line is drawn around the layup just distal to the edge of the cone. All the areas below this line are covered with masking tape (<b>Fig. 10B</b>). </p> <p> A batch of resin is mixed as follows: </p> <table> <tbody><tr> <td>ERL2795...................</td> <td>45.5 grams</td> </tr> <tr> <td>Versamid 140..............</td> <td>24.5 grams</td> </tr> <tr> <td>Trichloroethylene.........</td> <td>30.0 grams</td> </tr> </tbody></table> <p> Sufficient pigment is added to give a slight color to the batch. </p> <p> The entire layup is inverted and brush-coated with this resin mixture. The excess resin is "strung" down toward the wrist unit (<b>Fig. 10C</b>). </p> <p> The layup is now placed for 30 min. in a pre-heated oven set at 115 deg. F (47 deg. C) for the pre-cure. After the cone has been pre-cured for 30 min., the oven temperature is increased to 212 deg. F (100 deg. C) and the cone is cured for 30 min. at this temperature. </p> <p> The layup is then removed from the oven, the masking tape is removed from the lavup, and the cone is separated from the inner socket. The Mylar sheeting is removed from inside the porous cone. The porous cone is sanded around the wrist unit until a smooth taper is obtained (<b>Fig. 11</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Sanding the porous cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> With the table contained in Appendix A (page 29) as a guide, a 250-gram batch of resin mixture is prepared, including in it a suitable amount of pigment. </p> <p> At this point the PVA sheet placed over the socket layup early in the procedure is removed, and a PVA sleeve is placed over the socket layup. </p> <p> The inner socket layup is impregnated with resin in the usual manner. Excess resin is removed from the layup by "stringing," the PVA sleeve is removed from the layup, and any excess resin is "strung" out. </p> <p> Now the porous cone is pulled down over the inner socket and aligned so that the wrist unit is in the proper position. The stockinet is tied at the base rod (<b>Fig. 12A</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Preparing the layup combining the socket and the porous cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A piece of Banlon stockinet is cut so as to be 3 to 5 in. longer than the layup, and a piece of orthopedic stockinet is cut so as to be twice the length of the Banlon stockinet. One end of the Banlon stockinet is tied around the wrist unit. The orthopedic stockinet is pulled over the Banlon stockinet and tied at the middle around the wrist unit. (Additional layers of stockinet may be used if greater strength is required.) All layers of stockinet are pulled down over the layup and tied at the base rod (<b>Fig. 12B</b>). </p> <p> The layup is now thoroughly impregnated with the remaining resin mixture, with the use of a PVA sleeve and "stringing." It is very important that all the excess resin be "strung" down toward the proximal end, so that there will be no pooling of resin when a PVA bag is pulled down in a subsequent step. A few pieces of scrap stockinet should be wrapped around the base pipe to absorb excess resin. </p> <p> The layup is now placed for 30 min. in an oven pre-set at 115 deg. F (47 deg. C) for a pre-cure. While the layup is pre-curing, a PVA sleeve is prepared to fit the forearm. The PVA sleeve is wrapped in a moistened towel for 10 to 15 min. during the pre-cure. At the end of the pre-cure, the layup is removed from the oven and any excess resin is "strung" out. The oven temperature is increased to 212 deg. F (100 deg. C). Meanwhile, the moistened PVA sleeve is pulled down over the layup so that the entire laminate is in firm contact with the sleeve. If the sleeve is sufficiently moist, it will slide easily over the layup without causing any resin pools. However, if any resin pools do form, they should be "strung" out of the laminate. The PVA sleeve is taped around the wrist unit and any undercut areas to insure proper lamination. </p> <p> The laminate is now placed for 60 min. in the oven, previously set at 212 deg. F (100 deg. C). At the end of 60 min., the laminate is removed from the oven and the PVA sleeve is stripped off. At this point, the laminate should be free from tackiness. </p> <p> For the final cure, the laminate is replaced in the oven, still set at 212 deg. F (100 deg. C). </p> <p> After the final cure, the laminate is removed from the oven and cut to the desired length. The laminate should separate easily from the mold. </p> <p> The prosthesis is held firmly on the amputee's stump, and the trim line is marked. Then the socket is removed and trimmed in the usual manner. </p> <h4> Polyester-Resin Mixture </h4> <p> Shortly after the initial success of the porous epoxy laminates, attempts were made to produce similarly porous polyester laminates. At first these attempts were unsuccessful. Although highly porous laminates were produced, their physical strengths were inadequate for prosthetic application. </p> <p> However, because of significant improvements in the method of preparing porous epoxy laminates, particularly through the reapplication of a PVA bag at a critical time in the curing process, it was decided to reinvestigate the porous polyester system. The Army Prosthetics Research Laboratory has produced a series of cylindrical, porous polyester laminates which have shown when tested a strength sufficient for prosthesis<a></a>. Preliminary results of the evaluation are promising. The fabrication procedures presently recommended are the same as have been described for porous epoxy laminates in this article and set forth in full in <i>A Manual for the Preparation of Above and Below Elbow Prostheses, </i><a></a> published by the Army Prosthetics Research Laboratory. <b>Appendix A</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Appendix A: Color appropriate for the individual should be added to the resin mixture and stirred in until it is uniformly blended. For a 100-gram mixture, 1 to 4 grams of color is sufficient. Epoxy pigment, Caucasian, tan, No. 22826 (60% pigment) and epoxy pigment, Negroid, brown, No. 22831 (53% pigment) (Plastics Color Company, 22 Commerce Street, Chatham, N. J.) have been used successfully at New York University (7). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The following polyester-resin formulation is tentatively suggested for a medium below-elbow porous prosthesis: </p> <table> <tbody><tr> <td>Laminae 4110<a style="text-decoration:none;">*</a></td> <td>80 grams</td> </tr> <tr> <td>Paraplex P-13<a style="text-decoration:none;">*</a></td> <td>20 grams</td> </tr> <tr> <td>Luperco ATC<a style="text-decoration:none;">*</a></td> <td>3 grams</td> </tr> <tr> <td>Trichloroethylene</td> <td>43 grams</td> </tr> <tr> <td>Naugatuck Promoter No.3<a style="text-decoration:none;">*</a>   </td> <td>6 drops</td> </tr> <tr> <td>Polyester pigment</td> <td> +/- 1 gram</td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li><p>Gray, Henry, <i>Anatomy of the human body</i>, 26th edition, Charles Mayo Goss, ed., Lea and Febiger, Philadelphia, Pa., 1954. </p> </li> <li><p>Hill, James T., <i>A manual for the preparation of above and below elbow porous prostheses</i>, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </p> </li> <li><p>Hill, James T., and Egbert de Vries, <i>Evaluation of porous epoxy laminates for use in prosthetic arms</i>, Army Prosthetics Research Laboratory Technical Report No 5820, July 1958. </p> </li> <li><p>Hill, James T., Egbert de Vries, and Fred Leonard, <i>Porous plastic laminates</i>, SPE Journal, Vol. 16, No. 9, September 1960. </p> </li> <li><p>Hill, James T., <i> Porous polyester laminates</i>, Army Prosthetics Research Laboratory Technical Report No. 6217, August 1962. </p> </li> <li><p>New York University, <i>Adult Prosthetic Studies</i>, Research Division, College of Engineering, Report of evaluation of the APRL porous laminate technique, November 1960.</p> </li> <li><p>New York University, Prosthetics and Orthotics, Post Graduate Medical School, <i>Guide for fabrication of double wall porous epoxy prosthesis for short B/E</i>, September 1961. </p> </li> <li><p>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis</i>, J. B Lippincott Co., Philadelphia, Pa., 194S. </p> </li> <li><p>University of California (Los Angeles), Department of Engineering, <i>Manual of upper-extremity prosthetics</i>, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </p> </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">U. S. Rubber Co., Naugatuck Chemical Division, Naugatuck, Conn.</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">Wallace and Tiernan, Incorporated, Lucidol Division, 174 Military Road, Buffalo, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Rohm and Haas Company, Philadelphia 8, Pa.</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">American Cyanamid Company, Plastics Division, 30 Rockefeller Plaza, New York 20, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., A manual for the preparation of above and below elbow porous prostheses, Army Prosthetics Research Laboratory, Washington, D. C, January 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>5.</b> </td><td class="clsTextSmall">Hill, James T., Porous polyester laminates, Army Prosthetics Research Laboratory Technical Report No. 6217, August 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>9.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper-extremity prosthetics, 2nd edition, W. R Santschi and Marian P. Winston, eds., 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">Wm. H. Horn and Bros., Philadelphia, Pa.</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"> Western States Lacquer, Dallas, Tex. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper-extremity prosthetics, 2nd edition, W. R Santschi and Marian P. Winston, eds., 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">Both accounts compiled for CPRD, NAS-NRC, from A Manual for the Preparation of Above and Below Elbow Porous Prostheses(2), published by the U.S. Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington 12, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">DuPont Corporation Trademark.</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">General Mills Chemical Division, Kankakee, Ill.</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">Shell Chemical Company, New York, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Bakelite Chemical Division, Union Carbide Chemical Company, New York, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Effective porosity is the ratio of the quantity of water that flows through the laminate to the amount that flows through the stockinet alone.</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, Adult Prosthetic Studies, Research Division, College of Engineering, Report of evaluation of the APRL porous laminate technique, November 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., A manual for the preparation of above and below elbow porous prostheses, Army Prosthetics Research Laboratory, Washington, D. C, January 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>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Hill, James T., and Egbert de Vries, Evaluation of porous epoxy laminates for use in prosthetic arms, Army Prosthetics Research Laboratory Technical Report No 5820, July 1958. </td></tr><tr><td class="clsTextSmall"><b> 4.</b> </td><td class="clsTextSmall">Hill, James T., Egbert de Vries, and Fred Leonard, Porous plastic laminates, SPE Journal, Vol. 16, No. 9, September 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Gray, Henry, Anatomy of the human body, 26th edition, Charles Mayo Goss, ed., Lea and Febiger, Philadelphia, Pa., 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Leonard, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Scientific Director, APRL, WRAMC, Washington 12, 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>James T. Hill, C.E., B.S. </b></td></tr><tr><td class="clsTextSmall">Chief, Process Engineering Section, U.S. Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington 12, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-21.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-22.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-23.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-24.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-25.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-26.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-27.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-28.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-29.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-29b.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-31.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-32.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-33.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 Porous Plastic Laminates for Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource James T. Hill, C.E., B.S. * Fred Leonard, Ph.D. * https://staging.drfop.org/files/original/d7b675b0378cee1912a8d5e84687921d.pdf 9d96407f8c68159964c5da7b9a38bd7f https://staging.drfop.org/files/original/3d9d7c0b41f15695d1d34ad758690f2a.png 69bc94cb8f542767a5c7ce6a7afa1b4a https://staging.drfop.org/files/original/d65d1661f0886e3d968a3606ff3a6a5c.jpg 87ff5e2a3fe1a34b03c0c39672002824 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_01_033.pdf Text Any textual data included in the document <h2>Immediate Post-Operative Orthotic Impression Technique for Thermoplastic Spinal Orthoses Following Spinal Surgery</h2> <h5>James T. Lehner, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Wilbur A. Haines, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Mark E. Horwitz, CO.&nbsp;<a style="text-decoration: none;">*</a><br />Cynthia J. King, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Spinal surgery has been revolutionized in recent years by advances in surgical approaches, surgical techniques, and forms of internal fixation. Post-operative management has progressed from bed rest with log rolling, to mobilization in plaster casts, to modern technology orthoses. Co-polymer plastic composite orthoses have been used by the authors during the last few years. The orthoses have been easy to apply and have been comfortable for our patients. There have been no associated complications which would jeopardize the outcome of the operative procedure.</p> <h3>Patient Selection</h3> <p>The original patient the authors selected for management using a thermo-plastic orthosis was a retarded child with cerebral palsy who had previously been intolerant of casting, developing pressure sores within the cast. Molding for the co-polymer orthosis had to be done while the patient was anesthetized, since this patient was combative and otherwise difficult to work with. While the impression for this patient was being made, it became apparent that this molding technique would be easy to do in the operating room at the conclusion of operative spinal procedures. Initially, this postoperative molding technique was used for "special cases." These included patients with cerebral palsy, myelomeningocele, severe osteoporosis, and patients with severe respiratory problems. Eventually, the older adult idiopathic population which seemed very intolerant of rigid metallic orthoses or casting, was included. Things have gradually evolved to a point where most patients, other than teenage idiopathics, are candidates for this type of orthosis. The authors still prefer using a Kosair metallic axillary crutch style orthosis postoperatively for adolescent idiopathic scoliosis patients, since they seem to tolerate the rigidity of this system well.<a></a></p> <p>The first 80 patients fitted with the co-polymer postoperative spinal orthotic system are reviewed in this study.</p> <p>Diagnoses include all the aforementioned, plus other types of muscular dystrophy, congenital scoliosis, tumors, post-menopausal deformities, and degenerative spinal deformities. All orthoses were applied after long (minimum of six vertebral levels) spinal fusions. All surgical cases, except those of congenital scoliosis, were routinely done with instrumentation.</p> <h3>Orthosis Impression Technique</h3> <p>The orthotic impression is taken immediately after the spinal surgery while the patient is still asleep. The technique is:</p> <ol> <li> <p>After the skin incision is closed, a light layer of Adaptic® and one layer of sterile four-by-fours are placed over the wound.</p> </li> <li> <p>The skin is bilaterally marked longitudinally along the mid-axilla (mid-coronal line) using a wet indelible pencil. Perpendicular hash marks are randomly made across the mid-axillary line to be used as "key" reference marks later.</p> </li> <li> <p>Sterile Vidrape® is placed across the patient's back to establish an impermeable membrane.</p> </li> <li> <p>The Vidrape® is marked by superimposing onto it the marks made previously on the patient's skin.</p> </li> <li> <p>Plaster splints are draped across the required area of the patient's torso, making sure that the plaster crosses the mid-axillary lines on both sides of the patient. The first layer is applied using two or three thicknesses of plaster. Subsequent reinforcing layers are applied, using about six layers of plaster. Finally, a few strips are applied to help prevent distortion of the mold. These are placed across the mold at two or three locations in the shape of an inverted "V."</p> </li> <li> <p>At this point, the posterior section of the impression is removed from the patient when hard (<a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-1.jpg"><b>Fig. 1</b></a>).</p> <span><strong>Figure 1. Orthotist removing posterior mold. Note Vidrape® and markings in mid-axillary line</strong>.</span></li> <li> <p>The Vidrape® is then removed in a manner which keeps plaster or water from touching the wound.</p> </li> <li> <p>Sterile dressings are applied by the scrub nurse, who has remained sterile to this point.</p> </li> <li> <p>The patient is placed on the post-operative bed that has been prepared using one extra sheet.</p> </li> <li> <p>Vidrape® is then applied to the patient anteriorly in preparation for the anterior section molding. (Cover breast and groin areas with four-by-fours or diapers.)</p> </li> <li> <p>The indelible pencil marks are again superimposed onto the Vidrape® along the mid-axillary lines, and appropriate relief markings are made on the rib cage and iliac crests.</p> </li> <li> <p>The anterior mold is made using the technique described in step five. When set, the plaster is removed.</p> </li> <li> <p>Finally, the Vidrape® is carefully removed and the patient is ready to go to the post-operative recovery room.</p> </li> </ol> <p>After the impression has hardened sufficiently, a cast cutter may be used to cut along the mid-axillary indelible lines, visible on the inner surfaces of each half of the impression. Using the "key" hash marks established previously, the two impression halves are joined together with plaster strips. The impression is now ready for orthotic fabrication using the method of choice.</p> <p>Since the impression has been made with the patient in the prone and supine positions, the orthotist must take this into account when fabricating the orthosis. The medial-lateral dimension of the patient is distorted normally about one inch due to the flattening effect created by the patient's weight against the operating and post-operative bed.</p> <p>The time required for the impression procedure adds 15 to 20 minutes of extra anesthesia and operating room time. There have been no infections in any of these cases.</p> <h3>Results</h3> <p>The orthosis described has been applied to 80 post-spinal surgery patients between January 1980 and October 1984. There were no cases of rod dislodgement or pseudoarthrosis. Fifty-eight patients had instrumentation done using segmental spinal wiring with either L-Rod or Harrington Rod fixation. One Mongoloid boy broke a wire in his L-Rod fixation, but over a subsequent 24 month follow-up, has shown no further wire or rod breakage. No other incident of internal fixation failure while wearing the orthosis has been encountered to date. Early in the series, one orthosis had to be remade due to pressure problems. No other orthosis has required anything except routine minimal corrections of trim lines. In the beginning, the average time of orthotic application was the eighth post-operative day. Later in the series, this dropped to the fifth post-operative day. Orthotic application varied from the second to the thirteenth day post-op and was determined by the patient's medical condition in all but one case. The patients were placed upright immediately upon application of the orthosis (<a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg"><b>Fig. 2</b></a>). They were dismissed from the hospital an average of four days after the orthosis was applied.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg">Figure 2.</a> Post-op Spina Bifida child two days after brace application and four days post-operatively. Note colostomy site on right lower quadrant.</strong><br /> <p>Orthoses were worn about six and one half months post-operatively (the first 25 patients wore theirs for eight months post-op; all subsequent patients have worn theirs for six months post-operatively).</p> <p>Compliance has been monitored by the parents or guardians of the patients. They have reported 100 percent compliance. The parents are instructed that the orthosis may be removed when the patients are supine, for bathing, skin care, and pulmonary toilet as needed. Patients are never allowed up in the sitting position without wearing the orthosis during the six month post-operative period. One-half of the patients were non-ambulatory.</p> <h3>Discussion</h3> <p>This is an easy, quick, and accurate way to measure and apply post-operative thermoplastic orthoses after spinal surgery. It has been possible to eliminate patient discomfort during the molding process and no manipulation of the patient was required during the procedure.</p> <p>While this technique requires a close working relationship between physician, hospital personnel, and orthotist, it has virtually eliminated time delays in orthotic delivery. Historically, orthotic impressions were taken "when the patient was ready post-operative-ly." This left the impression making process in a nebulous time frame. Typically, patients were delayed in the application of their orthosis by a few days. This added additional patient time in the hospital with little benefit. Also, the orthotist had to schedule the impression making process at a time convenient to appropriate hospital personnel.</p> <p>The technique described gives the orthotist and his/her staff adequate time to properly design and fabricate the orthosis. Although none of the patients were felt to be ready to ambulate or sit on the first post-operative day, it would be possible to apply the orthosis, if necessary, within 24 hours. Many of the severe respiratory cases (spinal muscular atrophy) were fitted with their orthoses and sat up while still on a respirator in intensive care. There was only one case where orthotic application delayed patient mobility (orthosis revision was necessary). Usually, comfort was the deciding factor in-getting patients up. Later in this study group, when indications were broadened to include healthier patients, the time frame post-op of ambulation decreased significantly.</p> <p>It is believed that molding for a spinal orthosis while the patient is awake, several days after surgery, is unnecessarily painful. It also places the patient in some jeopardy of dislodging the instrumentation while having the impression made. It is also considered irrational to mold patients for an orthosis at a time when they are actually ready to be up and around. The authors do not trust segmental spinal instrumentation without external bracing, and reports now indicate this conservative approach, including the use of an orthosis, in this group of patients is warranted.<a></a> Retarded children and patients with anesthetic skin easily get into trouble with body casts and non-removable orthoses. The orthotic system described certainly helps to alleviate many of the problems previously encountered with post-operative spinal orthoses. This technique is still not used for the standard adolescent idiopathic patient, who in our judgment currently does well with Harrington Instrumentation fixation and post-operative bracing using a rigid metallic Kosair type orthotic system.</p> <h3>Advantages</h3> <p>The co-polymer post-operative orthotic spinal system has many advantages:</p> <ol> <li> <p>Minimal patient discomfort;</p> </li> <li> <p>Expedient spinal orthosis application;</p> </li> <li> <p>Maximum utility for patient care (skin cleansing, checking anesthetic skin, respiratory therapy, etc.);</p> </li> <li> <p>Taking an accurate impression with minimal post-operative movement of the patient; and</p> </li> <li> <p>Excellent wearing compliance by patients.</p> </li> </ol> <h3>Disadvantages</h3> <p>While there are disadvantages to most anything, the negative points of this technique and system are few. They would include:</p> <ol> <li> <p>Increased anesthesia and operating room time (15-20 min.);</p> </li> <li>Tight post-op scheduling of the orthotist's time (Requires a close working relationship with physician, hospital personnel, and orthotist).</li> </ol> <em><b><br />*James T. Lehner, M.D. </b>James T. Lehner, M.D. is from the Wright State University College of Medicine, Division of Orthopedics.<br /><br /><b>*Wilbur A. Haines, C.P.O. </b>Wilbur A. Haines, CO. is President of LaForsch Orthopedic Laboratories, 536 Valley Street, Dayton, Ohio<b><br /><br />*Mark E. Horwitz, CO. </b>Mark E. Horwitz, CO. is Director of Orthopedic Services for LaForsch Orthopedic Laboratories.<b><br /><br />*Cynthia J. King, CO. </b></em><span><span><em>Cynthia L. King, CO. is with the Clinical Orthotic Services at LaForsch Orthopedic Laboratories</em><br /><br /></span></span> <p><b>References:</b></p> <ol> <li>Benson, S.; McKinley, L.M.; Martin, T., Delto-Pec-toral Axillary Lumbar Thoracic Support. Kosair Orthotic Laboratory, Louisville, Kentucky (Unpublished Data).</li> <li>Broadstone, P.; Johnson, J.R.; Holt, R.T.; Leath-erman, K.D., "Consider Post-operative Immobilization of Double-L Rod S.S.I. Patients," <i>Orthopedic Transactions</i>, 8(1):171-172, 1984.</li> <li>Taddonio, R.F.; Weller, K.; Appel, M., "A Comparison of Patients With Idiopathic Scoliosis Managed With and Without Post-operative Immobilization Following Segmental Spinal Instrumentation With Luque Rods," <i>Orthopedic Transactions</i>, 8(1): 172, 1984.</li> <li>Wallace, S.L.; Fillauer, K., "Thermoplastic Body Jackets for Control of Spine after Fusion in Patients with Scoliosis," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 3, pp. 20-24, September, 1979.</li> </ol> Page Number(s) 33 - 37 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Immediate Post-Operative Orthotic Impression Technique for Thermoplastic Spinal Orthoses Following Spinal Surgery Creator An entity primarily responsible for making the resource James T. Lehner, M.D. * Wilbur A. Haines, C.P.O. * Mark E. Horwitz, CO. * Cynthia J. King, CO. * https://staging.drfop.org/files/original/f2f2342e1e6c5a7524fbbb113dcd429d.pdf b5a27a06fe4080ab7de494f9ef3f12a2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_006.pdf Text Any textual data included in the document <h2>What is Spina Bifida?</h2> <h5>Jeannie Gruse&nbsp;</h5> <p>I have chosen to do this report on spina bifida because of little Stephen Smith, a happy, loving, well-adjusted boy, who was born thirteen years ago with this condition. Stephen's parents are friends and neighbors, and I well remember the day that Kent came over to tell us about the birth of their first son.</p> <p>When he described their handsome baby boy, and then explained that he had a birth defect called spina bifida, I had no idea what he was saying; I had never heard of this condition. Pam and Kent knew very little at that time, either, but in nine years of surgery, emergencies, difficult care, exercising, training, and learning, this has certainly changed for them. Kent is currently the Executive Director of The Spina Bifida Association of America, dedicated to "making the public, professional and all governmental agencies more aware of this worldwide health problem and assisting parents in helping their children." The program is also directed toward improving comprehensive medical care for children and adults with spina bifida, and expanding research programs which will search for the cause of this birth defect.</p> <p>Spina bifida is a serious condition, and until thirty years ago, few babies born with it survived beyond infancy. The treatment techniques developed within the last two decades make it possible for the majority of these children to grow to adulthood and live happy, productive lives in spite of their disability.</p> <p>Spina bifida is not a new birth defect; it was referred to 2,000 years ago, and was described by a Dutch physician, Nicholas Tulp, friend of Rembrandt, in 1652. The technical terms, spina bifida aperta or spina bifida manifesta relate to a structural defect caused by failure of the neural plate to develop into a tubular structure. In the area where this occurs, the defect is technically referred to as myelomeningocele (G. myelos = marrow; meninx = membraine; kele = hernia). In development, plates of bone fail to close over the defective area of the spinal cord and there is a short spine on each side of open spinal cord rather than a single one in the midline, therefore the term spina bifida. If the bony plate does not close over the spinal cord during infancy, this defect is referred to as spina bifida occulta (hidden). This type generally causes no problems.</p> <p>The newborn baby will have an obvious lump or cyst-like lesion on the back. It may be covered with skin, or more often wholly or partially covered with translucent bluish or white membranes. There may be a flat plate of imperfectly formed spinal cord on the surface of the cyst which may be leaking cerebro-spinal fluid.</p> <p>While there are many claims or suggestions of causes of spina bifida, it is generally considered to be caused by an unknown environmental agent interacting with genetic factors, according to Dr. Swinyard, Stanford University authority on spina bifida. Multiple complex problems presented by newborns with spina bifida have discouraged some physicians from applying the available intensive medical care and technologies to preserve lives of the more severely defective newborns. A number of physicians have advocated strongly that such treatment be withheld from newborns, presenting certain criteria with the expectation that these babies would soon die. This presents serious moral and legal problems, obviously, relating to rights of the children and the rights of parents to make such decisions, and since the predictability of death is quite uncertain, those who survive may have unnecessarily serious and lasting damage.</p> <p>There are many problems associated with spina bifida besides the obvious surgery necessary, often immediately, to correct the condition. There is loss of awareness of touch, pain, pressure, and heat or cold in those areas of skin normally innervated by nerves involved in the spinal cord defect. There is muscle weakness in the lower limbs and lower trunk, the latter often resulting in weakness in muscles of the bladder and bowel, preventing normal control.</p> <p>Nearly 70 percent of infants with spina bifida develop an associated defect known as hydrocephalus, causing a rapid enlargement of the head from the abnormal accumulation of fluid inside the brain. Although it does not occur in all of the infants, this problem is potentially a life threatening one which requires prompt attention of a neurosurgeon, and even then may often result in varying degrees of brain damage.</p> <p>The degree of severity of these conditions associated with spina bifida varies widely. Some children will be able to walk without assistance, others may need braces or a wheelchair. Because spina bifida is such a complex condition, these cases are usually referred to a pediatric neurosurgeon who is part of an organized team. He will decide on the surgical closure of the myelomeningocele, carefully watch for signs of hydrocephalus, and be responsible for the management of this condition if it occurs.</p> <p>Development of hydrocephalus would involve a serious neurosurgical emergency, as severe brain damage or death could result from the pressure of the fluid within the brain. A shunting procedure is used to reduce this condition, which consists of inserting one end of a flexible tube info a brain ventricle and passing the tube through a small opening in the skull. It is then passed underneath the skin from the head, either to the heart or to the abdomen, and includes a one-way valve which prevents the backward flow of spinal fluid. Even this procedure, a vital one to prevent pressure on the brain, is not totally free of dangers, as shunts can be obstructed or collapse, and revision is often necessary. However, it is the best procedure, and the only effective treatment currently available to allow the brain to develop more normally.</p> <p>Besides the neurosurgeon, spina bifida children will be seen by a number of different specialists. A urologist may be necessary to control urinary infections, and to keep the lack of bladder control from becoming a problem. The pediatrician will watch the child's general health and work on management of the problems relating to lack of bowel control.</p> <p>The orthopedic surgeon will have as his primary concern the growth and development of the bones and muscles. Children with spina bifida often have hip dislocation, club feet, scoliosis, kyphosis or lordosis. He will suggest surgery, braces or crutches when needed. An orthotist will fill the surgeon's prescriptions and work with the child as he grows. In conjunction with the orthotist, a physical therapist will also help carry out the plans made by the orthopedic surgeon and will suggest others designed to strengthen weak muscles.</p> <p>Finally, an occupational therapist may also aid in carrying out the physician's suggestions. She will work primarily with motor coordination and preceptual-motor impairment, and will assist in helping the child adapt to his physical environment in activities. Even with all of these trained experts' help, it is obviously the parents who are chiefly involved in the daily training and care of spina bifida children.</p> <p>I feel fortunate to have been involved, along with my daughter, friends, relatives, and church member volunteers in a program of "patterning" with little Stephen a few years ago. The theory of the program was that an infant's ordinary body movements stimulate brain development through sensory-motor input. Gradually the child's movements become coordinated in cross-patterned crawling, creeping, and walking. By stimulating the body in various ways it was hoped we could "wake up" and condition the pathways to the brain and activate the millions of unused cells within the brain. The method involved artificially recreating patterns of movement in hopes of reaching the brain and having the brain take over these same movements on its own. With three people helping three or four times a day, we helped Stephen and his mother go through his prescribed exercise schedule according to the training his mother had previously received.</p> <p>While some individuals with spina bifida have average or above average intelligence, those who also have hydrocephalus may, as a result, have some degree of mental retardation. The best school placement and curriculum planning will depend also upon physical limitations. The main consideration is mat the child be placed in a flexible situation for effective learning.</p> <p>Since many spina bifida children do have learning problems, teaching must be individualized, based on strengths and weaknesses. This may be possible in a regular classroom, mainstreamed partially, or in a self-contained situation, depending on the severity of the physical condition and the extent of the learning disability.</p> <p>When Stephen was nine years old, he was completing first grade work, and beginning second, at the Fullerton School, in Addison. He was in a structured, protective environment with reinforcement of one full-time teacher and an aide to six or seven students; this was a self-contained room called Orthopedic-Learning Disabilities, with mainstreaming for music and art.</p> <p>Having spina bifida means different things to different people. The actual physical condition varies greatly from person to person. How a person manages in life depends not only on the severity of the actual physical condition, but also upon the support he gets from others, the adaptations in the environment, and most of all, how the person feels about himself. With the tender, loving care and dedication of parents such as Pam and Kent Smith, spina bifida children like Stephen have a chance to grow up, able to cope with their own limitations, and to manage very well in life, feeling good about themselves.</p> <p><b>References:</b></p> <ol> <li>Anderson, Elizabeth M., and Spain, Bernie, <i>The Child With Spina Bifida</i>, London: Methuen and Co. Ltd., 1977.</li> <li>Kieran, Shari Stokes, Ed.D., and Connor, Frances Partridge, Ed.D. "Mainstreaming Preschoolers," <i>Children With Orthopedic Handicaps</i>, U.S. Department of Health, Education, and Welfare.</li> <li>Klein, Stanley D., Ph.D., <i>Psychological Testing of Children</i>. The Exceptional Parent Press, 1977.</li> <li>Lindsay, Carolyn N., M.Ed., <i>An Educator's Guide to Spina Bifida</i>, U.S. Department of Health, Education, and Welfare, 1978.</li> <li>Osman, Betty B., <i>Learning Disabilities, A Family Affair</i>, New York: Random House, 1979.</li> <li>Pieper, Betty, <i>By, For and With . . . Young Adults With Spina Bifida</i>, Chicago: Spina Bifida Association of America, 1979.</li> <li>Pieper, Betty, <i>Sticks and Stones, The Story of Loving a Child</i>, Syracuse: Human Policy Press.</li> <li>Pieper, Betty, <i>The Teacher and the Child With Spina Bifida</i>, Chicago: Spina Bifida Association of America, 1979.</li> <li>Pieper, Betty, <i>When Something is Wrong With Your Baby</i>. Chicago: Spina Bifida Association of America, 1977.</li> <li>Reid, Robert, <i>My Children, My Children</i>, New York: Har-court Brace Jovanovich, 1977.</li> <li>Swinyard, Chester A., M.D., Ph.D., <i>Decision Making and the Defective Newborn</i>, Springfield: Charles C. Thomas, 1978.</li> <li>Swinyard, Chester A., M.D., Ph.D., <i>The Child With Spina Bifida</i>, Chicago: Spina Bifida Association of America, 1977.</li> </ol> Page Number(s) 6 - 8 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Expert 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 What is Spina Bifida? Creator An entity primarily responsible for making the resource Jeannie Gruse  https://staging.drfop.org/files/original/25d7008c03dbf5520812970f5e24a3b8.pdf 5e4f5d62d004e9714dae9287001a5288 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_088.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 88 - 116 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_088.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_088.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee, VII. Psychological Factors</h2> <h5>Jerome Siller, Ph.D. <a style="text-decoration:none;">*</a><br />Sydelle Silverman, M.A. <a style="text-decoration:none;">*</a><br /></h5> <p> With the possible exception of the introductory Section I (Artificial Limbs, Spring 1958; Vol. 5, No. 1), the foregoing presentations in this series have in general been concerned with the biomechanical aspects of the man-machine entity in prosthetic restoration. If, however, our understanding of amputee needs and limitations is to be comprehensive, we must inquire also into the mental and emotional characteristics of the man served by the machine. Consideration of the psychological factors in amputee rehabilitation was therefore an important aspect of the Upper-Extremity Field Studies, and the results of these investigations are summarized in this three-part article. The first part, <i>Personality Dynamics of Amputees,</i> discusses a number of the psychological variables that are relevant to amputation. The second deals with <i>Social and Functional Factors in Prosthetic Wear.</i> And the final one, <i>Attitudes Toward Prosthetic Wear, Before and After Fitting,</i> describes the attitudes shown toward arm prostheses by amputees who had never before worn an artificial arm. The rationale of the study, and the data-collecting instruments here referred to as "appendices," are all to be found in Section I (Artificial Limbs, Spring 1958; Vol. 5, No. 1; pp. 46 through 56). </p> <h3>Personality Dynamics of Amputees</h3> <p>At present no single theory, or combination of theories, encompasses all the central problems arising in man from the loss of a limb. One reason for this circumstance is that the special problems and needs of the amputee have never been defined adequately. What does an amputation mean to the amputee? What does it mean to his family, friends, and co-workers? What reaction does the amputee have to his loss? How is he affected socially, vocationally, emotionally? Does his amputation cause basic psychological changes? What major needs are frustrated? What new needs arise? Does prosthetic restoration affect personality restoration? These are but some of the questions that seem pertinent and to which answers were sought during the NYU Upper-Extremity Field Studies.</p> <p>A probing of specific amputee problems was considered to be the most fruitful approach, and accordingly a set of questions was designed to elicit information about areas in which the amputee might be expected to have significant problems. By means of a 57-item, multiple-choice questionnaire (Appendix IIIE), supplemented by a 9-item instrument calling for narrative answers (Appendix IIIF), nine personality variables (acceptance of loss, identification with the disabled, functional adequacy, independence, sensitivity, appraisal of acceptance by others, sociability, frustration, and optimism) were identified and defined. Of 359 adult male amputees who responded in this phase of the investigation, all but 55 were currently wearing prostheses or had worn one in the past.</p> <p>Each of the nine personality variables has many ramifications, and it was possible to investigate a limited number only. Moreover, a preliminary analysis indicated that the data did not differ significantly for different levels of amputation, and accordingly the responses of the three groups (below-elbow, above-elbow, and shoulder-disarticulation) were combined. The results therefore represent only an early exploration of the field with two principal purposes-first, to stimulate further inquiry, and, second, to build a more general awareness of the psychological aspects of treating and dealing with amputees. While the central concept of each variable is discussed here, emphasis has been placed on principles of theoretical and practical interest to those concerned with the management of amputees. Whenever possible, the interrelationships between a particular concept and other variables are examined, and an effort is made to bring out implications for research and practice. Vocational attitudes provided an additional area of interest, as did also the shifts in the valuation of prosthetic service.</p> <p>The data presented are chiefly those gathered after the period of treatment and fitting. Although the treatment procedure produced few measurable changes of any consequence, where such changes were observed they are also discussed.</p> <h4>Acceptance of Loss</h4> <p>"Acceptance of loss" refers to the amputee's ability to accept the physical limitations that result from his injury, to avoid depreciating or pitying himself, and to recognize the social implications of his loss without exaggerating or denying them. This matter was explored by means of questions relating to the amputee's adaptation to his loss, his wishful thinking about the lost limb, and his reaction to the artificial one.</p> <p>When the treatment period was over, most of the subjects claimed to be adapted to their loss:</p> <table> <tbody><tr> <td> <p><b> To what extent do you feel that you have become adapted to the loss of your limb?</b> </p> </td> </tr> <tr> <td> <p>Completely</p> </td> <td> <p>42%</p> </td> </tr> <tr> <td> <p>Almost completely</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Considerably</p> </td> <td> <p>16</p> </td> </tr> <tr> <td> <p>Somewhat</p> </td> <td> <p>5</p> </td> </tr> <tr> <td> <p>Slightly</p> </td> <td> <p>5</p> </td> </tr> </tbody></table> <p>Before the treatment period, only 35 percent of the amputees said that they felt completely adapted to their loss. The increase to 42 percent after completion of the treatment program would seem to indicate that the fitting of the artificial limb had a strong positive effect upon the adaptation of at least a small number of amputees.</p> <p>Although 90 percent of the amputees claimed either complete, almost complete, or considerable adaptation to their respective losses, it is doubtful that so many had really achieved it. While some may truly have accepted their physical loss and its implications, there were surely many who were trying to maintain feelings of bodily integrity and adequacy by denying the personal and social concomitants of amputation. Clearly, they preferred to de-emphasize regret and any hint of abnormality and difference. In keeping with this feeling, 86 percent of the amputees said that they rarely, very rarely, or never felt sorry about their loss:</p> <table> <tbody><tr> <td> <p><b> Do you feel sorry that you're an amputee?</b> </p> </td> </tr> <tr> <td> <p>Most of the time</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>13</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>12</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>33</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>41</p> </td> </tr> </tbody></table> <p> But it should be noted that many amputees <i>do</i> admit that they have fantasies about the matter: </p> <table> <tbody><tr> <td> <p><b> Do you find yourself wishing you were a two-handed person?</b> </p> </td> </tr> <tr> <td> <p>Much of the time</p> </td> <td> <p>8%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>45</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>28</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>10</p> </td> </tr> </tbody></table> <p>A second question also explored this phenomenon :</p> <table> <tbody><tr> <td> <p><b> Do you ever think of how much better off you would be if you had not lost an arm?</b> </p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>6%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>16</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>14</p> </td> </tr> </tbody></table> <p> Thus it appears that, although most amputees try to avoid thinking about themselves as amputees, regrets over their loss <i>do</i> come out in fantasy. Other indications of this subconscious process can be seen in the contradictory data resulting from different avenues of questioning. About half of the amputees indicated that they frequently tried to perform with their prostheses tasks which they knew would be difficult, and approximately the same number said that what bothered them most was "the inability to perform as I used to." Both of these reactions, which persisted throughout the entire period of participation in the program, seem to represent the amputee's attempt to retain his status as an active, competent, and self-sufficient person. But an amputee who frequently tries to use his artificial arm for a task that he knows will be difficult must have an unrealistic attitude toward his physical limitation. He is evidently demonstrating an unwillingness to accept the full implications of his loss. </p> <p>Among the many considerations involved in the loss of an arm, the most obvious is the inability to perform at one's previous level. Others are the loss of normal appearance and the thought of not being like other people. Although 57 percent of the amputees said that performance was their most bothersome problem, while only 15 percent mentioned the other two considerations, it is difficult to accept such a response at face value. It is likely that the loss of normal appearance and the thought of not being like other people bother amputees far more than they are willing to admit.</p> <p>Two factors lead us to this belief. First, we are convinced that people (and men in particular) hesitate to admit that they are concerned over their appearance or over the thought of not being like other people. An amputee probably finds it much more acceptable, both personally and socially, to seize upon the very real functional and vocational problems caused by his amputation and to use them as the "real" causes of his distress. Secondly, an amputee who admits to being bothered by his inability to perform is really also saying that he is concerned about being different from others, since performance difficulties as well as altered appearance make one "different."</p> <p>Amputation has also other, less obvious aspects that are even more difficult for the amputee to accept. These involve the subconscious effects of the loss, such as the thwarting of life goals, threats to masculinity-femininity identifications, and the arousal of latent fears of castration. Although the reality and importance of these problems have repeatedly been demonstrated clinically, controlled investigation designed to explore them is exceptionally difficult and has not yet been undertaken. Hence most of the subconscious effects of amputation cannot yet be evaluated systematically, even though it seems clear that they exert a great influence upon the amputee's acceptance or nonacceptance of his loss.</p> <p> In general, it may be concluded that an amputee's acceptance of loss depends upon many factors, the most important usually being beyond his own control. His ability to accept depends upon his conscious and subconscious interpretation of his status. If he feels that his amputation has relegated him to an inferior social and vocational status, that he can no longer achieve his principal goals, that he is inferior, and that he has been reduced in functional and sexual potency, he will naturally attempt to reject the implications of his loss. If he looks upon his amputation as a means of escaping from the competition of everyday life, he may accept his loss. If it justifies catering to his need to feel dependent, he may even derive satisfaction from it. But when the amputee is able to look upon his experience as primarily a major frustration that must be overcome-and that <i>can</i> be overcome by his own efforts, in cooperation with family, friends, and rehabilitation personnel-then the stage is set for a real acceptance of loss. </p> <p> Although it seems clear that when first seen many of the participating amputees had not achieved full acceptance of their loss, experience shows that, after the early postamputa-tion period of readjustment, and after satisfactory prosthetic fitting, most amputees <i>do</i> accept their loss to a significant degree. </p> <h4>Identification with the Disabled</h4> <p>"Identification with the disabled" refers to the degree to which the amputee considers his abilities, general appearance, and personality similar to those of other persons physically impaired. To a great extent this factor serves as the basis for his interaction with others.</p> <p>The basic question exploring this matter was:</p> <table> <tbody><tr> <td> <p><b> I think of myself as a:</b> </p> </td> </tr> <tr> <td> <p>physically abnormal person....</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>normal person except for a major physical defect....</p> </td> <td> <p>18</p> </td> </tr> <tr> <td> <p>normal person except for a slight physical defect....</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>normal person except for a very slight physical defect....</p> </td> <td> <p>24</p> </td> </tr> <tr> <td> <p>completely normal person...</p> </td> <td> <p>28</p> </td> </tr> </tbody></table> <p>Obviously the subjects tended to describe themselves as normal persons and to de-emphasize their physical defects. Of particular interest are the 28 percent who described themselves as completely normal, not even conceding a "very slight" defect.</p> <p>Few of the subjects admit that amputation is of considerable consequence:</p> <table> <tbody><tr> <td> <p><b> Do you think being an amputee makes:</b> </p> </td> </tr> <tr> <td> <p>a considerable difference?</p> </td> <td> <p>7%</p> </td> </tr> <tr> <td> <p>some difference?</p> </td> <td> <p>31</p> </td> </tr> <tr> <td> <p>a slight difference?</p> </td> <td> <p>19</p> </td> </tr> <tr> <td> <p>a very slight difference?</p> </td> <td> <p>26</p> </td> </tr> <tr> <td> <p>no difference at all?</p> </td> <td> <p>17</p> </td> </tr> </tbody></table> <p>In keeping with their expressed tendency to place the fact of amputation in the background, and to consider themselves physically normal persons, most claimed that they often forgot about their amputations:</p> <table> <tbody><tr> <td> <p><b> I forget that I am an amputee:</b> </p> </td> </tr> <tr> <td> <p>never.</p> </td> <td> <p>7%</p> </td> </tr> <tr> <td> <p>rarely.</p> </td> <td> <p>4</p> </td> </tr> <tr> <td> <p>sometimes.</p> </td> <td> <p>21</p> </td> </tr> <tr> <td> <p>most of the time.</p> </td> <td> <p>61</p> </td> </tr> <tr> <td> <p>all of the time.</p> </td> <td> <p>7</p> </td> </tr> </tbody></table> <p>Still tending to play down any differences, 67 percent of the subjects said that they thought amputees had about the same number of personal problems as did nonamputees. At the start of the treatment program, only 57 percent of the amputees felt that way. But even then a sizable minority (30 percent) believed that amputees did have more personal problems than nonamputees. In any case, it is noteworthy that, in an area where one might reasonably expect some expression of difference, so large a percentage of the subjects denied any difference at all. A strong tendency to reject any hint of abnormality or "difference" appears throughout the study.</p> <p>In setting goals and evaluating achievements, most of the amputees would like to be considered as nondisabled persons:</p> <table> <tbody><tr> <td> <p><b> In deciding what you should be physically able to do, do you compare yourself with:</b> </p> </td> </tr> <tr> <td> <p>very active nonamputees?</p> </td> <td> <p>16%</p> </td> </tr> <tr> <td> <p>active nonamputees?</p> </td> <td> <p>53</p> </td> </tr> <tr> <td> <p>inactive nonamputees?</p> </td> <td> <p>2</p> </td> </tr> <tr> <td> <p>active amputees?.</p> </td> <td> <p>28</p> </td> </tr> <tr> <td> <p>inactive amputees?</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p>Over two thirds seem to feel that their physical abilities should be comparable to those of active or very active nonamputees. In short, amputees want to be considered normal and would like to discount their physical defects. Since most arm amputees can function in society without serious disadvantage, they would seem to have a sound basis for de-emphasizing their handicaps.</p> <p> There is, of course, a stigma attached to those who are "different," and this circumstance also gives the amputee a strong reason for rejecting identification with the disabled. Thus he tends to maintain that being an amputee does not really "make a difference," although what is certainly implied is that he feels it <i>should not</i> make a difference. It is difficult to believe that so many can forget a fact of such consequence as amputation. But obviously they would <i>like</i> to forget it, and many <i>do</i> forget it, at least intermittently. For them to repress the amputation completely would be to deny the loss rather than to accept it, and this would be an equally unrealistic type of adjustment. From clinical observation, we have the impression that few amputees wear their loss as a badge, but the fact of amputation does seem to underlie a good part of their behavior. Whether this results in a neurotic fixation or is viewed as one more of life's frustrations to be overcome depends upon the individual. </p> <p>The fact that 30 percent of the amputees seem to feel that they have more personal problems than do nonamputees should not be taken as showing that amputees are more poorly adjusted than nonamputees. Other studies on physical handicap and amputation have indicated that, although particular problems of adjustment differ, there is generally no marked difference in adjustment between those who are handicapped and those who are not.<a></a></p> <p>An amputee has mixed conscious and subconscious identifications both with disabled and with nondisabled groups. Whichever group he primarily identifies with provides the basis for his concept of himself, the goals he sets, the aspirations he has, and the way he interacts with others. The amputees in the NYU Field Studies overwhelmingly elected a non-amputee, nondisabled frame of reference. In such a course lie dangers for them-dangers of self-deception, of denial and distortion of reality. Yet advantages follow too. Identifying with the nondisabled provides stimulation and drive to actualize the potential that each amputee has. It helps to combat defeatist attitudes and withdrawal into lethargy and invalidism. The amputee who is able to recognize and accept his identifications with both the disabled and the nondisabled groups maintains the soundest approach to personal adjustment.</p> <h4>Functional Adequacy</h4> <p>"Functional adequacy" refers to the amputee's estimate of his level of competence in performing physical activities. Questions were asked exploring the amputee's evaluation of his physical abilities. As has already been seen, over two thirds of the amputees seemed to feel that their physical abilities should be comparable to those of active or very active nonamputees. How well did they think that they met this exacting standard? Generally speaking, they said that they were able to achieve their high goals:</p> <table> <tbody><tr> <td> <p><b> As compared to nonamputees, I am generally able to do:</b> </p> </td> </tr> <tr> <td> <p>much less.</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>somewhat less.</p> </td> <td> <p>35</p> </td> </tr> <tr> <td> <p>as much.</p> </td> <td> <p>49</p> </td> </tr> <tr> <td> <p>somewhat more.</p> </td> <td> <p>14</p> </td> </tr> <tr> <td> <p>much more.</p> </td> <td> <p>0</p> </td> </tr> </tbody></table> <p> Only about one third conceded that they could not do as much as nonamputees. Furthermore, 68 percent of the amputees said that "very little effort" or "a little extra effort" was required to keep up with nonamputees. Ten percent even claimed that <i>no</i> extra effort was required. But 21 percent did admit that "a lot of extra effort" was necessary to keep up with others. </p> <p>In response to other questions, 92 percent said that they believed their work to be as good as or better than that of their nonamputee co-workers, and 66 percent said they felt they could be employed in jobs requiring "almost as much use of the prosthesis as of the normal hand."</p> <p>Comparing their present abilities with those had before amputation, 83 percent said they found doing things only "slightly more difficult now." Speaking of the things they could do before their loss, 96 percent said that they could still do "many," "almost all," or "all" of them. Only 8 percent said that being an amputee restricted their capacities "considerably." But 97 percent believed that they could do as much as, or more than, most other amputees.</p> <p>Here again the optimistic responses show some increase after the treatment period, and there are still other indications that the amputee's feelings of competence are related to the use of the new type of prosthesis. After treatment, 81 percent of the amputees said that they were "very much; or ;completely" satisfied with their prostheses, whereas at the beginning of the treatment program only 58 percent said so. Improved prosthetic equipment and better management procedures seem largely responsible for the favorable results.</p> <p>Generally speaking, we may describe the picture as follows. The amputee sets high limits to his physical accomplishments, most often aiming to equal the nonamputee. He will sometimes concede that he can do less than a nonamputee, but more often than not he will claim that he can do as much or more. While he almost never admits to a substantial inferiority, he will acknowledge that it takes a little extra effort to keep up with nonamputees. He feels competent to handle the daily routine of living, and he expresses no deprivation associated with his functional limitations. Finally, his estimate of his own abilities increased as a result of participation in the research program.</p> <p>Taken at face value, this self-picture by the amputee seems a blissful one. But experience indicates that, while some amputees do approach the ideal state, the average patient is far more concerned about his functional adequacy than the responses show. Some of the amputee's description of his high level of competence must certainly be the result of wishful thinking. Concerned with maintaining his self-esteem and confidence, he surely must often distort reality so as to diminish the gap between what he imagines he can do and what he actually can do. And his feelings of great competence may also reflect certain changes in his habits since his amputation-changes that have brought his activities more into line with his new physical abilities.</p> <p>Complete analysis of functional adequacy requires both objective and subjective estimates of competence and a study of the effect that the difference between the two has upon the amputee's adjustment. In the absence of such an investigation, the data presented are best considered as the responses of people who are concerned with maintaining their self-esteem, their feelings of confidence, and their sense of adequacy. The responses show what the amputee subconsciously desires in the way of treatment from nonamputees. In effect, what we have here is the collective mask that amputees present to the public-and often to themselves. The extent to which we can accept this mask, or how we need to modify it, is a clinical problem that can be resolved only when the amputee's real and fancied achievements are considered in the light of his basic needs.</p> <h4>Independence</h4> <p>"Independence" refers to the extent to which the amputee can make a reasonable effort to be self-sufficient while still feeling free to call for assistance or to use help that is offered. It has been seen that the amputees in this study tend to characterize themselves as self-sufficient. When the amputee knows himself to be capable of handling a situation, he usually declines offers of help:</p> <table> <tbody><tr> <td> <p><b> When I know that I am capable of handling a task, I:</b> </p> </td> </tr> <tr> <td> <p>never accept help.</p> </td> <td> <p>28%</p> </td> </tr> <tr> <td> <p>very rarely accept help.</p> </td> <td> <p>34</p> </td> </tr> <tr> <td> <p>rarely accept help.</p> </td> <td> <p>12</p> </td> </tr> <tr> <td> <p>sometimes accept help.</p> </td> <td> <p>22</p> </td> </tr> <tr> <td> <p>frequently accept help.</p> </td> <td> <p>4</p> </td> </tr> </tbody></table> <p>In keeping with this desire for self-sufficiency, almost three quarters of the amputees said that they rarely or very rarely solicit help:</p> <table> <tbody><tr> <td> <p><b> How often do you call for help from others?</b> </p> </td> </tr> <tr> <td> <p>Never.</p> </td> <td> <p>5%</p> </td> </tr> <tr> <td> <p>Very rarely.</p> </td> <td> <p>57</p> </td> </tr> <tr> <td> <p>Rarely.</p> </td> <td> <p>14</p> </td> </tr> <tr> <td> <p>Occasionally.</p> </td> <td> <p>23</p> </td> </tr> <tr> <td> <p>Frequentrly.</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p>Two facts are of particular interest here. First, the course of treatment provided by the program increased from 49 percent to 57 percent the proportion of those who claimed they very rarely called for help. Secondly, none of the most physically disabled patients (bilateral and shoulder-disarticulation cases) reported frequent calls for help. In answer to other questions, only 1 percent of the amputees said that they refuse help under any circumstances. More than half said that they accept help only when it means the difference between success or failure. About one quarter said they accept help if it makes the task easier. And 14 percent said they accept help even if it does not make the task easier.</p> <p>It is clear that the amputee is vitally concerned about his sense of independence. He tends to depict himself as a self-sufficient individual who rejects offers of help whenever he can and who asks for help only occasionally. Despite the stress he places on self-sufficiency, however, the amputee almost always accepts the fact that complete independence is impossible. But he will be practically certain to reject any suggestion of serious dependence.</p> <p> Why does the amputee value his independence so highly? The answer seems to lie with our society, which places a high premium on personal competence and achievement. The dependent person often finds himself assigned an inferior status in his group. The amputee, constantly faced with this prospect, feels a strong need to prove that he is self-sufficient and that he does not differ from other people. In any case, a handicapped, dependent person is seriously restricted in his ability to reach simple goals that are easily achieved by others.<a></a> </p> <p> Before the amputee can judge the extent of his handicap, he must go through an extensive trial-and-error period, particularly in the early stages of his loss. Depending on how realistically he views his limitations, dependency will or will not become a critical problem. At this point, three kinds of reactions are possible: he may appraise realistically his functional capacities and limitations; he may partly deny his limitations, at the same time often attempting to compensate for them; he may deny his limitations completely. <a style="text-decoration:none;">*</a> Underlying all three of these reactions is the basic need of all persons to maintain feelings of self-sufficiency-if necessary, by distorting reality. Thus an amputee may distort the extent of his dependence on others and exaggerate his abilities to fulfill society's demands for independence. Conversely, some amputees may distort reality in the other direction, emphasizing their loss in order to help them think of themselves as dependent, affection-seeking persons. In general, however, the amputee's ability to make a realistic appraisal of his capacities, to recognize a certain amount of dependency where it is inevitable, and to ask for help when necessary will depend above all on his feelings of basic security. The amputee who is insecure will be more likely to seek help indiscriminately or to reject it unreason-ably.<a></a> </p> <p> To avoid overdrawing the negative effects of reality distortion, a distinction must be made between extreme distortion of reality and its temperate shaping. We tend to admit into our perceptions things in line with positive self-feelings and to eliminate or modify those which might cause anxiety. This is a form of adaptive, nonpathological distortion involving control of situations so that, when reality must be faced, it may be done despite the temporary pain associated with the process. Some avoidance of harsh reality is sometimes necessary in order to preserve equanimity in the face of many daily frustrations. In some cases, however, the amputee displays an extreme form of dependence that has been called "invalidism."<a></a> When this happens, the amputee exploits those about him by harping on his incapacities more than his injury warrants. He uses his handicap to avoid responsibilities. While it is true that anyone might be tempted to plead illness to avoid an unpleasant experience, in invalidism the individual employs his loss as a constant way out. Invalidism can also be an attention-getting device as well as an attempt to obtain love that the amputee is not sure of having otherwise. It is used to threaten and control other persons and sometimes provides the disabled person with the means of taking revenge upon others by limiting their freedom of action and making them anxious and guilty. </p> <p> Whatever the reaction, the family plays an important role in the amputee's attempts to achieve self-sufficiency and yet to fulfill his needs for dependency. The attitude of the family is often thought to be at least as important as the physical injury itself in determining the amputee's reaction to his disability.<a></a> The amputee's attitude toward his family is a combination of a drive for independence and a plea for aid, explicit or implicit. In the ideal family relationship, both needs will be satisfied. But the stress should be upon helping the amputee to take his place in society as a self-respecting, adequate person. </p> <h4>Sensitivity</h4> <p>"Sensitivity" refers to the amputee's subjective appraisal of the effect of his physical condition on others and to the feelings of self-consciousness he experiences as a result of this appraisal. Sensitivity about disability may therefore be related to two sources: perception of the negative appraisals of others, and the individual's own self-rejection. These two factors are of course not entirely independent, since an amputee's notions of what others think of him may largely determine what he thinks of himself.</p> <p>The majority of the amputees in the study readily admitted concern about the opinion of others, but it is noteworthy that almost a fourth of the group refused to admit anything more than a "little" sensitivity:</p> <table> <tbody><tr> <td> <p><b> How much do you care about what others think of you?</b> </p> </td> </tr> <tr> <td> <p>Considerably.</p> </td> <td> <p>53%</p> </td> </tr> <tr> <td> <p>Somewhat.</p> </td> <td> <p>23</p> </td> </tr> <tr> <td> <p>Little.</p> </td> <td> <p>8</p> </td> </tr> <tr> <td> <p>Very little.</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Not at all.</p> </td> <td> <p>7</p> </td> </tr> </tbody></table> <p>The clinical treatment program had the effect of reducing the self-consciousness admitted. Amputees who said that they never, rarely, or only sometimes felt self-conscious about their personal appearance went from 59 percent before treatment to 72 percent afterward. But 28 percent still said they felt self-conscious most of the time or almost always.</p> <p>Twenty-one percent of the amputees said that they felt they looked "the same as most people," and 62 percent answered "almost the same as most people." In keeping with this attitude, most of the amputees claimed that they did not feel themselves to be conspicuous. But a significant 22 percent confessed that the idea occurred to them with some frequency:</p> <table> <tbody><tr> <td> <p><b> The idea that people are looking at me:</b> </p> </td> </tr> <tr> <td> <p>is almost always on my mind.</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>sometimes occurs to me.</p> </td> <td> <p>20</p> </td> </tr> <tr> <td> <p>rarely occurs to me.</p> </td> <td> <p>17</p> </td> </tr> <tr> <td> <p>very rarely occurs to me.</p> </td> <td> <p>38</p> </td> </tr> <tr> <td> <p>never occurs to me.</p> </td> <td> <p>23</p> </td> </tr> </tbody></table> <p>The majority of the amputees said that they expected other people to discuss the disability. Only a few believed this occurred frequently, and even fewer denied its existence:</p> <table> <tbody><tr> <td> <p><b> Do you think that people talk about your disability?</b> </p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>3%</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>30</p> </td> </tr> <tr> <td> <p>Occasionally</p> </td> <td> <p>57</p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Always</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p> Most amputees (67 percent) denied that they felt any resentment over the curiosity of other people. The rest maintained a ratio of three positive reactions <i>(e.g.,</i> pride in demonstrating the prosthesis, appreciation of interest) for every negative reaction <i>(e.g.,</i> self-consciousness, resentment, nervousness). In all, reactions of annoyance caused by people's curiosity decreased significantly by the end of the treatment period. </p> <p>Although 99 percent of the amputees said that they seldom or never tried to hide the fact of their amputation, the overwhelming majority said they would not tell a new acquaintance about it unless asked.</p> <p>The question of whether to fit a hook or a hand is often decided on the basis of the amputee's sensitivity. Those particularly sensitive about their amputation might be expected to reject a hook because of its appearance. The majority of the amputees in this study (61 percent) said that they believed hooks to be mechanical-looking but not unsightly, while a significant additional number (25 percent) expressed a more negative attitude concerning their appearance. But only 1 percent said they would not use one under any condition:</p> <table> <tbody><tr> <td> <p><b> I think that a hook is :</b> </p> </td> </tr> <tr> <td> <p>so ugly I would never wear one...............................</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>so ugly I would never wear one when I'm with other people...</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>unsightly but not enough to prevent me from wearing one...</p> </td> <td> <p>23%</p> </td> </tr> <tr> <td> <p>mechanical looking but not unsightly..............................</p> </td> <td> <p>61%</p> </td> </tr> <tr> <td> <p>as natural looking as any artificial hand........................</p> </td> <td> <p>13%</p> </td> </tr> </tbody></table> <p>The composite data indicate that, although the amputees showed considerable awareness of their appearance, they did not brood about it. When asked directly, they were much more likely to deny being sensitive than to admit being preoccupied with their condition. They were well aware that amputations and prostheses arouse curiosity, but they maintained that they (the amputees) were "normal" and so did not feel resentful toward these attentions. Amputees who do acknowledge self-consciousness are most likely to do so in situations where there is no social pressure against displaying sensitivity.</p> <p>On the basis of other evidence, there seems to be considerably more indication of sensitivity and of hostility toward the curious person than is revealed by the questionnaire. This is to be expected, for clinical situations induce greater rapport and permit the amputee to express hostile feelings with less fear of social criticism. Thus, it is quite likely that the amputee's sensitivity is much greater than he is willing to admit.</p> <p> The universal unwillingness of amputees to admit that they differ from others rests in part on the fact that in many respects they are indeed no different from other people. But it also may represent a "whistling-in-the-dark" attitude, an attempt to deny something that the amputee really believes to be true <i>(e.g.,</i> that he <i>is</i> handicapped or inferior), and may reflect the amputee's resistance against the social consequences of being "different." </p> <p>As has already been mentioned, amputees are likely to incorporate the negative attitudes of others into their own self-concept. Most amputees recognize that nonamputees are more comfortable when the fact of amputation is not conspicuous, and they will attempt by various means to "spare the feelings" of others by trying to reduce the visual "shock" for the nonamputee. Many of the subjects are not, however, merely responding appropriately to social cues but rather are using this explanation as a rationalization for their own self-rejecting thoughts. The same self-rejection may be responsible for the denial of sensitivity, which the questionnaire data show to be characteristic of a sizable minority of the sample.</p> <h4>Appraisal of Acceptance by Others</h4> <p>Appraisal of acceptance by others" refers to the amputee's evaluation of the effect his disability has on the approval others may give him. Less than 5 percent of the amputees said that they felt they were being treated any way different from that in which they had been treated before amputation. Almost all of the subjects claimed that their amputation had had little or no effect upon their acceptance by others. They rejected overwhelmingly the suggestion that their amputation merited them either special treatment or discrimination in their job, family, or social relationships. Most of them said they did not feel that people paid them undue attention. In general, the data indicate that amputees feel they receive sufficient but not excessive attention in social situations. A small percentage admit that some sympathetic behavior is displayed consistently in their job and family relationships.</p> <p>The amputee claims to be accepted by others on the same basis as anyone else, and he rejects strongly the suggestion of "different" treatment. But he will more readily admit to being favored than to being rejected. The treatment program seemed to bring a slight increase in the number of those who felt they were accepted on the same basis as other people. But little change was noted among those who claimed to be the recipients of either favoritism or antagonism. The data suggest that the treatment program was psychologically beneficial to those who were "uncommitted" on the first testing but that it had no effect on those who were convinced of their "different" status.</p> <p> The cumulative evidence about the social position of the disabled person strongly suggests that the results of the survey again represent the amputees' <i>wishes</i> rather than the actual situation, a finding supported by the fact that, when asked indirectly how they thought amputees should be treated, the majority revealed that they preferred to have little made of their physical handicap: </p> <table> <tbody><tr> <td> <p><b> If you were a nonamputee, how would you react to an amputee?</b> </p> </td> </tr> <tr> <td> <p>I would ignore the fact that the person is an amputee</p> </td> <td> <p>16%</p> </td> </tr> <tr> <td> <p>I would treat him as a normal person who just happens to have lost an arm or hand</p> </td> <td> <p>72</p> </td> </tr> <tr> <td> <p>I would expect less from him physically</p> </td> <td> <p>6</p> </td> </tr> <tr> <td> <p>I would be more kind and thoughtful of his feelings</p> </td> <td> <p>5</p> </td> </tr> <tr> <td> <p>I would know that, as an amputee, he requires special treatment</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <h4>Sociability</h4> <p>"Sociability" refers to the extent to which the amputee seeks, and derives pleasure from, social relationships. In this connection, the subjects said that they looked forward to social functions and enjoyed them. The treatment program had the effect of increasing by about one fourth the number of amputees who said that they "always" enjoyed these functions. All but a very few of the subjects said that they had greater social confidence with their new prostheses. Neither before the treatment period nor after, however, did more than S percent confess to any lack of social confidence. Over three quarters of the amputees said that neither their amputations nor their prosthesis-wearing had caused any change in their social relationships. Those who did report changes were almost unanimous in claiming that the changes were toward greater sociability.</p> <p>These results reaffirm the earlier observations that the amputee tends to deny he has any major problems of acceptance. He usually claims that he engages in social activities eagerly and freely and experiences no prejudice because of his disability. But here again it is possible to read these results as expressing not so much the real facts as the wishes of the amputee to be accepted fully into the nonamputee world. Nevertheless, the indications are clear that the amputee tends to have more social confidence after suitable prosthetic fitting and treatment, the implications being that superior prosthetic equipment provides the basis for the ability to meet others with less trepidation and with greater feelings of personal adequacy. It also confirms indirectly the significance of feelings of functional adequacy and of ability to be independent.</p> <h4>Frustration</h4> <p>"Frustration" refers to the amputee's experience resulting from his inability to achieve personal, social, and vocational goals because of his amputation. The term refers both to whatever blocks or interferes with the amputee's strivings and to his subjective feelings of annoyance, confusion, or anger when he is thwarted. While 58 percent of the amputees said they rarely or never were prevented from achieving their goals, the other 42 percent claimed to feel frustrated from time to time as a result of amputation:</p> <table> <tbody><tr> <td> <p><b> Does being an amputee prevent you from doing things you really want to do?</b> </p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>20%</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>27</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>11</p> </td> </tr> <tr> <td> <p>Someties</p> </td> <td> <p>37</p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>5</p> </td> </tr> </tbody></table> <p>When, however, absence of a limb prevented performance of a task, a considerable proportion of the amputees (86 percent) felt annoyed. They almost unanimously (98 percent) said that they did not give up trying to do something because it was difficult, or that they gave up only after repeated failures.</p> <p>As for vocational goals, a majority of the amputees refused to admit more than slight difficulties. Some 40 percent indicated that there was some substantial interference:</p> <table> <tbody><tr> <td> <p><b> Do you feel that your amputation interferes with your getting a job?</b> </p> </td> </tr> <tr> <td> <p>Not at all</p> </td> <td> <p>27%</p> </td> </tr> <tr> <td> <p>Very slightly</p> </td> <td> <p>15</p> </td> </tr> <tr> <td> <p>Slightly</p> </td> <td> <p>18</p> </td> </tr> <tr> <td> <p>Somewhat</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>Seriously</p> </td> <td> <p>11</p> </td> </tr> </tbody></table> <p>Here the fact that the more seriously disabled (bilateral and shoulder-disarticulation cases) responded as did the other amputees seems to suggest that the results do not accurately reflect the real situation.</p> <p>The relatively small degree of frustration the amputees reported is surprising in view of the many frustrating situations they encountered. It suggests that many of the responses were given because they seemed socially desirable and because the test situation did not encourage the amputee to express freely his aggressive or negative feelings. But it is also possible that repeated experiences of frustration, together with the strong motivation to be "like anyone else," which is so characteristic of the subjects studied, can produce in many amputees a truly high level of frustration tolerance. To this must be added the active efforts to avoid situations potentially frustrating.</p> <p>Any interference with goal-directed activity constitutes a frustration. But interpreting frustration in others has certain dangers because what frustrates one individual may not frustrate another. The nonamputee who fails to consider this circumstance is likely to make toward the disabled person unnecessary offers of help. The amputee may take such overtures as indicating that people believe him to be incompetent and may, consequently, feel downgraded in his status as a functioning person. In a sense, the real frustration in this particular situation is the nonamputee's lack of awareness of the amputee's competence.</p> <p>The intensity of an amputee's frustration depends upon how important his thwarted goals are to him. And while he may not feel seriously deprived if he cannot accomplish some trivial task, his frustration may be great if the particular failure happens to symbolize his inability to reach some more important goal. A minor frustration may assume importance if it symbolizes a general downgrading of status. Furthermore, when frustration is chronic the setting is ripe for the development of neurotic symptoms that represent the amputee's attempt to escape from an intolerable situation. It is considerably easier for anyone to deal with a short-term frustration than to adapt to a long-term one. Amputation is permanent and hence can lead easily to chronic frustrations and to neurotic solutions for the frustrations.</p> <p>The amputees in question showed two general types of reaction to frustration. One was concerned with overcoming the obstacles that interfere with the attainment of goals. In the other, the concern had more to do with preserving self-esteem and warding off anxiety than with achieving thwarted objectives. The first, or goal-directed, reaction to frustration is characterized by the amputee's ability to accept the reality of his amputation with a minimum of self-deception. In this type of reaction, the amputee seeks goals that are in line with his reduced capabilities and takes whatever steps he must to overcome the barriers imposed by his amputation. When questioned, he admits to being frustrated sometimes, but he shows a high toleration for frustration and tends to give up only when a task is clearly beyond his abilities, at which time he is willing to accept appropriate help. Besides, he will probably accept himself as a person and neither brood over nor resent his situation.</p> <p> In the second, or "ego-protective," reaction to frustration, the amputee refuses to accept reality. Instead, he distorts it and tries to create situations in which he can be at ease and relatively free of anxiety. If necessary, he will go so far as to deny his disability. He tends to set such low limits for achievement that he can avoid frustration, and he often sharply restricts his involvement in life as he seeks to eliminate opportunities for frustration. Such protective action is likely to lead to neurotic symptoms-to hypersensitivity, invalidism, defeatism, somatic complaints, anxiety, social withdrawal, and so on. In an earlier publication, Siller <a></a> observed that amputees who achieved good adjustment were often strongly oriented toward compensating for their loss. They were, in other words, showing a goal-directed reaction to frustration. It was also observed that amputees who adjusted poorly often directed their efforts toward avoiding the implications of their loss, thus showing an ego-protective reaction to frustration. </p> <p>As a result of the treatment program in the NYU Field Studies, there was a small increase in the number of amputees who reported a moderate degree of frustration tolerance combined with the ability to recognize their limitations clearly. While in answering the test questions the amputees undoubtedly had a tendency to deny unfavorable feelings and behavior, the subjects as a whole still showed a rather high tolerance for frustration.</p> <h4>Optimism</h4> <p>"Optimism" refers to those feelings of adequacy, of self-confidence, and of positive future outlook that the amputee experiences. The negative aspects of this personality variable are pessimism, depression, and feelings of inadequacy and inferiority. While the subjects in the study tended to stress their positive feelings of optimism and to de-emphasize their pessimistic feelings, few denied that they experienced depression at times:</p> <table> <tbody><tr> <td> <p><b> How often do you feel "down in the dumps" or "blue"?</b> </p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>3%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>21</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>39</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>8</p> </td> </tr> </tbody></table> <p>The treatment period had the effect of increasing from 33 percent to 39 percent those amputees who answered "very rarely," and in general the fitting of new prostheses increased slightly the claims of optimism. Most of the amputees professed to be very optimistic about their future prospects, and none at all said that they expected to be unsuccessful:</p> <table> <tbody><tr> <td> <p><b> Does your future promise to be:</b> </p> </td> </tr> <tr> <td> <p>extremely successful?</p> </td> <td> <p>14%</p> </td> </tr> <tr> <td> <p>moderately successful?</p> </td> <td> <p>66</p> </td> </tr> <tr> <td> <p>slightly successful?</p> </td> <td> <p>11</p> </td> </tr> <tr> <td> <p>neither successful nor unsuccessful?</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>unsuccessful?</p> </td> <td> <p>0</p> </td> </tr> </tbody></table> <p>Throughout the questionnaire, the subjects tried to avoid responses indicating pessimism, depression, and feelings of inadequacy or inferiority. They were more likely to admit feelings of superiority than of inferiority, but in general they avoided admitting extreme feelings in either direction:</p> <table> <tbody><tr> <td> <p><b> Do you ever have feelings of:</b> </p> </td> </tr> <tr> <td> <p>Inferiority?</p> </td> <td> <p></p> </td> <td> <p>Superiority?</p> </td> </tr> <tr> <td> <p>38%</p> </td> <td> <p>Never</p> </td> <td> <p>29%</p> </td> </tr> <tr> <td> <p>28</p> </td> <td> <p>Very rarely</p> </td> <td> <p>22</p> </td> </tr> <tr> <td> <p>12</p> </td> <td> <p>Rarely</p> </td> <td> <p>15</p> </td> </tr> <tr> <td> <p>20</p> </td> <td> <p>Sometimes</p> </td> <td> <p>30</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>Frequently</p> </td> <td> <p>4</p> </td> </tr> </tbody></table> <p>The amputees tried of course in their answers to place themselves in a socially favorable light-to shun answers with negative implications. But we may still estimate the feelings of the average amputee. He resists, rejects, and resents any suggestion that as a person he differs from anyone else; at the same time he acknowledges some (but not too much) physical difference and handicap. If he senses that the nondisabled people about him consider him "different" because of his loss, he may often go to extremes to deny pessimistic feelings which in a more relaxed environment he might well acknowledge.</p> <p>Amputees are not alone in their desire to be placed in a favorable light. The tendency to respond in a socially desirable manner seems to be characteristic of all groups when tested under conditions similar to those of the present study. Nevertheless, when we consider the very real handicaps amputees must face, we may conclude that those studied here are for the most part maintaining an optimistic outlook.</p> <h3>Social and Functional Factors in Prosthetic Wear</h3> <p>The attitudes of amputees toward prostheses have in the past received little systematic study. The amputee's preferences in artificial limbs, and his habits in using them, are evidently not based entirely upon his objective assessment of his functional and social needs. They are influenced also by emotional factors arising from the meanings he attaches to the wearing of artificial limbs. Little organized information is available about these attitudes, whether rational or irrational, and we know little as yet about the specific effects that an amputee attributes to his prosthesis once he has accepted and worn it. What difference does he think it makes in his daily life?</p> <p> The prosthetic-reaction test (Appendix IIIG), designed to explore in a systematic way some of the attitudes and reactions underlying prosthetic wear, attempted to gauge, in various situations, the amputee's response, both when he is considered to be <i>wearing</i> an artificial arm and when he is considered <i>not</i> to be wearing one. In a series of nine different pictures, a fictitious amputee, "John," was shown in some everyday situations-some in which his sensitivities as an amputee might be expected to be aroused. Below each picture were from five to nine statements indicating possible responses that John, the amputee in the picture, might make to the situation depicted. The subjects under test were asked to select the statement most nearly describing what John might say, feel, or do in each case. The assumption, of course, was that the amputees would attribute to the imaginary John some of their own feelings and reactions. It was thought that, as the amputees thus responded to specific life situations through the medium of this other person, their attitudes might be expressed more freely than they would be through direct questioning. </p> <p> The test was administered to each of the amputees three times, once at the beginning of the research program (Evaluation I) and twice at the end of the studies (Evaluation II). In Evaluation I, and at the first administration during Evaluation II, the subjects were asked to select John's response <i>"if he were wearing a prosthesis as he usually does."</i> Immediately after the amputees had completed the test for the first time during Evaluation II, they took it again but now were asked to select John's response <i>"if he never wears a prosthesis."</i> For convenience, we shall refer to these three administrations of the test as El, E2a, and E2b. Together, the three provide data for the study of three major questions: </p> <ol> <li>In the difficult social situations that an amputee faces daily, what are his most frequent responses and his most commonly held attitudes?</li><li>What changes, if any, in his attitudes and reactions came as a result of his being fitted with a new prosthesis and taking part in the research program?</li><li>In these difficult social situations, how does the wearing of a prosthesis affect the amputee's responses?</li></ol> <p>Each of these problems shall be taken up in turn.</p> <p>The prosthetic-reaction test touches upon a number of aspects of an amputee's performance. Foremost is the general area of "security," which involves the amputee's basic acceptance of himself and others, particularly his personal adjustment to the loss of his arm. Included within the concept of security were such constructs as self-acceptance (the ability to view the loss without self-pity, exaggeration, or denial, and without resorting to maladaptive means of defending self-esteem) and reality-facing (the ability to appraise environmental situations as they are). In addition, there was evidence that several of the cartoons strongly measured a second variable, "independence," which describes the amputee's motivation to be self-sufficient and to function adequately with a minimum of assistance.</p> <p> Psychologically, strivings for independence are likely to stem from the individual's feelings of security, and as such the two must be considered related phenomena. But since the need to be independent is a major concern of amputees, separate analyses of the data concerning independence were made whenever appropriate. Each statement in the test was therefore rated first for "security" and, when indicated, for "independence." Four psychologists ranked from 1 to 5 all possible responses according to the extent that the individual variables were reflected therein. <a style="text-decoration:none;">*</a> Personal differences in ranking were resolved through mutual discussion among the four. </p> <p>Responses rated 1 or 2 were considered "high." A rating of 3 was considered "intermediate," a rating of 4 or 5 as "low," and the terms "high," "intermediate," and "low" were used as relative terms to describe the individual's position along the "security" and the "independence" scales. For example, Picture VI (Appendix IIIG) showed an amputee in a restaurant with a steak that seemed too tough for him to cut. The seven statements given beneath the picture were ranked and judged as shown in the following tabulation:</p> <p>The prosthetic-reaction test, then, tells us how amputees appraise various social situations and what they think about the worth of artificial arms in these situations. It also gives us some indication of their feelings of independence and security, both when they are wearing prostheses and when they are not. What light does this information shed upon the three major problems already mentioned?</p> <h4>Amputee Responses to Everyday Social Situations</h4> <p> The most outstanding finding of this study was that the amputees overwhelmingly-in fact, almost invariably-selected the most positive responses to the situations depicted in the cartoons, particularly when the amputee was assumed to be wearing an artificial arm. For almost every situation of the series, the statement most frequently chosen was one extremely high in both independence and security. Moreover, for most of the pictures well over half the sample responded with statements that were judged "positive" <i>(i.e.,</i> high in security or independence). Even in E2b, where positive responses were considerably fewer, they still accounted for a large segment of the sample. Typical percentages of amputees showing high, intermediate, and low "security" and "independence" responses to each cartoon are shown in <b>Table 1</b> , where the data are derived from E2a (post-treatment) and refer to circumstances in which John was supposed to be wearing a prosthesis. For the sample as a whole, there were negligible differences between the El (pretreatment) and the E2a (post-treatment) data. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 1</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> For every situation, more than 60 percent of the sample chose positive responses, and in only one instance did more than a negligible proportion choose a statement reflecting definite insecurity. As for that item, many of the respondents had not correctly interpreted the other person to be the amputee's wife. Even more striking is the fact that from a fourth to a half gave as their response the single most positive statement. It is clear, then, that the majority of the amputees wished to be viewed as functionally independent, having confidence in their ability, with a desire to demonstrate their functional achievements, and willing to accept some aid if it is found to be needed. The vast majority of the responses expressed an acceptance of the loss of the limb, a willingness to discuss the amputation with others, and a general self-assurance in social situations. ( <b>Fig. 1</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In general, the most popular responses were those which emphasize functional effectiveness, self-confidence, and lack of sensitivity about amputation. Reactions suggesting any admission that the amputee considered himself at all "different" from anyone else were extremely rare. It seems clear that the subjects readily recognized the socially desirable responses and favored them overwhelmingly. To what extent this eventuality represents the true feelings and behavior of the group, and to what extent it represents wishful thinking, cannot be determined from these data-a situation that reflects a weakness in the prosthetic-reaction test as currently conceived. Evidence indicates that amputees are very much concerned with conforming to the important cultural values of self-reliance and self-confidence and that they abhor any suggestion of a departure from complete normality. <b>Table 1</b> </p> <h4>Changes in Responses as a Result of Fitting</h4> <p>For the group as a whole, there were virtually no significant differences between El and E2a, even though the latter was administered after a considerable period of time had elapsed. This result would suggest that the treatment program had little or no effect on the expressed attitudes of the group. But when we consider separately those amputees who were being fitted for the first time and those who had worn prostheses before, some changes can be detected among the new wearers. Since the number of amputees being fitted for the first time was small (only 55), no extensive quantitative analysis can be made. Nevertheless, a few general conclusions can be drawn.</p> <p>First of all, the responses after fitting indicated that new wearers were slightly disappointed in the functional efficacy of their artificial arms. While initially (on El) a large number of these amputees revealed expectations that the prosthesis would enable them to do "almost everything," particularly in their occupational roles, the E2a responses indicated more modest attitudes. But these changes were not toward more negative responses. Rather, they reflected the fact that the amputees concerned had indulged in unrealistic expectations for the prostheses and then had adjusted to a more realistic view after some experience with their new arms. There were, moreover, indications of a greater degree of security in social situations. After fitting, some of the new wearers indicated an increased acceptance of their amputation-a greater ability to talk about it, less tendency to withdraw from situations revealing the disability, and less expectation of pity from others. Besides this, they expressed a greater readiness to ask for help without apology or embarrassment.</p> <h4>Effects of Fitting Upon Responses to Everyday Situations</h4> <p> As has already been indicated, the primary aim of the prosthetic-reaction test was to evaluate the amputee's feelings about the part that an artificial arm plays in the common difficult situations of his life. The statements the subjects chose as describing John's behavior may therefore be taken as reflecting aspects of their own behavior. Consequently, if we compare the results of E2a (in which John is considered to be <i>wearing</i> a prosthesis) with those of E2b (in which he is considered <i>not</i> to be wearing one), both tests having been administered at the end of the studies, we discover some of the effects that wearing an artificial arm has on the daily life of an amputee. Toward this end, the two personality variables, independence and security, were considered. In separate analyses of the data from the "nonprevious prosthesis wearers" (referred to as NPPW's) and the "previous prosthesis wearers" (PPW's), it was found that the two groups did not differ in their responses except as discussed specifically hereafter. <a style="text-decoration:none;">*</a> </p> <p> A review of the E2a (prosthesis worn) and E2b (prosthesis not worn) responses follows: <b>Fig. 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Greater tolerance of curious strangers is exhibited when a prosthesis is worn. In E2a the amputees appear better able to view the situation without misinterpretation, to be more sure of themselves and less likely to pity themselves or to expect pity from others. The PPW's are somewhat more secure in the E2a situation than are NPPW's, even though both groups were wearing prostheses at the time of the tests. The most reasonable explanation for this difference would seem to he in the fact that the period of prosthetic wear for the NPPW group was insufficient for feelings of conspic-uousness to disappear.</p> <p> <b>Fig. 3</b> , <b>Fig. 4</b> , <b>Fig. 5</b> , <b>Fig. 6</b> , <b>Fig. 7</b> , <b>Fig. 8</b> , <b>Fig. 9</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Differences between the E2a (with prosthesis) and E2b (without prosthesis) responses were considerable throughout the entire test, both for amputees who were being fitted for the first time and for those who had previously worn prostheses. We may thus conclude that the positive acceptance of prostheses reflects not merely the enthusiasm of new wearers but rather the genuine value of prosthetic wear in its own right.</p> <p>The indications are clear that amputees regard a prosthesis as a definite asset in functionally demanding situations and that they think of it as something enabling them to be more independent, more secure, and more willing to accept their condition. In the potentially threatening situations that an amputee must face from time to time, a prosthesis contributes to his ability to handle himself easily and self-confidently, even in cases where the prosthesis does not have immediate functional value.</p> <p>The data for "emotional" situations indicate that the amputees' positive expressions of security were definitely greater when the protagonist was wearing a prosthesis than when he was not. An artificial arm apparently gives many amputees an increased confidence in their functional adequacy. This in turn helps them to achieve a greater self-acceptance, enables them to face their disability more realistically, and lets them view the reactions of others without feeling quite so threatened.</p> <p>Of the two personality variables considered, independence and security, independence appears to be the more strikingly affected by prosthetic restoration. The subjects tend to expect that the amputee who wears a prosthesis will be more effective functionally, more self-sufficient, and generally more adaptive than the nonwearer. When the matter of security is concerned, the role of the prosthesis is less pronounced. Still, most of the amputees think of prosthesis wearers as more self-accepting, less shy, and less easily embarrassed than non-wearers.</p> <p>The responses to the prosthetic-reaction test strongly indicate that amputees feel there is both functional and psychological advantage in the wearing of a prosthesis. They consistently attribute more positive responses to the amputee wearing an artificial arm than they do to the nonwearer in the same situation. But of course all of these findings are merely projections upon a fictitious amputee pictured in a cartoon; we do not yet know the precise extent to which these projections reflect the actual responses amputees make in life situations. Nevertheless, it is clear that the wearing of a prosthesis has a positive effect upon the way an amputee perceives and reacts to many social situations in his daily life.</p> <h3>Attitudes Toward Prosthetic Wear, Before and After Fitting</h3> <p> The discussion thus far indicates that the amputee believes strongly in the importance of wearing an artificial arm. He tends to feel that a prosthesis increases his functional capabilities and helps him to cope with social situations. He retains these beliefs, even reinforces them, after participating in the research program. To analyze still further amputee attitudes toward the wear and use of a prosthesis, additional studies were designed to seek answers to the questions <i>Are the expectations of nonprosthesis wearers fulfilled by a prosthesis?</i> and <i>Can the postfitting attitudes of amputees toward their prostheses be predicted on the basis of their prefitting expectations?</i> </p> <p>As for the first of these queries, the amputee who does not wear a prosthesis holds certain preconceived opinions about the value of an artificial limb before he ever undertakes to wear and use one. If these expectations are fairly realistic, his experience with his prosthesis may be gratifying. But unrealistic expectations can interfere with the successful wearing of a prosthesis. For this reason, a study was made of the alterations in attitudes of nonwearers after they had used a new prosthesis. As for the second question, it is reasonable to expect that the opinion an amputee holds about prostheses before he receives one will be related to his opinion after he has been fitted. If these relationships are stable enough to be predicted, potential problems may be anticipated and perhaps avoided. It is well known that a negative attitude on the part of an amputee interferes with his wholehearted participation in the rehabilitation process and thus reduces the probability of success. Identifying such a situation is the first step toward correcting it.</p> <h4>Are the Expectations of Nonprosthesis Wearers Fulfilled by a Prosthesis?</h4> <p>Among the subjects for whom data were available in this aspect of the study were 45 amputees who had never worn prostheses before their participation in the research program. About half of them were relatively "new" amputees who at the time may not yet have had an opportunity for fitting. The other half consisted of persons who had been amputees for from one to 27 years and who were therefore considered to have had ample opportunity to obtain prostheses had they wanted to. Although it is possible that some in the latter group may have been discouraged long ago by the lack of adequate prostheses for shoulder disarticulation and for certain other types of amputation, some had stumps relatively easy to fit, and accordingly factors other than lack of prosthetic equipment seem to have been present.</p> <p>Because this study was only one phase in a more general investigation of the conditions underlying the wear or nonwear of a prosthesis, use was made of a broad approach in which was collected information generally related to amputation and to prosthetic restoration. Gathered by means of a questionnaire probing prior beliefs and attitudes on a variety of matters relating to prostheses (Appendix IIIH), the data sought included sources of prosthetic knowledge and an estimate of its extent, functional expectations, opinions of the appearance of prostheses, opinions of the comfort of prostheses, attitudes toward prosthetic training, attitudes toward the general value of artificial arms, and anticipated difficulties with prostheses. Approximately six months after the fitting of a prosthesis to these patients, the questionnaire was given again to obtain post-fitting attitudes.</p> <h5> <i>Sources of Prosthetic Knowledge and Estimate of Its Extent</i> </h5> <p> The extent of prosthetic knowledge claimed by the subjects increased only slightly after they had participated in the program. Before fitting, 95 percent said they knew little or nothing about artificial arms; after fitting 85 percent still said so. Even after some six months of having worn prostheses, only 14 percent said they knew "much" about the subject. These findings may of course only reflect restraint and modesty. If they reflect the situation accurately, the amputees are indeed poorly informed. To determine whether the sources of information had any bearing on the state of amputee enlightenment, the subjects were asked to name their principal source of information, As can be seen in <b>Table 2</b> , the answers were rather diverse. Mentioned were five major sources of information before fitting. Three of these (other amputees, friends, self) are generally unreliable in matters of prosthetics. Friends and one's own self are hardly qualified without special training, and other amputees, as has been indicated already, are not necessarily well informed. Medical personnel, including physical therapists, occupational therapists, and nurses, were cited by only one amputee as a source of information. But after the amputees had participated in the program, the picture changed sharply. Then most of them mentioned medical personnel as the main source of information, while "other amputees" were not mentioned at all. <b>Table 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 2</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the extensive list of pretreatment sources of information may indicate that the amputees were alert, receptive, and inquisitive, seeking information from all quarters, it may on the contrary mean that they used all these sources because they were not given information by those most competent to provide it. The general impression is that adequate information about prosthetics is not readily available to the average amputee and that there is therefore a real need for a more thorough prosthetics education of medical personnel. We might even suggest that more attention be given to improving knowledge of prosthetics among new amputees. One approach would be to furnish literature portraying different types of prostheses-along with a sober appraisal of the utility, as well as of the disadvantages, of current prosthetic equipment. Doing so would help the patient to acquire more realistic expectations, to eliminate some of his trepidation, and to fill his individual needs more successfully.</p> <h5> <i>Functional Expectations</i> </h5> <p> Experience tends to modify any overly ambitious ideas the amputee may have about the value of the prosthesis. Most of the amputees in the study had more realistic expectations after they had been fitted with their artificial limbs than before: ( <b>Fig. 10</b> ).The 73 percent who before fitting said they believed prostheses were essential included 21 percent who said they thought artificial arms were "as good as normal limbs." Among those who after fitting said they believed prostheses to be very important, there were still 10 percent who said they thought their prostheses were as good as normal limbs. Apparently the fitting of the prosthesis reduces the number of amputees who deny reality but does not eliminate that group completely.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Before they were fitted, the amputees tended to expect that artificial limbs would take a considerable expenditure of energy for effective operation, but experience showed them that these estimates had been too pessimistic: ( <b>Fig. 11</b> ), ( <b>Fig. 12</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those who deal with prospective wearers should make use of the general tendency among amputees to believe that prostheses are helpful. But unless the limitations as well as the advantages of artificial arms are explained, false hopes and unreasonable expectations will result.</p> <h5> <i>Opinions on the Appearance of Prostheses</i> </h5> <p>Judgment of appearance is a complex and subjective process. The phrase "acceptable appearance" means many things to many people because the component factors are not often defined. In this study, three factors were identified. The first relates to the appearance of the prosthesis itself-to the degree to which it resembles the natural limb. The second relates to the readiness with which the artificial limb is recognized by observers. And finally the third relates to the appearance of the prosthesis when it is actually in use by the amputee.</p> <p>Roughly 75 percent of the subjects said they believed that their prosthetic arms and hands closely resembled normal limbs. Although the remainder said they found no strong resemblance, it was clear that in general the amputees accepted the appearance of their prostheses. One patient alone gave "unfavorable appearance" as the reason for not wearing a prosthesis.</p> <p>At this point it is perhaps worth noting that medical personnel who see many varieties of prosthetic equipment tend to develop, out of their own experience, personal sets of standards about the appearance of prostheses and sometimes impose these standards upon an amputee. But the patient, having had very little experience with prostheses, bases his opinions on quite personal factors, and these may be at great variance with those which influence the judgment of the clinic team. We must therefore strive to fulfill the actual needs of the individual amputee rather than to satisfy our own honest but at times inappropriate standards.</p> <p> Initially, most of the amputees said they expected to be recognized as amputees even when wearing prostheses, an expectation apparently confirmed by experience: ( <b>Fig. 13</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These findings are especially interesting when we recall that about 75 percent of the amputees said they thought their prostheses closely resembled natural arms and hands. Yet only a few of the subjects, either before or after fitting, said that they believed they could be taken for nonamputees. It seems apparent, therefore, that more than just the physical appearance of the artificial arm was involved. A strong similarity may be thought to exist, but generally the amputee does not believe similarity alone will enable him to pass as a nonamputee.</p> <p> Data from studies by Dembo and Tane-Baskin <a></a> on the noticeability of a cosmetic glove indicate that noticeability depends upon the "intensity" of the situation, that is, upon the closeness of the amputee's social and physical contact with others at any particular time. In view of this observation, it is clear that the inability to discriminate between situations of varying intensity keeps us from interpreting the present data any further. The amputees' responses in the study came from their experiences in both casual and intense situations, and we cannot distinguish between the two. </p> <p>Ease and smoothness of operation constitute another important factor in the general appearance of the amputee. The well-trained, smoothly functioning amputee contrasts strongly with a less-trained, uncoordinated, and awkward one. Full evaluation of appearance must, therefore, also take into account the dynamic factor, the impression given by smooth, normal-appearing movement as contrasted with that given by halting, uncoordinated motions.</p> <p>We see, then, that there are at least three important considerations involved in any judgment of an amputee's appearance-the actual appearance of the prosthesis apart from its functioning (the "static factor"), the naturalness with which the prosthesis is used (the "dynamic factor"), and the intensity of the amputee's situation (the "situational factor"). Treatment personnel usually place greatest emphasis on the appearance of the limb itself; the amputee may base his impression more upon the other two considerations.</p> <h5> <i>Opinions on the Comfort of Prostheses</i> </h5> <p> The amputees' statements about the comfort of artificial limbs did not change very much with experience. Both before fitting and after some period of wear, about 25 percent of the subjects claimed considerable discomfort, while 50 percent or better had no complaints on this score: ( <b>Fig. 14</b> ). For three quarters of the prosthesis users, comfort does not appear to be an important problem, and expectations of comfort seem to be borne out by actual experience. But the 25 percent who complained about discomfort <i>do</i> represent a very significant problem because discomfort is a common cause for rejection or infrequent use of artificial limbs. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At present, research aimed at eliminating discomfort focuses on prosthetic and physiological factors, an emphasis that seems appropriate in view of the fact that the principal objective causes of amputee discomfort are related to fit of the socket and harness and to weight of the prosthesis. But the problem has several other aspects, and these might also be explored profitably. There is for example the question of education-of how to prepare the amputee to expect at least some degree of initial discomfort. Another possible factor relates to the early use of the new prosthesis unwisely and too well. The mere statement, "At first this may be uncomfortable," may be insufficient warning for the new user. This phase of orientation needs more emphasis. Otherwise there is always the danger that amputees not fully aware of the difficulty of initial adjustment may give up with the feeling that prostheses are not for them.</p> <p>In addition to all these matters, there are psychological problems related to the amputee's pain tolerance. The way the amputee reacts to pain is influenced by such psychological factors as his acceptance of the amputation and his unrealistic hopes for the prosthesis. Finally, there is a need to recognize the special social attitudes that an amputee elicits when he expresses discomfort.</p> <h5> <i>Attitudes Toward Prosthetic Training</i> </h5> <p> Training to operate a prosthesis effectively requires a period of time ranging from a few hours to many hours, as correctly anticipated by all but three percent of the subjects: ( <b>Fig. 15</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig.15</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As we have seen, the subjects of study generally knew little about the potentials of prosthetic restoration. When, on top of the amputee's functional disability, there is superimposed the unavoidably new and ambiguous situation, anxiety and feelings of dependency are created. Since at a number of points in the rehabilitation process the physical and occupational therapist is in closest contact with the patient and is offering direct functional assistance, he is one of the natural recipients of these negative reactions. It should be possible during training for the therapist to use these dependency feelings and other factors to instill in the patient an attitude of realistic independence. Moreover, the training situation offers the amputee opportunity to develop and to demonstrate his functional competence under professional guidance. Regulated training routines have many advantages. Learning is quicker and more efficient, and the number of successful experiences can be maximized while failures are held to a minimum. For the amputee, the training experience should result not only in proficiency with the artificial limb but also in a realistic functional independence and a general sense of adequacy and personal competence.</p> <h5> <i>Attitudes Toward the General Value of Artificial Arms</i> </h5> <p>In an effort to determine the significance that artificial arms had for the amputees, the subjects were asked to express their opinions in terms of three frames of reference the advantages of using a prosthesis, the general functional help of a prosthesis, and the importance of the artificial arm.</p> <p> <i>Advantages.</i> The overwhelming opinion among the amputees, both before and after fitting, was that artificial arms have more advantages than disadvantages: ( <b>Fig. 16</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>General Help.</i> The prosthesis enabled the amputees to get along better. Most of them maintained that they could get along <i>much</i> better. A few said that it hindered them slightly. No one said that it really interfered. But among the amputees who had expected to find extreme advantages, there were indications of marked changes of opinion. That the group with the highest expectations dropped from 78 percent to 59 percent illustrates the development of more realistic values through experience. The same kind of change is illustrated by the increase in the number of amputees who said they thought a prosthesis could help them to get along "about the same" or "slightly worse": ( <b>Fig. 17</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Importance.</i> Despite a drop of 9 percent in the two most favorable categories of response, over 70 percent of the amputees said after fitting that they still believed it "very important" or "extremely important" for them to wear artificial arms. There was, however, an increase from 4 percent to 12 percent in the number of amputees who said they thought their prostheses "not at all" or only "slightly" important: ( <b>Fig. 17</b> ) </p> <p>It seems clear that the amputees retain favorable attitudes toward their prostheses after a period of wear. They appear to consider prostheses generally helpful, to believe that the advantages far outweigh the disadvantages, and to be convinced of the importance of artificial arms.</p> <p>If these findings are accepted as showing the general feelings of the amputees, the next step is to relate these attitudes to the amputees' actual use of their prostheses. The relevant factors here are the amount and type of use, the situations in which prostheses are worn and employed, and the amputee's reasons for discarding a prosthesis.</p> <h5> <i>Anticipated Difficulties With Prostheses</i> </h5> <p>As regards the wearing of an artificial arm, the amputees foresaw certain difficulties. They anticipated problems in becoming accustomed to wearing the arm, in learning to operate it, in dealing with fatigue, and in avoiding awkwardness. With the exception of the second difficulty, learning to operate the arm, all of these turned out to be real problems, and some additional ones, such as mechanical failure of the prosthesis, stump pain, and excessive heat, developed.</p> <p>The difficulties that amputees experience with their artificial arms range from relatively trivial annoyances to serious complications. Most of them may be placed in either of two categories-problems related directly to mechanical, functional, or medical disorders, and problems related to emotionally based preoccupation with conditions otherwise insignificant. Those in the first category disappear when the relevant conditions are corrected. Those in the second category reflect personality variations. In the interests of clarity and emphasis, these emotion-laden complaints have been classified in accordance with six hypothetical kinds of personality. Although having no value in themselves the stereotypes thus created are not intended as "pigeon-holes," they serve nevertheless as organizing aids for identifying the problems.</p> <p> <i>The Unmotivated.</i> The unmotivated amputee does not expend the effort necessary to overcome obstacles in using a prosthesis. The person without drive wears and uses his prosthesis so long as everything operates smoothly, but when even slight difficulties arise he lacks the motivation to continue with the limb and to expend any extra effort needed to operate it. Wear and use are thus limited. In justification of his action in discarding the prosthesis, the amputee may present many rationalizations in the form of spurious complaints about comfort and effectiveness. </p> <p> <i>The Ghost Story.</i> Complaints derived from phantom sensation are likely to occur among amputees who are unaware of the common phenomenon and who consequently do not anticipate it. Still others, on experiencing the phantom, fall prey to misconceptions about it and fail to acknowledge the experience for fear of implying that they are disoriented or are suffering from mental disturbances. Through ignorance, such patients may attribute their phantom sensation or phantom pain to poorly fitting sockets or harnesses. Complaints usually disappear when the amputee has been well informed. </p> <p> <i>Mind Over Matter.</i> People vary in the amount of discomfort they can accept. Since it is probably impossible to eliminate discomfort entirely, some dissatisfaction is inevitable. But this common difficulty may be reduced to some extent if, before fitting, the amputee develops realistic attitudes toward whatever discomfort he cannot escape. Forewarning the amputee may help him to avoid disappointment and exaggeration of his discomfort. </p> <p> <i>The Exaggerators.</i> Some amputees tend to elaborate upon their complaints and to distort the situation out of all proportion to its real significance. They develop fixations about relatively unimportant details or symptoms, and they are not open to persuasion or logical argument. Most often such a complaint is based upon a personal need, as for sympathy or attention, perhaps only remotely related to the actual prosthetic condition. But until this personal need is satisfied, little success can be expected in handling the related prosthetic or medical conditions. </p> <p> <i>Motor Trouble.</i> Difficulties associated with the actual operation of a prosthesis result from two conditions-from poor neuromuscular endowment, or from tensions and anxieties producing awkwardness and lack of coordination. In the first condition, the amputee possesses in balance and coordination basic deficiencies which together operate to reduce his functional potential. Owing to the effects of banging and twisting in awkward and erratic movements, the prospects of prosthetic maintenance tend to increase. In such a case, faults that are apparently prosthetic are really human faults. </p> <p>The second condition typifies the anxious person who always anticipates something bad. He looks upon every squeak, every irritation, and every temporary malfunction as a sign that the prosthesis is falling apart or at least is in need of adjustment. He differs from the exaggerator in that his reactions are much more diffuse and not nearly so emphatic. Anxiety induces characteristic muscular tension, which interferes with function in much the same way as does an innate psychomotor inferiority. Since the latter condition offers a poorer prognosis and dictates a different course of care, it is necessary to make a distinction based upon etiology.</p> <p> <i>The Comparison Shopper.</i> Every prosthetist knows of amputees who are always looking for something better. Sometimes such persons channel their needs constructively and make a contribution by entering the field of prosthetics development. More often, however, they dissipate their energies going from limbshop to limbshop looking for satisfaction they probably cannot get. These amputees are apt to become a matter of professional concern, for they often tend to depreciate the efforts, skill, and integrity of the art. </p> <p> <i>Recapitulation.</i> It is likely that a single explanation runs through several of the foregoing categories, for the amputee's subconscious nonacceptance of his amputation may underlie lack of motivation, phantom sensation, over-reaction, and inability to be satisfied. The problems of phantom sensation and of low discomfort tolerance may be accounted for physiologically, and the conditions of over-reaction and constant apprehension may be traced to personality factors more general than refusal to accept amputation. In any event, the categories can be made more useful, or at least revised constructively, if conceptual and experimental analysis is undertaken to establish the extent of each category, the etiological backgrounds, and the best manner of treatment in each case. </p> <p>Two general considerations should govern the follow-up of complaints-improvement of undesirable conditions, and the identification and description of the "complainers." The first is limited only by the present state of technical knowledge and skill in the field of limb prosthetics. The second has received only casual attention in the past. Further work in this area of psychology could prove to be fruitful.</p> <h4>Can the Postfitting Attitudes of Amputees Toward their Prostheses be Predicted on the Basis of their Prefitting Expectations?</h4> <p> As we have seen, the attitudes held by the amputees before they had participated in the program were modified by their subsequent experience with prostheses. The shift was generally toward a more realistic opinion of the results that could be obtained with prostheses. In addition to these changes, however, the attitudes of the amputees both before and after fitting showed that they placed a great deal of importance on the desirability of wearing a prosthesis. The next step, then, was to study the relationship between an amputee's attitude before fitting and his attitude afterwards. Our aim was to determine whether or not it is possible to predict an amputee's postfitting adjustment from a knowledge of his expectations before he is fitted. To this end, the question was asked: <i>Are the prefitting attitudes of amputees toward prosthetic restoration related to the attitudes they hold after fitting and a period of usef</i> Or, to put the question more specifically, will the amputee who approaches the fitting with a positive attitude about prostheses tend to maintain that attitude after he has worn and used an artificial arm, and, conversely, will the amputee who starts with a less positive, ambivalent, or negative attitude toward prostheses persist in that attitude after wear and use? </p> <p> Appendix IIIH, used previously to determine the degree of satisfaction of amputee expectations, was now applied to test whether or not postfitting attitudes could be predicted from the corresponding prefitting attitudes. <a style="text-decoration:none;">*</a> Selected for this analysis were 42 amputees, none of whom had worn a prosthesis before participating in the program. They included 18 below-elbow, 18 above-elbow, and 6 shoulder-disarticulation cases ranging in age from 17 to 54 years, in education from none to postgraduate school, and in the year of amputation from 1916 to 1955. The group was, in short, highly diverse. According to their combined expectancy scores, the subjects were placed on a continuum ranging from high to low in prosthetic expectation and were then divided into three equal groups representing high, intermediate, and low prosthetic expectancy. For comparative purposes, only the upper third, representing high expectancy, and the lower third, representing low expectancy, are used in the following analyses. </p> <h5> <i>Combined Expectancy Score of High Group Compared With That of Low Group</i> </h5> <p>The first step was to determine whether the initial attitudes of the high-expectancy and low-expectancy groups were maintained after prosthetic experience or were modified by it.</p> <p> Accordingly, the attitudes of the high and low groups were compared before and after fitting, <a style="text-decoration:none;">*</a> as indicated in <b>Table 3</b> ]. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In both instances, the difference between the average combined expectancy scores of the high-expectancy group and of the low-expectancy group was found to be statistically significant (P 0.05). Moreover, the mean score for each group did not change significantly after fitting (P 0.05). Thus in general positive or negative attitudes within the group were maintained after fitting.</p> <p>The individual items of the questionnaire were studied in an effort to determine why within each group there was only insignificant change in the combined expectancy scores from before fitting to after fitting. Was this result owing to lack of systematic differences between evaluations? Or were gains in positive feelings toward some items canceled out by loss of positive feelings toward other items?</p> <h5> <i>High and Low Group Comparisons for Individual Items</i> </h5> <p> Within each group an analysis was made of the way in which the responses to individual questionnaire items changed after fitting. The opinions expressed by the high-expectancy group and by the low-expectancy group about each item before and after fitting are listed in <b>Table 4</b> , where it may be seen that the nine items originally used to differentiate high prosthetic expectancy from low continued to differentiate the two groups, the "high's" in every instance remaining more favorably disposed than the "low's." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Inspection of the data indicates that the lack of change from prefitting to postfitting evaluations, as measured by the combined expectancy score, does not result from the cancellation of negative changes by positive ones. The average score of both the high-expectancy and the low-expectancy groups increased (became less positive) on most items. The conclusion may thus be drawn that experience with prostheses led both groups to expect less in the way of functioning (items 1 and 2), to expect less resemblance between prostheses and natural arms (item 3), and to expect artificial arms to be more uncomfortable (item 5). On the other items, the average score either decreased or remained about the same. Both groups said that the artificial hand more closely resembled the normal hand than they had expected (item 4). The "low's" apparently found (more so than the "high's") that they had not sufficiently appreciated the advantages of wearing prostheses (item 8). Of considerable interest were the group differences in response to item 6 (the importance of wearing an arm). The "high" group showed a lessening of positive opinions, and this decrease corresponded to a decline in negative attitudes among the "low's."</p> <h5> <i>Certainty of Response</i> </h5> <p> Throughout the questionnaire, the amputees had been asked to indicate by code the degree of certainty they felt about each of their responses. After the initial investigation, a study was made of the certainty with which any particular response had been expressed. In the code <i>AS</i> (absolutely sure), <i>VS</i> (very sure), <i>FS</i> (fairly sure), <i>SU</i> (somewhat unsure), <i>VU</i> (very unsure), <i>AS</i> was arbitarily assigned a weight of 1; <i>VS</i> a weight of 2; <i>FS,</i> 3; <i>SU,</i> 4; and <i>VU,</i> 5. Thus was obtained an average certainty score for each person in each group. The mean certainty scores for each group, prefitting and postfitting, are shown in <b>Table 5</b> . </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 5</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputees with high expectancy express themselves as being a good deal more certain of their responses than do the low-expectancy amputees, although both are generally quite affirmative. Since in general the amputees admit to very little prosthetic knowledge, one may wonder about the basis for such certainty. After they had acquired experience with their prostheses, both groups became even more certain in their responses, as might have been expected. But the increase in certainty among the "low's" was considerably less than the increase expressed by the "high's." There would seem to be much value in further analysis of the relationship between attitude toward prostheses and certainty of response.</p> <h5> <i>Relationships Between Expectancy and Other Factors Related to Amputation</i> </h5> <p> In order to learn whether or not there were systematic relationships between prosthetic-expectation level and certain other factors, the "high" and the "low" groups were compared with regard to amputation type, hand dominance, marital status, age, educational level, and age at time of amputation. Analysis indicated no statistically significant differences<a></a> between the group with high expectancy and the group with low expectancy. <a style="text-decoration:none;">*</a> It would appear that, for this sample, the amputees who expect considerable returns from prosthetic service and those who do not expect very much are not greatly different in the factors of amputation type, handedness, marital status, age, education, and time since amputation. The suspicion that "attitudes held by amputees about prosthetic restoration before fitting are related to the attitudes they hold after fitting and a period of use" is therefore confirmed by the data. The findings also substantiate the more specific hypothesis: <i>The amputee who approaches the fitting with a positive attitude about prostheses will tend to maintain that altitude after he has worn and used one; the amputee who starts with a less positive, ambivalent, or negative attitude toward prostheses will persist in that attitude after wear and use.</i> </p> <p>It must be emphasized that these findings relate to the amputees' general attitudes toward prosthetic restoration. Any particular reaction will be a function of the general prosthetic attitude and also of the specific factor involved, whether it be that of appearance, of function, or of something else.</p> <h5> <i>Relationships Between High and Low Expectancy and Other Attitudes of Amputees</i> </h5> <p>In the course of the studies, information also was gathered describing the attitudes, experience, and expectancies of the subjects. Not all of these data were thought to be directly related to the question of what the amputees expected from prosthetic restoration. But in continuation of the study of amputee attitudes toward prosthetic service, they were examined anyway. A nonstatistical comparison, made between high-expectancy and low-expectancy groups to detect differences with respect to other reactions, uncovered the following distinctions:</p> <ol> <li>On the whole, the group with the high expectations reported a great deal of improvement in performance. But the low-expectation group said that performance of a number of activities was impaired after prosthetic treatment. The degree of negative change reported by the "low's" was not as great as the degree of improvement reported by the "high's." Activities showing the greatest amount of change were eating, dressing, driving, and participating in sports. The "low" group expressed the most disappointment about eating, dressing, and sports activities. The "high" group reported its greatest improvements in the areas of dressing and driving.</li><li>The "low's" expected more difficulties than did the "high's" (18 to 12), and in the evaluations after fitting they continued to report more difficulties (19 to 14).</li><li>More "high's" than "low's" reported having had favorable comments made to them about the appearance of their prostheses.</li><li>More "low's" than "high's" admitted to negative changes in feelings since amputation.</li><li>Before wearing a prosthesis, four "low's" felt resentful when new acquaintances asked about the amputation; none of the "high's" expressed any negative feelings. After wear, the "high's" still did not express resentment, although three "low's" did.</li><li> The most outstanding difference between the "high" and "low" groups was manifest in response to the question, <i>If you don't consider appearance, do you think that you could get along as well without a prosthesis as with one?</i> Before fitting, none of the 28 subjects responded in the negative (perhaps because they were getting a free prosthesis). Three of the "high's," however, gave extremely positive responses ("The prosthesis is like a part of my body; I cannot do without it."), while the rest of the "high's" and all of the "low's" answered more temperately ("It facilitates things, increases independence."). In the postfitting evaluation, one of the "high's" said that he could do without a prosthesis, as his was not too helpful; two of the "high's" gave extremely positive replies; and the rest were more moderately positive. The "low's" presented a much more negative picture in the postfitting evaluation. Four said that they felt they could do without a prosthesis, and only one expressed himself as being oriented very positively. </li></ol> <p>The validity of the group division appears to be supported by the sample findings from the rest of the psychological data. Although we are concerned at present with establishing points of difference between the "high" and the "low" groups, it is well to add that in many other variables, such as social sensitivity and reactions to frustration, use of these measuring instruments revealed no differences.</p> <p>In conclusion, then, the hypothesis was confirmed that the attitudes of nonwearers toward prosthetic restoration are related to their attitudes after they have worn prostheses. Through the use of a set of questions, it was found possible to differentiate between favorable and unfavorable attitudes. The division of the amputees on the basis of their general attitudes toward the usefulness of prostheses gave some indication of being related to other than prosthetic factors. But judging from the results, the establishment of predictive indicators of attitude toward prosthetic restoration appears to be feasible. It should be possible to develop a predictive scale which will have clinical and research utility and which at the same time can be administered and interpreted in a relatively simple way.</p> <h3>Summary</h3> <p> Throughout this section a number of recurrent themes have been encountered. Chief among these has been the amputees' need for unprejudiced recognition by nonamputees. In order to gain this recognition, the amputees consistently present themselves in a manner which only partially represents their true feelings. The interpretation of the data has therefore been that the amputees utilized the questionnaires more to express their feelings about how an amputee <i>should</i> be regarded than to state how he actually <i>is</i> treated. From this point of departure the information has been handled at two levels-the first involving the assumption that the data are valid and meaningful in themselves, the second based on the premise that the responses reflect the conscious and subconscious wishes of the subjects. </p> <h4>Personality Dynamics of Amputees</h4> <p>Although 90 percent of the amputees said that they were adapted to their loss, it is doubtful that so many had really achieved this result. Evidence seemed to indicate that many of the amputees were trying to maintain feelings of bodily integrity and adequacy by denying the personal and social concomitants of amputation. Any implication of abnormality was overwhelmingly rejected. Their physical defect was consistently de-emphasized, and their goals and values were those of the normal, nondisabled person.</p> <p>In almost all instances, amputees portray themselves as being as able an nonamputees. While almost never admitting to being substantially inferior to nonamputees, they do acknowledge that some extra effort is necessary to keep up with them. Other evidence confirms that amputees are, in the main, correct in stressing their ability. But their consistent refusal to acknowledge limitations reflects their own self-concern. Apparently they must exaggerate to maintain a social and vocational status equal to that of nonamputees.</p> <p>Considerable stress is placed upon self-sufficiency. Amputees say they resist accepting help because it is generally unnecessary. Unexpressed, but no less important, is the feeling that to accept help makes one dependent and lowers one's status.</p> <p>Sensitivity about physical prowess and appearance is one of the crucial influences in the psychological functioning of the amputee. The subjects in this study readily admitted their concern about the opinions of others, but few were ready to admit any considerable amount of sensitivity. They claimed not to resent curiosity about their appearance and to expect people to look at them. Clinical experience, however, indicates that amputees are much more sensitive and hostile toward the curious person than was indicated by the data. Not infrequently such sensitivity is denied not only to others but also to themselves.</p> <p>Amputees claim to be accepted by others on the same basis as anyone else, and they reject strongly the suggestion of "different" treatment. Mostly, the subjects did not feel that amputation had been a serious source of frustration. They felt they usually could do the things they wanted. When they were unable to perform because of the amputation, their usual reaction was to try all the harder.</p> <p>Finally, the general tone of the amputees is to give the impression of being optimistic about their abilities, acceptance by others, and future goals.</p> <p>The positive effect of the experimental treatment program on many of these variables was demonstrated. Although no radical personality changes were observed, there were consistent indications that some decrease in sensitivity and frustration resulted from the improved management procedures and from the improved prostheses. In addition, some degree of greater acceptance of loss, increased feelings of functional adequacy, and greater ease in social situations were noted.</p> <h4>Social and Functional Factors in Prosthetic Wear</h4> <p>The prosthetic-reaction test resoundingly confirmed the data from the questionnaires. It was clear that participation in the treatment program resulted in an increase in those responses indicating greater independence and increased feelings of security. The amputees believed there was both functional and psychological advantage in the wearing of a prosthesis. They viewed prostheses as providing the wherewithal for independent functioning. Increased confidence in their functional adequacy helped them to achieve greater self-acceptance, enabled them to face their disability more realistically, and let them view the reactions of others without feeling quite so threatened. They expected nonwearers to be more shy, more easily embarrassed, and less adaptive.</p> <h4>Attitudes Toward Prosthetic Wear, Before and After Fitting</h4> <p> In the final phase of the investigation two questions were asked: <i>Are the expectations of nonprosthesis wearers fulfilled by wearing a prosthesis?</i> and <i>Can the postfitting altitudes of amputees toward their prostheses be predicted on the basis of their prefitting expectations?</i> </p> <p>A number of avenues of approach were utilized to answer the first question. It was found that the extent of prosthetic knowledge claimed by the amputees was very small. The implications of the lack of information were discussed, with stress upon the opportunity ignorance presents for the development of unrealistic expectations (which may influence negatively future attitudes toward prostheses). Overly ambitious ideas as to the value of prostheses were modified with experience, and after being fitted most of the amputees had more realistic expectations of the advantages to be derived from prosthetic wear.</p> <p>General acceptance of the appearance of the prosthetic components was clear. There was little change in opinion regarding the extent to which prosthetic arms and hands resembled normal members. Three important constituents to the final judgment of amputee appearance were identified-the static factor of the cosmetic value of the prosthesis irrespective of function, the dynamic factor of natural appearance in use, and the situational factor of the intensity of the contact.</p> <p>Preconceptions regarding comfort did not change markedly with experience. Although comfort appears to be no important problem for three fourths of the amputees, the remaining one fourth found their prostheses to be uncomfortable.</p> <p>The amputees retained favorable attitudes toward the prostheses after a period of wear. Prostheses were considered to be generally helpful and very important to the amputees, the advantages far outweighing the disadvantages.</p> <p>With the exception of "learning to operate," most of the difficulties anticipated in wearing an arm actually developed. In addition, other problems evolved, such as mechanical failure, stump pain, and excessive heat. A number of hypothetical personality types were described to help identify complaints based upon emotional factors as contrasted with those directly related to prosthetic or medical problems. The second question was directed toward the idea that attitudes held before prosthetic fitting may influence the valuation of prosthetic usefulness regardless of experience. Tested and confirmed was the hypothesis that attitudes held by amputees about prosthetic restoration before fitting are related to the attitudes held after fitting and a period of use. Amputees holding favorable attitudes before using prostheses tended to maintain those attitudes after wear and use; subjects negatively disposed continued to be less favorably inclined.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, <i>Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability,</i> Social Science Research Council, New York, Revised 1953. </li> <li> Cameron, N, and A. Magaret, <i>Behavior pathology,</i> Houghton-Mifflin, Boston, 1951. </li> <li> Dembo, Tamara, and Esther Tane-Baskin, <i>The noticeability of the cosmetic glove,</i> Artificial Limbs, 2(2) :47 (May 1955). </li> <li> Dembo, Tamara, Gloria Ladieu Leviton, and Beatrice A. Wright, <i>Adjustment to misfortune - a problem of social-psychological rehabilitation,</i> Artificial Limbs, 3(2) :4 (Autumn 1956). </li> <li> Ladieu, G., E. Hanfmann, and T. Dembo, <i>Studies in adjustment to visible injuries: evaluation of help by the injured,</i> J. Abnorm. and Soc. Psychol., 42:169 (1947). </li> <li> Meyerson, L., <i>Physical disability as a social psychological problem,</i> J. Soc. Issues, IV(4):2 (Fall 1948). </li> <li> New York University, Prosthetic Devices Study, Report No. 115.07 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Social usefulness of the cosmetic glove: its notice-ability and appearance,</i> October 1949. </li> <li> New York University, College of Engineering, Research Division, Prosthetic Devices Study, Report No. 115.21, <i>Surveys of child amputees at the Mary Free Bed Hospital, Grand Rapids, Michigan,</i> Prepared for the Prosthetics Research Board, National Research Council, May 1957. </li> <li> Siegel, S., <i>Nonparametric statistics for the behavioral sciences,</i> McGraw-Hill, New York, 1956. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Kolmogorov-Smirnov and Fisher Exact Probability Tests (Siegel) indicated P&gt;0.05 in all instances.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall"> Siegel, S., Nonparametric statistics for the behavioral sciences, McGraw-Hill, New York, 1956. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be remembered that expectancy scores approaching 1 indicate favorable prosthetic attitudes, those approaching 5 indicate unfavorable attitudes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A measurement of prosthetic expectancy was obtained by a system of scores and ratings similar to that used in the analysis of the results obtained with Appendix IIIG. Each question in Appendix IIIH had five possible answers ranging from one that expressed very positive feelings to one expressing very negative feelings. The response reflecting the most favorable attitude was given a score of 1, that reflecting the least favorable attitude a score of 5. There was thus obtained a score for each item as well as an average score for the questionnaire as a whole (combined expectancy score). Each amputee was then assigned a rating which represented the direction and intensity of his feelings about prosthetic restoration and which was therefore a measurement of his prosthetic expectancy.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Dembo, Tamara, and Esther Tane-Baskin, The noticeability of the cosmetic glove, Artificial Limbs, 2(2) :47 (May 1955). </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall"> New York University, Prosthetic Devices Study, Report No. 115.07 [to the] Advisory Committee on Artificial Limbs, National Research Council, Social usefulness of the cosmetic glove: its notice-ability and appearance, October 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be remembered that on the average E2 was administered about six months after fitting. It is probable that, had this test been administered to the NPPWs before they received and used artificial arms, considerably greater differences between PPWs and NPPWs would have been found.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Six of the nine cartoons portrayed situations not relevant to independence and were therefore rated for security only. See Table 1, page 102.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall"> New York University, College of Engineering, Research Division, Prosthetic Devices Study, Report No. 115.21, Surveys of child amputees at the Mary Free Bed Hospital, Grand Rapids, Michigan, Prepared for the Prosthetics Research Board, National Research Council, May 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall"> Cameron, N, and A. Magaret, Behavior pathology, Houghton-Mifflin, Boston, 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> Dembo, Tamara, Gloria Ladieu Leviton, and Beatrice A. Wright, Adjustment to misfortune - a problem of social-psychological rehabilitation, Artificial Limbs, 3(2) :4 (Autumn 1956). </td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall"> Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The third reaction represents an extremely poor adjustment, for it leads to withdrawal from any situation that might point out the true extent of dependency. Typically, such amputees are characterized by sharply restricted behavior and a limited involvement in life.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall"> Meyerson, L., Physical disability as a social psychological problem, J. Soc. Issues, IV(4):2 (Fall 1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sydelle Silverman, M.A. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic Devices Study, Research Division, College of Engineering, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jerome Siller, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Research Scientist, Prosthetic Devices Study, Research Division, College of Engineering, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee, VII. Psychological Factors Creator An entity primarily responsible for making the resource Jerome Siller, Ph.D. * Sydelle Silverman, M.A. * https://staging.drfop.org/files/original/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/89e34b5363a6e2997d50157f759ed25d.pdf be2d67e33fc2cf47d7f30766ca9a7815 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_001.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_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>Prelude, Prophecy, and Promise</h2> <h5>John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) <a style="text-decoration:none;">*</a><br /></h5> <p> than a dynamic mechanism. The degree of disappointment and measure of failure in these simple objectives, without change in fundamental concepts, is to be seen in the countless empirical modifications of initial designs which bestrew the literature on artificial limbs over the past hundred years and more. </p> <p> Earlier optimisms were gradually replaced by indifference and the inertia of failure, as is well known to those associated with the problem of the amputee after World War I. Locomotion, as we ordinarily understand it, is impossible on a single extremity. But it was realized insufficiently that, unlike the upper extremities, the two lower limbs together constitute but a single organ-the organ of locomotion. Consequently, the complexity of locomotion in relationship to prosthetics design never really was understood, and even where designs were in question the available information was inadequate to support newer developments of principle. </p> <p> Preliminary efforts in the study of human locomotion are to be found in the work, <i>De Motu Animalium, </i>of the Neapolitan mathematician and physician, Giovanni Borelli (1608-1679). As a pupil of Galileo, he was stimulated to take a mechanistic view of bodily function and to study locomotion as a problem in leverage, but his theories and those of his followers soon were reduced to absurdity in the attempt to apply the same mechanistic principles to the whole of medical practice. Continuation of Borelli's approach had to await the nineteenth century and the advent of the Weber brothers, Edward (1806-1871) and Wilhelm (1804-1891), physician and physicist respectively, who with primitive electrical apparatus made the first accurate measurements of gait and undertook its mathematical analysis. The development of photography as a method of recording enabled Etienne-Jules Marey (1830-1904) to avoid previous errors and to correct earlier ideas, and further improvements in photography led to the classical work of Christian Braune and Otto Fischer, <i>Der Gang des Menschen </i>(1895), which has constituted the main source in the formulation of principles for the construction of artificial legs, as in the well-known books of H. von Recklinghausen (1920) and Frederich Mommsen (1932). Over more than a decade (1933-1945) Elftman published the results of extensive locomotion studies. To these and many others we owe a great debt. </p> <p> Despite all these investigations, at the end of World War II our knowledge of human locomotion was still quite incomplete, and such knowledge as existed was only poorly understood. Thus it was that, when approached in September of 1945 by the then Committee on Artificial Limbs of the National Research Council, the representatives of the College of Engineering and of the Medical School of the University of California could point to the necessity of the adoption of a long-term outlook which envisioned the study of the fundamentals of human locomotion, of the amputee who must wear a lower-extremity prosthesis, and of the prosthesis itself. It could be shown that the experience of 400 years in trial-and-error techniques had offered little and that a firm basis for progress could be established only by a systematic approach. It was predicted that at least seven years of study would be required to collect the fundamental data necessary for improved design of artificial legs. </p> <p> That that prophecy was not needlessly pessimistic is revealed in the fact that only today can it be said with a degree of confidence that we are about to enter a period of practical development in the evolution of a truly satisfactory lower-extremity prosthesis. Within the next two or three years we should see the appearance of sound improvements based upon the preceding nine years of pioneering work. </p> <p> But the problems of the leg amputee are not wholly "prosthetic." Such a patient presents a clinical picture of considerable significance. The whole being the sum of its parts, the amputee can scarcely be looked upon as normal in the medical sense, however good general health may be. He is, indeed, quite abnormal, for from amputation of an extremity come changes in skeletal, muscular, and circulatory systems to be dealt with in the design and application of the prosthetic replacement. Complications of pain, real and phantom, and of skin disorders are other matters needing the skills and experience of the medical profession. </p> <p> Taking cognizance of this situation, the Advisory Committee on Artificial Limbs, in the spring of 1953, recommended that the University of California initiate an extensive clinical program to be integrated with the work already under way in the fundamentals of locomotion and in the techniques of lower-extremity fit and alignment. Utilizing space and services afforded by the U. S. Naval Hospital at Oakland and personnel from the University of California Medical and Engineering Schools, the Clinical Study aims to apply to the practical problems of difficult amputee cases the results of the earlier work on the Berkeley Campus. </p> <p> This issue of Artificial Limbs is concerned with two major factors in the management of the lower-extremity amputee-the solution of medical problems associated with the amputated state, and the proper application of the prosthetic replacement on the basis of established biomechanical considerations. In the first of two articles, an orthopedic surgeon and an engineer collaborate in describing the origin, observations, and objectives of the Lower-Extremity Clinical Study. In the second, an engineer develops the principles of alignment and socket fit so indispensable to comfort and function, and hence to the success, of the above-knee artificial leg. In this cooperative effort is reflected the whole basic philosophy of the Artificial Limb Program in approaching the problems of the amputee. </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>John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) </b></td></tr><tr><td class="clsTextSmall"> Professor of Anatomy, School of Medicine, University of California, San Francisco. </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 Prelude, Prophecy, and Promise Creator An entity primarily responsible for making the resource John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) * https://staging.drfop.org/files/original/7a7cd68d5bd0095b317a4f44affc0941.pdf d7e865477f5445c4a9c985354cc6bd99 https://staging.drfop.org/files/original/8f0c35d069948e0004acb926243104e3.jpg d66267d487f5ad7b5cb149ee357ca97d https://staging.drfop.org/files/original/153e5ba3b516d61a2c180b74512debd5.jpg 181b23a4816351a5231a249d74444720 https://staging.drfop.org/files/original/88f27d9100c85efdefc153a74675137b.jpg 81d4538609ad379bbc4a53f1a5928edc https://staging.drfop.org/files/original/f98e862183e5762fac48c707098889f5.jpg c474c3993fb68bf29c0fdae290d520fb Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_015.pdf Text Any textual data included in the document <h2>Dynamics and the L3 Through L5 Myelomeningocele Child</h2> <h5>John Glancy, CO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Since 1970, the orthotic management of myelomeningocele children treated at Indiana University has focused primarily on musculoskeletal deformities that develop after birth. Much of our effort has been directed to children with L3 through L5 lesions, because of their potential to be community walkers.<a></a> The decision to direct our attention to the problems that these lesion levels present also relates to the fact that they constitute the majority group among the myelomeningocele population. The range of orthotic dysfunctions, in kind or degree, that children with these lesion levels are prone to today, are identical to the orthotic dysfunctions that like youngsters had to endure in 1970.</p> <p>Myelomeningocele remains "the most complex, treatable congenital anomaly consistent with life."<a></a> What has changed, in the interim, is our understanding of the pathodynamics acting upon the musculoskeletal systems of children with L3 through L5 lesions. The introduction of thermoplastic materials, along with vacuum forming techniques, now allow orthotists greater freedom of design. Consequently, there is a gradual change occurring in orthotic management, from the traditional approach based upon statics, to a growing appreciation of dynamics as a means of preserving function by preventing the formation of secondary dysfunctions caused by gravity, growth, and time. How may one describe the benefits these changes portend for the L3 through L5 myelomeningocele child, present and future? It now appears that while present-day children with L3 through L5 lesions may have the same vulnerability to secondary dysfunctions as the children of 1970 . . . they may not have to endure them, in kind or degree.</p> <p>Those concerned with the care of these children face the same dilemma today as was experienced in 1970-how to provide long-term protection from secondary dysfunctions without introducing unacceptable inhibitions to daily activities. Fortunately, some of the specific challenges within the makeup of this dilemma have been satisfactorily met:</p> <ul> <li> <p><b>The polypropylene Solid-Ankle Orthosis<a></a></b> offers long-term protection to the foot/ankle complex. The Carlson, Berglund technique<a></a> adds to the efficiency of this orthosis.</p> </li> <li> <p><b>Lightweight KAFO's</b> that utilize a unilateral upright with offset free knee joint, modified quadrilateral thigh cuff and dynamic knee extension assist<a></a> offer long-term protection to myelomeningocele knees.</p> </li> <li> <p style="text-align: left;"><b>A polypropylene thoracopelvic unit<a></a></b> offers a promising foundation for achieving acceptable, long-term control of the trunk with L3 through L5 lesion levels, without having to extend the exoskeletal system below the anatomic hip joints (<a href="/files/original/f98e862183e5762fac48c707098889f5.jpg"><b>Fig. 4</b></a>).</p> </li> </ul> <p>Since the 1976 report on the dynamic orthotic system was published,<a></a> we have refined the modular aspects of the system for two primary reasons: (1) To ensure that each component meets the requirements for which it is designed, i.e., providing no more, nor no less control than needed, and (2) To encourage the night use of the daytime system by the utilization of quick releases, in order to remove any components unrelated to the areas requiring night-time dynamic control (<a href="/files/original/8f0c35d069948e0004acb926243104e3.jpg"><b>Fig. 1</b></a>). These modular refinements were also prompted by our recognition of a correlation between early application and night-time dynamic control, to success in the prevention of secondary dysfunctions. Due to the complexities of the pathodynamics involved, particularly in the hip complex and lumbopelvic regions, an efficient night-time unit must be equally as functional as the daytime unit, hence the economic necessity that a single system provide both day and night protection against secondary dysfunctions.</p> <strong><a href="/files/original/8f0c35d069948e0004acb926243104e3.jpg">Figure 1.</a> Features of modular system: (A) Assembled system for fitting: elastic components to knee and pelvic extension assist are not attached. (B) Modified quadrilateral thigh cuff; showing Nylon receptacle and locking nut for quick release of AK module. (C) Solid-ankle AFO with lateral off-set knee joint and pivotable attachment portion of knee extension assist assembly. Shockcord is not shown. (D) Thoracopelvic unit; receptacles for the quick release of the KAFO's and reinforcing horizontal bar are visible. Note: The combination polycentric and lateral motion joint shown in A. The lock joint shown in B is used for post-op cases.</strong><br /> <p>The importance of night-time use became even more evident with an awareness of the startling amount of regression that often occurs during short periods of time when the system is not worn. Rapid regression occurs with discouraging frequency about the hips and lumbopelvic regions especially. Such 'down time' often is more frequent within the three-to-six month periods between orthotic checkup visits than we understood to be the case. For example, in addition to the usual childhood diseases, colds, etc, these children are subject to episodes of kidney and/or bladder infection and periodic revisions to their shunts. The success or failure of the dynamic orthotic system appears to be proportional to the frequency and duration of these occurrences. Without an appreciation for the circumstances just described, orthotists will experience constant frustration as they seek explanations for the gradual regression their patients present, because they will unintentionally attribute the cause to often non-existent weaknesses in the design of a given orthotic system.</p> <p>The answer lies not only with better control of the hip and lumbopelvic regions, but also with constancy of control. We must be as persistent with our applications of biodynamics as nature is with the pathodynamics acting upon these regions. There are three needs that must be considered, which hopefully can be met by a single dynamic thoracopelvic design. They are:</p> <ol> <li> <p>A reliable method of eliminating jack-knifing of the trunk during ambulation without the use of locks.</p> </li> <li> <p>Control of the lumbopelvic and hip regions in a manner which does not require extensions to the lower extremities. The need to protect the growing child's lumbar spine when his gluteous maximum muscles are paralyzed, but his hips and/or knees do not require protection (L4 and L5 levels), has yet to be met.</p> </li> <li> <p>The controls in 1 and 2 above, must operate with the same efficiency during night-time wear as they do during the day, in order to reverse the inevitable regression resulting from unavoidable periods when illness prohibits wearing the orthosis.</p> </li> </ol> <p>Granted, these design criteria demand a major breakthrough in the state-of-the-art. Nevertheless, using our current thoracopelvic unit as a point of departure, an acceptable solution seems within our grasp. <a href="/files/original/153e5ba3b516d61a2c180b74512debd5.jpg"><b>Fig. 2</b></a>, <a href="/files/original/88f27d9100c85efdefc153a74675137b.jpg"><b>Fig. 3</b></a>, and <a href="/files/original/f98e862183e5762fac48c707098889f5.jpg"><b>Fig. 4</b></a> show our progress to date. A resolution to this problem would have broad orthotic applications-it should be vigorously pursued. Our work on this project is ongoing, and we invite our readers' active participation.</p> <strong><a href="/files/original/153e5ba3b516d61a2c180b74512debd5.jpg">Figure 2</a>. (A &amp; B) Sitting stability and comfort is enhanced by the flat, posterior surfaces of the modified quadrilateral cuffs, abduction motion and polycentric feature of the hip joints. (C) Posterior view: Thoracopelvic unit on casts with the new pelvic extension assist showing right rubber strap detached from the upright. (Note how the model has dropped on the right side.) (D) Side view showing how rubber strap attaches to upright. AK and BK quick releases and Delrin fitting for shockcord of the knee extension assembly. (E) Posterior view with both rubber straps of the pelvic extension assist attached to the uprights. (Note the horizontally level suspension of the cast, demonstrating the force the rubber straps generate.)<br /></strong><br /><strong><a href="/files/original/88f27d9100c85efdefc153a74675137b.jpg">Figure 3.</a> Most recent prototype: (A) Dacron straps with slide-bar buckles serve as a passive, adjustable 'pelvic band.' Puhient weighs 43 lbs. Each rubber strap is set to generate 14 force pounds equal to 62 inch pounds of extension moment which resists the first 20 degrees of forward flexion of the lumbar spine. Any voluntary forward flexion of the trunk beyond 20 degrees overrides the dynamic extension. (Note: Posterior polypropylene bar must be slotted at pelvic end (drawn in) to permit forward rotation of lumbar spine, as the dacron straps check unwanted forward rotation of the pelvis.) (B) Side view: Lock used for 2-3 months post-op. Dynamic extension is fully operative even with locks. Patient has 45 degree hip contractures, which explains posterior gap of thigh cuff in post-op alignment. (C) Anterior view: Note Nyloplex stud medial to hip joint which is the pivotal attachment point for slide-bar buckle. (D) Posterior view of Plastazote® lining showing the sealed 'pockets' at waistline level. Pockets are filled with #382 Elastomer. (E) Model shown in seated position. Although 28 force lbs. (both rubber straps) are acting to extend the lumbar spine when sitting, this force has no effect upon the lower extremities. (F) Bottom view: showing 'shelves' formed with the lining and filled with Elastomer via the pockets shown in photo D. Their effectiveness in transferring the weight of the thorax to the uprights is well demonstrated. This technique prevents pressure sores to insensitive skin.<br /><br /><a href="/files/original/f98e862183e5762fac48c707098889f5.jpg">Figure 4</a>. Schematic lateral view of normal lumbopelvic relationship to the horizontal. Shaded areas show the optimum sacral angle of 30 degrees, with respect to the center of the hip joint, during normal standing posture. The normal amount of postural lordosis resulting from the optimum sacral angle is also depicted. The unshaded outline shows the pelvis rotated 20 degrees about the hip joint in an anterior direction, taking the entire trunk with it, indicated by arrow in upper left. The downward oblique line, originating from hip center, indicates the maximum distal point (gluteal fold), relevant to the horizontal at hip level, which is feasible as an attachment point for passive pelvic control when fitting small children (see A &amp; B, Figure 3). The arrow between the horizontal and oblique lines, to the right of the figure, demonstrates that beyond 20 degrees of forward rotation of the pelvis, the distal attachment point will rise <i>above</i> the horizontal. The contribution of the passive pelvic control, relative to forward rotation of the pelvis above the horizontal, is nil. However, the intimate fit of the thoracopelvic unit (especially the abdominal position) ensures that the optimum relationship between the lumbar spine and the rotating pelvis is passively maintained throughout the full range of pelvic A-P rotation. Consequently, any <i>involuntary</i> forward rotation of the trunk about the hips (within the first 20 degrees) can be controlled as a single body segment. The functional status of the abdominal and particularly the hamstring muscles, may be expected to be crucial contributors to the system's success. <i>Unless the pelvis and lumbar spine can be passively placed in a normal standing posture to begin with, neither can be controlled in an upright position without locks.</i></strong><br /> <h3>Acknowledgment</h3> <p>I wish to express my thanks to John G. Patsko, CO, whose fine photography adds so much to the text.</p> <p><b>References:</b></p> <ol> <li>Glancy, J. and R.E. Lindseth, "A dynamic orthotic system to assist pelvic extension: A preliminary report," <i>Orthotics and Prosthetics</i>, 29:1, pp. 3-9, March, 1975.</li> <li>Bunch, W.H., A.S. Cass, A.S. Bensman and D.M. Long, "Modern management of Myelomeningocele," Pub. Warren H. Green, Inc., St. Louis, 1972.</li> <li>Glancy, J. and R.E. Lindseth, "The polypropylene solid-ankle orthosis," <i>Orthotics and Prosthetics</i>, 26:1, pp. 14-26, March, 1972.</li> <li>Glancy, J., "A dynamic orthotic system for young myelomeningoceles: A preliminary report," <i>Orthotics and Prosthetics</i>, 30:4, pp. 3-15, December, 1976.</li> <li>Carlson, J.M. and G. Berglund, "An effective orthotic design for controlling the unstable subtalar joint," <i>Orthotics and Prosthetics</i>, 33:1, pp. 39-49, March, 1979.</li> </ol> <div style="width: 400px;"><b>*John Glancy, CO </b> John Glancy, CO., is Assistant Professor and Director of Orthotics in the Orthotics Division at James Whitcomb Riley Hospital for Children, Room 1100, Indiana University Medical Center, 702 Barnhill Drive, Indianapolis, Indiana 46223.<br /><br /><br /></div> Page Number(s) 15 - 23 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_015/1984_04_015-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_015/1984_04_015-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_04_015/1984_04_015-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1984_04_015/1984_04_015-4.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 Dynamics and the L3 Through L5 Myelomeningocele Child Creator An entity primarily responsible for making the resource John Glancy, CO * https://staging.drfop.org/files/original/02e028e3e75d48a51464d262823def1c.pdf d29d6d36d9bfa48369439bb49c9a0cc0 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_04_199.pdf Text Any textual data included in the document <h2>The Basis of Orthotic Management in Quadriplegia</h2> <h5>John H. Bowker, M.D.&nbsp;</h5> <p>Statistics indicate that there are 150,000-200,000 spinal cord injured persons in the United States.<a></a> Each year, approximately 10,000 newly injured are added to this figure. About 80% are males under the age of 40 years, while slightly more than half (53%) are quadriplegics, with low cervical injuries being most common.<a></a> In recent years, improved medical management has led to an increase in post-injury life expectancy in spinal cord injury to a probable 30 to 40 years.<a></a> This ever-increasing national prevalence of spinal cord injury poses major problems in rehabilitation, several of which will be addressed in this issue of <i>Clinical Prosthetics and Orthotics</i>.</p> <p>When the spinal cord team first confronts a person with a cervical spine injury, the first two priorities are preservation of life itself and prevention of further damage to the spinal cord and spinal nerve roots. Immobilization of the neck, followed by traction-reduction of vertebral malalignment, is carried out concomitantly with physiologic stabilization. Special studies, including magnetic resonance imaging, are then done to determine the need for immediate surgical relief of extrinsic pressure on the cord due to residual vertebral malalignment and/or fragments of bone or intervertebral disc. Intraoperative imaging with ultrasound further aids in the identification and removal of fragments causing extrinsic pressure. The preservation or restoration of function of just one nerve root by precise surgery of this sort can make the crucial difference between a modicum of independence and total dependence in self-care. Depending on the specific injury and the surgeon's preference, stabilization of the spine may be accomplished by means of a halo external fixation system alone or by internal fixation with wires and bone grafts, supplemented by an orthosis. In either case, stabilization will expedite the rapid mobilization of the patient. At this point, a decision can be made regarding the appropriateness of orthotic fitting.</p> A brief mention has been made of the functional significance of each residual cervical nerve root in the quadriplegic. This may be further elaborated upon as follows:<br /><br /> <ul> <li><b>Fourth cervical root (C-4):</b> innervates the diaphragm, allowing independent breathing.</li> <li><b>Fifth cervical root (C-5):</b> innervates the deltoid and biceps/brachialis, providing shoulder abduction/flexion and elbow flexion, respectively.</li> <li><b>Sixth cervical root (C-6):</b> innervates the radial wrist extensors, permitting wrist dorsiflexion and a passive opposition of thumb and fingers by "tenodesis effect" of the finger flexors.</li> <li><b>Seventh cervical root (C-7):</b> innervates the triceps, wrist flexors and finger extensors, allowing elbow extension, wrist volar flexion, and finger extension, respectively.</li> <li><b>Eighth cervical root (C-8):</b> innervates the finger flexors, allowing a gross grasp.</li> <li><b>First thoracic root (T-1):</b> innervates the intrinsic muscles of the hand, resulting in complete hand function, including grip and a precise thumb to finger pinch.</li> </ul> <p>It is important to note three features of this progressive classification to develop a clearer understanding of its relative limitations. Firstly, many muscles are supplied by two roots. The root associated with a given muscle in the list above is that which primarily innervates that muscle. The preservation of the next lower root provides not only an additional distal function, but also greater strength in the muscle just above, due to the activation of additional motor units by this secondary nerve root. Again, this argues for preservation of every possible root. Secondly, preservation of root function is often asymmetrical. For example, a quadriplegic may have a functional level of C-5 on one side and C-6 on the other. In this case, an orthotic prescription for one side will be totally inappropriate for the other. Thirdly, with nerve fiber (axon) regrowth, improvement in strength of a given muscle may occur over time. Occasionally, even the next higher root may recover as well. Monitoring by repeated muscle testing can thus lead to a progressive change in orthotic prescription. The occupational therapist, by virtue of her close daily contact during the rehabilitation process, is often the first team member to note these changes. To aid in the prognosis of muscle return, it is now possible, by advanced biofeedback techniques, to find functioning motor units in muscles considered "paralyzed" by conventional muscle testing techniques. Following identification of working motor units, it may be possible to strengthen them with bio-feedback-directed exercise. This often results in the addition of another useful upper limb function with or without the help of an orthosis.</p> <p>Before an upper limb orthosis can be used, the quadriplegic must be positioned so that visual feedback allows contact between a partially insensate hand and the object to be manipulated. A properly designed and carefully fitted wheelchair can, therefore, be considered the basic orthosis for the quadriplegic. Lateral trunk supports or a corset may also be essential for functional sitting posture, freeing the upper limbs from supporting the trunk.</p> <p>Throughout the process of rehabilitation, the orthotist should work closely with all members of the team, but especially the occupational therapist, physical therapist, psychologist, and physician if acceptance and use of orthotic devices is to be achieved. Successfully fitted orthoses are useful not only for self-care, but can also play a major role in achieving the ultimate goal of rehabilitation, the return to gainful employment. Many types of electronic devices, including computers, are manipulated more easily with an orthosis.</p> <p>In conclusion, it is hoped that this issue will be helpful in not only delineating the unique role of the orthotist in the care of the quadriplegic, but equally importantly, in demonstrating the need for communication and cooperation among all team members, if we are to offer optimum care to our patients.</p> <p><b>References:</b></p> <ol> <li>DiVivo, M.J., Fine, P.R., Maetz, H.M., and Stover, S.L., "Prevalence of Spinal Cord Injury: A Re-estimation Employing Life Table Techniques," <i>Archives of Neurology</i>, 37:1980, pp. 707-8.</li> <li>Eisenberg, M.G. and Tierney, D.O., "Changing Demographic Profile of the Spinal Cord Injury Population: Implications for Health Care Support Systems," <i>Paraplegia</i>, 23:1985, pp. 335-343.</li> <li>Green, B.A., Callahan, R.A., Klose, K.J., and DeLa-Torre, J., "Acute Spinal Cord Injury: Current Concepts," <i>Clinical Orthopaedics and Related Research</i>, 154:January-February, 1981, pp. 125-135.</li> <li>Young, J.S., Burns, P.E., Bowen, A.M., and McCut-chen, R., <i>Spinal Cord Injury Statistics: Experience of the Regional Spinal Cord Systems</i>, 1982, pp. 13-14.</li> </ol> Page Number(s) 199 - 200 Year 1987 Volume 11 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Basis of Orthotic Management in Quadriplegia Creator An entity primarily responsible for making the resource John H. Bowker, M.D.  https://staging.drfop.org/files/original/c6a552f1c6b8ae5f6420670481497839.pdf 923a2e99a0c425a3af0735185997492f 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 Full Text PDF Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_010.pdf Text Any textual data included in the document <h2>Partial Foot and Syme Amputations: An Overview</h2> <h5>John H. Bowker, M.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Historical Aspects</h3> <p>Until the middle of this century, partial foot and Syme amputations were done almost exclusively as a sequel to trauma. The presumption was that the normal vascular supply of the remaining foot would usually lead to healing. Both dry gangrene due to peripheral vascular disease and wet gangrene, related to infection superimposed on dysvascularity, were commonly treated by above-knee amputation or below-knee amputation, the choice often being dictated by local surgical prejudice.<a></a> The rationale was to amputate at the level where one could anticipate primary healing. This had considerable validity in the pre-antibiotic era, when failure of primary healing might mean death of the patient from secondary infection. However, in the United States at the present time, a growing number of partial foot amputations are being done for patients with arterial and/or capillary blood vessel disease, the majority of whom have diabetes mellitus.</p> <p>This major turnaround in attitude on the part of progressive surgeons is due to a number of technological breakthroughs of the past two decades. These may be characterized as follows:</p> <ol> <li> <p>A proliferation of antibiotics to cover most aerobic and anaerobic bacterial infections, largely eliminating the specter of death following failure of an initial procedure.</p> </li> <li> <p>Development of techniques to measure limb blood flow, both in small distal arteries by means of the Doppler effect and at the tissue level, by determination of transcutaneous oxygen perfusion and other methods.<a></a></p> </li> <li> <p>The evolution of the operating microscope, which has led to the development of evermore distal arterial bypass procedures, including ankle to foot jump grafts.<a></a> These often allow healing of distal amputations which would not have healed prior to bypass.</p> </li> <li> <p>Development of new plastics with a variety of production-controllable characteristics in liquid, sheet, and foam versions. This has led directly to the design of more physiologic and cosmetic partial foot prostheses.</p> </li> <li> <p>Studies of energy consumption during gait which demonstrate the physiologic advantages of distal amputations such as the Syme.<a></a></p> </li> </ol> <p>With the risk to the patient minimized and the probability of better function, the surgeon should now be willing to risk the occasional failure, that is, the need for a secondary procedure, in order to better assist the vast majority of his or her patients.</p> <h3>Advantages of Partial Foot and Syme Amputations</h3> <p>The partial foot amputee continues to bear weight on the residual foot in a manner which approximates the normal in regard to proprioceptive feedback, as opposed to the below-knee level in which an entirely new feedback pattern must be interpreted. The great majority of adult onset diabetics with peripheral neuropathy also retain sensation in the arch and heel areas. The heel-lever is intact and variable portion of the toe-lever remains. This will range from full-length, as in the case of a ray (toe and metatarsal) amputation, to virtually none in the case of a Chopart (midtarsal) amputation. The ease of restoration of a normal gait pattern is largely dependent on the length of toe-lever remaining. Whenever possible, therefore, toe-lever length should be preserved by election of a longitudinal (ray) amputation rather than a transverse level (transmetatarsal, tarsometatarsal (Lis-franc) or midtarsal). A further advantage is, in an emergency, the partial foot amputee is not dependent on a prosthesis.</p> <p>There are also two distinct psychological advantages of partial foot amputations. The less drastic alteration of body image as compared to the below-knee level may decrease the sense of loss as well as produce a smaller disruption of an active life-style. The less conspicuous and more cosmetically acceptable prostheses available today, even for the more radical partial foot amputations, may also help reduce the impact of the psychological loss.</p> <p>There has been disagreement about whether the Syme amputation qualifies as a partial foot amputation because all the bony elements of the foot have been removed. The preservation of the heel pad, a major soft tissue component of the foot, in the Syme amputation is what confers full weight-bearing capability and distal proprioceptive benefits on the residual limb. The notion that the heel pad is not an important element of the foot is easily dispelled by observing the difficulty in effectively reambu-lating a person who has lost the heel pad in an otherwise intact foot. Studies of gait parameters including oxygen consumption, cadence and velocity have shown the advantages of the Syme over the below-knee level.<a></a> The benefits noted are not diminished by the need for a more extensive prosthesis than is necessary for less radical partial foot amputations.</p> <h3>Etiology</h3> <p>Trauma continues to result in a significant number of these amputations. In wartime, booby-traps and land-mind explosions are frequent, while in peacetime, accidents with motor vehicles, especially motorcycles and lawn mowers seem to be the most frequent causes. In northern latitudes, frostbite remains a common etiology.</p> <p>However, the majority of partial foot and Syme amputations in our institution are an indirect result of inadequate protective sensation to the feet, secondary to peripheral neuropathy. This loss of normal sensation is commonly associated with diabetes mellitus, alcoholism, Hansen's disease (leprosy), or myelomeningocele (spina bifida). The difficulty starts with injury to the foot, either acutely as a laceration, puncture or burn or, more commonly, from pressure or shear forces associated with ill-fitting shoes, and/or chronic overuse of the foot. In response to these forces, areas of skin over bony prominences develop calluses which then break down to form ulcers. These are most common under the metatarsal heads or on the toes. Infection ensues, progressing from cellulitis to abscess formation to septic arthritis and osteomyelitis, resulting in amputation.</p> <p>Circulatory factors also play a role, especially in diabetic patients. Small vessel disease results in restricted passage of oxygen and antibiotics, across the capillary basement membrane, to damaged and infected tissues. Atherosclerotic changes in the arterial tree can produce major blockage of blood flow correctible only by arterial reconstruction or by-pass. Smoking can play major roles both in the onset and aggravation of atherosclerotic arterial disease and in delaying or preventing wound healing after injury or surgery.</p> <p>In persons with neuropathy, compliance with a careful routine of foot care is mandatory if major problems are to be prevented. It is easy to deny that a problem exists when no warning pain is felt. Depression over the long-term possibility of limb loss may so depress many diabetic patients that they are immobilized, unable to protect themselves and to prevent what they most fear, amputation. Psychological counseling, individual or group, can aid in breaking patterns of denial and in dealing with the subsequent depression. Ultimately, the patient must accept the responsibility for foot care if amputation is to be avoided.<a></a></p> <h3>Surgical Considerations</h3> <p><i>Partial Foot Amputations</i></p> <p>The surgeon should attempt to preserve as much length and width of the foot as possible commensurate with:</p> <ol> <li> <p>Healing potential of the soft tissues as determined by circulatory evaluation;</p> </li> <li> <p>Eradication of the local disease process, i.e., removal of all necrotic and infected tissues;</p> </li> <li> <p>Closure of the wound with local skin flaps over all surfaces subject to major weight-bearing or shear forces (Split thickness skin grafts may be used elsewhere, such as the dorsal surface and arch of the foot.); and</p> </li> <li> <p>Good function. A lesser toe should not be left as the only remaining toe because of its increased susceptibility to injury. A second ray amputation is preferable to a second toe amputation alone because of the loss of lateral support to the great toe, which may result in a secondary bunion deformity. This constitutes a new bony pressure point likely to result in another ulcer.</p> </li> </ol> <p>With amputation at or proximal to the tarsometatarsal (Lisfranc) joint, care must be taken to balance the motor (muscle) function of the foot to prevent contractural deformity. At or above this level, release of dorsiflexor and evertor tendons without their reattachment leads to a severe equinovarus deformity due to the unopposed action of the triceps surae (gastrosoleus). Even with reattachment of the muscles at the more proximal level, their effective force is lessened due to shortening of the toe-lever. To overcome this advantage of the triceps surae, it is recommended that a fractional percutaneous heel cord lengthening of the Hoke-Hatt type be done as part of the initial surgery.<a></a> Even short transmetatarsal amputations may benefit from this procedure.</p> <h3>Syme Amputation</h3> <p>Full end weight-bearing on the heel pad with normally-channelled proprioceptive feedback is what distinguishes the Syme amputation from below-knee amputation. The three keys to success in Syme amputation are selection of the proper candidate, meticulous surgery to preserve the Syme's unique characteristics and maintenance of the weight-bearing heel pad in a centralized position. Since the heel pad is dependent on the posterior tibial artery for its blood supply, preoperative evaluation of the heel pad blood supply by Doppler or other means is recommended in order to reduce the chance of failure to 20% or less. Meticulous surgical technique is required throughout to avoid damage to the posterior tibial artery and to the vertically oriented, fat filled chambers of the heel pad, which provide the cushioning, allowing comfortable and long-lasting end-bearing.<a></a> Painful incisional neuromas are avoided by finding and cutting short all sensory nerves in both wound edges. Excessive laxity of the heel pad, which will cause difficulty in fitting, is avoided by several means. First, accurately planned incisions will avoid tissue redundancy. At closure, any excess skin should be trimmed, but closure under tension must be avoided. Second, suturing the deep fascial tissues of the heel pad to the anterior fascia or to the anterior tibial cortex will hold it firmly in place. Third, a light-weight carefully padded plaster cast (two 4" rolls) will prevent pad shift during the first four to five weeks of healing, when a snug walking cast can be applied. This is changed every two weeks until shrinkage has slowed. From this point on, centralization of the heel pad is a function of a carefully fit and maintained prosthesis.</p> <h3>Basic Problems to be Solved</h3> <p>Despite the obvious physical and psychological benefits of partial foot and Syme amputations, these procedures have not enjoyed wide popularity. In my opinion, this is largely due to a failure of dissemination of information regarding these advantages to the two groups most involved: amputation surgeons and pros-thetists/orthotists. On the one hand, amputation surgeons must be able to recognize potential candidates for conservative procedures and be willing to try them. On the other hand, the prosthetist or orthotist to whom he refers his patients must be able and willing to accept the challenge of fitting these sometimes difficult cases, e.g., producing a prosthesis which adequately meets the suspension needs of a Chopart amputation residual limb. Parenthetically, both the techniques and materials used put this area of expertise somewhere between prosthetics and orthotics, hence the name "prosthoses" for the devices constructed.</p> <p>Further refinement of present designs, especially in regard to cosmesis, and development of new concepts to produce better suspended and lighter prostheses are needed. Studies of gait patterns using these devices will assist in this effort and will help select the most physiologically effective designs. Elimination of shear forces, a function of both suspension and fit, will eliminate most of the criticism of these devices common in the past.</p> <h3>Summary</h3> <p>At the present time, partial foot and Syme amputations are considered viable alternatives to the below-knee level. This is true not only in trauma cases, but in diabetic patients with arterial and/or capillary blood vessel disease. Technological advances which have produced this change over the past two decades include: improved broad-spectrum antibiotics; effective devices for measurement of arterial blood flow and tissue oxygenation; development of arterial by-pass procedures, including the ankle and foot; and more physiologic and cosmetic partial foot and Syme prosthetic designs made possible by development of new plastics in a variety of physical forms. The end weight-bearing and proprioceptive benefits of these amputations lead to low excess energy demands on the amputee as compared to higher amputation levels. A major psychologic benefit is the relatively small alteration of body image. The etiology of these amputations and the surgical details to be observed and pitfalls to be avoided are discussed in some detail. Better dissemination of information to amputation surgeons and pros-thetists/orthotists regarding the benefits of these amputations is recommended. There is a need for the refinement of present designs as well as development of new concepts to produce better suspended, lighter and more cosmetic prostheses.</p> <p><b>References:</b></p> <ol> <li>Burgess, E.M. and F.A. Matsen, III, "Determining Amputation Levels in Peripheral Vascular Disease," <i>J. Bone and Joint Surgery</i>, 63A:1981, pp. 1493-1497.</li> <li>DiCowden, M.A., personal communication.</li> <li>Glattly, H.W., "A Statistical Study of Twelve Thousand New Amputees," <i>Southern Medical Journal</i>, 57:No-vember, 1964, pp. 1373-1378.</li> <li>Hatt, R.N. and T.A. Lamphier, "A Simplified Procedure for Lengthening the Achilles Tendon," <i>New England J. Med.</i>, 236:1947, pp. 166-169.</li> <li>Harris, R.I., "Syme's Amputation: The Technical Details Essential for Success," <i>J. Bone and Joint Surgery</i>, 38B:1956, p. 614.</li> <li>Taylor, L.M., Jr., E.S. Phinney, and J.M. Porter, "Present Status of Reversal Vein Bypass for Lower Extremity Revascularization," <i>J. Vascular Surgery</i>, 3:1986, pp. 288-297.</li> <li>Waters, R.L., J. Perry, D. Antonelli, and H. Hislop, "Energy Cost of Amputees: The Influence of Level of Amputation," <i>J. Bone and Joint Surgery</i>, 52A:1976, pp. 42-46.</li> </ol> <em>*<strong>John H. Bowker, M.D</strong>., is Professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami School of Medicine, and Medical Director of the University of Miami/Jackson Memorial Rehabilitation Center, 1611 N.W. 12th Avenue, Miami, Florida 33136.<br /><br /><br /></em> Page Number(s) 10 - 13 Year 1988 Volume 12 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Partial Foot and Syme Amputations: An Overview Creator An entity primarily responsible for making the resource John H. Bowker, M.D. * https://staging.drfop.org/files/original/0e21aacbf72bba2c34917b934ad97048.pdf 094d56220c0c63d9f7e92de77da375d2 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_002.pdf Text Any textual data included in the document <h2>Canons of Ethical Conduct and the Law</h2> <h5>John H. Harman&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Since its inception in 1947, the American Board for Certification in Orthotics and Prosthetics, Inc. has developed, perpetuated, and enforced a relatively straightforward and uncomplex set of rules for conduct in the profession of orthotics and prosthetics. Specifically, these rules are known as the Canons of Ethical Conduct and come under the jurisdiction of the Character and Fitness Committee, a permanent committee of the Board of Directors of ABC.</p> <p>The impact of the Canons has been progressively larger as time has passed. In particular, as certification in the field of orthotics and prosthetics has become more and more important, the loss of suspension from such certification due to violations of the Canons of Ethical Conduct has become much more important.</p> <p>Of course, canons of ethical conduct are nothing new. They have been around for hundreds of years. Virtually every profession that exists has some form of ethical code which is designed to bring a minimum level of moral conduct to bear upon the members of that profession. Of course, the nature and character of such codes differ vastly but their purpose is always important. Even insurers recognize that self-regulation through codes of ethical conduct reduces the claims experience of insurance companies with regard to malpractice and product liability insurance. Thus, the impact in the field of insurance is significant. Belonging to an organization which engages in self-regulation through a code of ethics is a basis and factor to be considered by the insurance company in setting rates for insurance.</p> <p>Orthotics and prosthetics is a unique profession. It has evolved from that of being more of an industry producing products to that which now is a technology of products bounded by professional services which are an integral part thereof. Thus, the Canons of Ethical Conduct for ABC, which are its self-regulating guide, parallel the canons of other professions, such as law and medicine, in a somewhat simpler form.</p> <p>Throughout most of this century, self-regulation was accepted and encouraged as a fundamental aspect of professionalism. Indeed, professional self-regulation was long regarded as necessary to set high standards and to protect the public from the unscrupulous or incompetent. Even the Supreme Court of the United States has stated that the ethics of a profession are but the consensus of expert opinion of the necessity of such standards. Indeed, for the first three quarters of the twentieth century, there was not one decision by the courts involving matters which questioned self-regulation in the professions.</p> <p>However, in the last decade, self-regulatory efforts have come under sharp and increasing attack. In various cases, the courts have held that various aspects of codes of ethical conduct violated fundamental antitrust laws and related legal principles. Prices set by ethical codes in minimum fee schedules have been stricken. Prohibitions against competitive bidding have been abolished. Likewise, prohibitions against advertising and solicitation have been eliminated.</p> <p>Further, the courts have held that associations which engage in standards-setting may be liable for improprieties promulgated in relation to such standards that affect competition.</p> <p>Self-regulation is particularly important in the professions because, to the extent that market forces do not function as effectively as in ordinary commerce, self-regulation can offer a degree of consumer protection that otherwise would be provided by competition.</p> <p>The premise, and thus the promise, of professional self-regulation is that it will raise the quality or lower the cost of services in areas in which lay persons, because of a lack of sophisticated training, are not particularly able to achieve these goals.</p> <p>However, the system has not functioned as envisioned. Professions have failed to one degree or another to effectively eliminate from their midst those who have abused their position. Professional discipline has become more and more the problem of state agencies and not the professions themselves.</p> <p>Worse still, those who were supposed to regulate themselves in the public interest sometimes chose to regulate themselves in their own interest. Finally, as social values evolved, some self-regulatory positions that had been adopted to protect the public came to be perceived as being selfishly motivated. Restrictions on professional advertising, for example, were imposed out of a conviction that any possible informative value would be outweighed by the potential for deception.</p> <p>As generally happens, the law has come to reflect the changes in society's attitudes. Where self-regulation once was uncritically accepted, the change in the prevailing view led to the placement of limits on the process.</p> <p>This is not to say that because of the application of antitrust laws and the active development by the courts in the last ten years of various theories which have nullified certain aspects of codes of conduct, such ethical codes are no longer valuable and should be abolished. Quite the contrary is true.</p> <p>Codes of ethical conduct contain basic fundamental ingredients and have applications which are important to self-regulation by the professions. However, those codes must conform to the judicial guidelines laid down involving restrictions and limitations on their content, application, and enforcement.</p> <p>It is still extremely important for the professions to regulate themselves and, indeed, their failure to do so may well be looked upon as equally as serious an impropriety as an over-zealous effort in self-regulation.</p> <em><b>*John H. Harman </b> Legal Counsel, American Board for Certification in Orthotics and Prosthetics, Inc. Coggins, Harman, Lackey and Lowe, P.A. Silver Spring, Maryland<br /><br /></em> Page Number(s) 2 - 2 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 Canons of Ethical Conduct and the Law Creator An entity primarily responsible for making the resource John H. Harman * https://staging.drfop.org/files/original/fdb824053cd07dc56b8a0f9bb5710f77.pdf 040eee9523be02600597ae2e21998310 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/1981_03_005.pdf Text Any textual data included in the document <h2>Editorial: Tightening The Loops On Sensory Feedback</h2> <h5>John Lyman, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Ma Bell's radio and TV ad theme, "reach out and touch someone", appeals to everyone. It represents contact with those sensitive, often sentimental, emotional connections we have with our environment and the people and things that we value. In real life, it is only one's voice and the feedback of the voices of our familiar compadres that makes situations comparable to the telephone company ad warm and real. We all know the experience. What makes it work?</p> <p>Many years of experience in the serious pursuit of possible answers to this question, and its broader implications concerning the role of sensory feedback in shaping human performance, have brought us only a few answers on which we can count. Mostly, we only know that the importance of sensory feedback varies greatly with specific situations, and that the role of the senses is very complex because of two-way filter interactions with the central nervous system. We do know quite a lot about the specifics of the sensory receptors themselves. It is, however, the manner in which the patterns of sensory stimuli provide information for processing by the spinal cord and higher levels that is clinically provocative.</p> <p>With specific reference to limb amputees, everyone agrees that to achieve functional unity with a prosthesis, there must be some form of awareness established by the wearer about the capabilities of the prosthesis. How reliably does it respond to the amputee's command? Does it react predictably to each familiar environmental situation so that the wearer has an accurate mental model of what to expect? Getting a wrong number does not reach out and touch the expected connection. After too many wrong numbers or too much noise in the connection, one tends to lose that warm feeling of predictable expectation. This appears to be the case in the matter of the state-of-the-art with sensory feedback in limb prosthetics.</p> <p>We have long known that the primary source of sensory feedback for limb prosthesis wearers was an "open loop" mental model of the space occupied by the prosthesis, its dynamic control features and pressure patterns on the stump-all modulated by visual, and sometimes auditory, information from both the prosthesis and its situational environment.</p> <p>To date, except for blind amputees where any feedback from the environment is helpful, we have not been able to definitively establish whether or not specialized sensors located on the prosthesis itself could effectively communicate signals to the wearer that would significantly enhance task performance. Experimental results have, for the most part, been marginal and frustrating, both scientifically and clinically.</p> <p>Despite many disappointments, especially in terms of immediately useable clinical benefits, our knowledge base has been substantially broadened, mostly concerning the scope and complexity of factors that realistically must be brought under control. For example, in the biological model of a limb, it is known that receptor density for cutaneous and kinesthetic senses (pressure, pain, thermal, etc.) may reach several hundred per square millimeter. These high receptor densities provide precise patterns of environmental information. They generate functionally important physiological and psychological adjustments of information flow rates. Refined movement may require highly defined sensory patterns to optimize the available muscle capability of the normal limb. The stability and continuity of these patterns is identified with the integrative function of the central nervous system. The distortion of the patterns by modification from disease, or by total physical destruction, requires laying down new cognitive adaptations. These adaptations can only reach a degree of approximation to the original system. The extent of the sensory side of the approximation is dependent on the capability for sensory input that remains or is replaced. Substitution of one pattern of signals for another depends on achieving a common coding scheme. Whatever scheme is achieved, it must be compatible at both the input and output sides of the person-prosthesis loop. Missing or distorted patterns are functionally reconstructed into new channels, both by means of the "software" of the brain, and substitution of sensors. When the sensations are natural, e.g., from the surface of a stump, the sensors available probably were not previously used for primary information about the location of and forces on the limb in space. New cognitive patterns must be brought into association. These new patterns may only provide part of the information previously presented, or the information provided may not be relevant. Thus, there may be a permanent substantial loss of skill.</p> <p>The original, natural, learning process in the intact person seems to make use of whatever sensory function is available to provide a pliable, plastic motor output capability. This is subject to refinement of precision according to criteria set genetically (e.g., walking), or learned according to environmental and personal, i.e., cognitive set standards for performance. "Normal" gait for a leg prosthesis wearer, "smooth," "coordinated" delivery of a fork full of food by an arm amputee, may have to come to mean something different, cognitively, than these actions for the non-amputee.</p> <p>For the amputee, complex situational vectors are set up by a combination of motor deficits and sensory deficits. This makes it especially difficult to independently assess the role of sensory feedback in task performance. For example, direct observations of the role of the senses is confounded by factors such as the transmission precision of the power train, by dynamic stability properties of the structural interface between the stump and the socket, and by task complexity, e.g., climbing stairs, rotating a door knob, etc. A simple analog would be to try to observe the role of sensory feedback in the performance of a non-amputee who was trying to write with a pencil that had the tip attached to a soft, compliant, rubber-like shaft. The capricious relationship between the tip of the pencil and the writer would make interpretation of the performance associate more closely with the hardware interface between the writer and his task than with the properties of the writer's sensory-motor system.</p> <p>To function with maximum effectiveness, the communications channels, as well as the energy (power) transfer channels, must be locked intimately and reliably together in both the relationship of time, e.g., minimum transmission time-lag, and geometric positions. It seems probable that sensory information, to be effective, must have a tight, reliable, one-to-one superposition with a tight, reliable motor output system.</p> <p>It is, thus, our view that perhaps a major reason for not being able to obtain clear-cut experimental results with artificial sensory feedback techniques for limb prostheses is that the linkages between the subsystem interfaces have usually been excessively "loose." The messages in both directions are garbled. As the requirement for task precision increases, the effects of loose communication links become increasingly evident. Softness of fit between the prosthesis and the flesh of the stump, for example, generates uncertain messages in both directions. The "reach out and touch" is a spongy approximation, a sensory haze at the cognitive level.</p> <p>The bad news is that in the prevailing situation, where direct bone attachments have not reached a level of development suitable for standard clinical practice, the tightening of sensory feedback loops and feed-forward loops seems to be inherently limited in promise. The good news is that with each year, the background research and technology is progressing to significantly more sophisticated levels, achieving denser, more accurate and less power-consuming transducer arrays for picking up the tactile features of the environment. As has often been the case before in the history of important prosthesis development, much of the technology for sensory augmentation is to be found in other applications, in this case, industrial automation and robotics. When, as will happen sooner or later, art and technology reach out and come together, the parts of the limb-prosthesis system will indeed, touch-with feeling.</p> <em><b>*John Lyman, Ph.D. </b> Professor and Chair, Engineering Systems Department Head, Biotechnology Laboratory, UCLA, Los Angeles, CA 90024</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 5 - 6 Year 1981 Volume 5 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 Editorial: Tightening The Loops On Sensory Feedback Creator An entity primarily responsible for making the resource John Lyman, Ph.D. *