10 20 371 https://staging.drfop.org/files/original/9fce2f56ec56ccbbaff5166e0706b01f.pdf 5548abda79aee7e1363a542a22e37550 https://staging.drfop.org/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg 0222f4152435fc260955f32524bbb711 https://staging.drfop.org/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg d1dbb049869929f1473972725498c986 https://staging.drfop.org/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg 3bafaaab01346b31406d8d2d21b0be9c https://staging.drfop.org/files/original/de4e477cd3382de1d4516750b81da61d.jpg abf27e1e5360c4d5dfa6da2f7932a611 https://staging.drfop.org/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg 7bc8b46ef73d497018dceb1b1133d3c5 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_04_027.pdf Text Any textual data included in the document <h2>Flexible Socket Systems</h2> <h5>David J. Jendrzejczyk, CP. <a style="text-decoration: none;">*</a></h5> Over the past two years there has been impetus towards the use of the flexible socket interface in above knee prosthetics. For our purposes here, it is widely accepted that the flexible socket is of multiple benefit to the patient. We will concentrate on discussing the different systems available. The history of flexible sockets dates back a number of years. The article by Charles Pritham, C.P.O., et. al. "Experience with the Scandinavian Flexible Socket"<a></a> provides a concise summary of this train of development. At the present time, there are numerous flexible socket systems being used in the United States and throughout the world. These sockets differ in design in two major areas: flexible socket interface and the outer hard socket. The flexible socket is currently being used with three types of support mechanisms: <ol> <li> Total hard socket as the support </li> <li> Hard socket with strategic fenestrations </li> <li> True frame design </li> </ol> The prosthesis discussed by R. Volkert in the article, "Frame type Socket for Lower Limb Prosthesis"<a></a> is constructed with a frame outer socket and an elastic stocking interface. This system can accommodate stump volume changes, therefore, it appears to be most useful with early amputees. The TC Couple Socket<a></a> above-knee prosthesis used a polyethylene flexible interface and an external polypropylene socket. There are no fenestrations in the outer socket, so it doesn't have some of the benefits of sensory feedback as a fenestrated outer socket would. The advantage of this system is its light weight polypropylene outer socket. Work done at the Institute of Rehabilitation Medicine, New York University Medical Center, is detailed in "Flexible Prosthetic Socket Technique."<a></a> Two systems are described in the article, both have a hard outer socket with windows cut out in strategic locations (<a href="/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg">Fig. 1</a>). The interface is either of thermo-formed polyethylene or of silicone elastomer lamination. <a href="/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg">Figure 1</a>. Prosthesis incorporating a flexible Polyethylene socket in a support with fenestrations in selected areas as fitted at the Rusk Institute of Rehabilitation Medicine (Photo courtesy RIRM). Currently, in the United States, the external frame with the thermoplastic interface seems to be the most commonly used. There are three major fabrication techniques for the frame system described. They are the IPOS System (<a href="/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg">Fig. 2</a>),<a></a> the ISNY (<a href="/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg">Fig. 3</a>),<a></a> and the SFS System (<a href="/files/original/de4e477cd3382de1d4516750b81da61d.jpg">Fig. 4</a>)<a></a> (Fillauer Technique).<a></a><a style="text-decoration: none;">*</a> <a href="/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg">Figure 2</a>. Flexible AK socket as fabricated by IPOS (Photo courtesy IPOS). <a href="/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg">Figure 3</a>. Icelandic Swedish New York (ISNY) flexible socket (Photo courtesy NYU). <a href="/files/original/de4e477cd3382de1d4516750b81da61d.jpg">Figure 4</a>. Scandinavian Flexible Socket (SFS) (Photo courtesy Durr-Fillauer Medical, Inc.). The intention of this article is to describe the differences and similarities of the above three systems. <h3>Socket Interface</h3> All three systems use a thermoplastic material for their inner socket. IPOS uses ipolen,<a></a> which is a specially formulated polyethylene and which reportedly provides a uniform socket thickness and has little shrinkage. The resulting socket is translucent. The ISNY system prefers polyethylene which has a tendency to shrink. NYU reports that the shrinkage is not a problem. This socket is also translucent. The SFS system recommends Surlyn®, but polyethylene can be used. Surlyn® is a thermo-formable plastic which shrinks little and provides a transparent socket. The thermo-forming method for the interface is basically the same for all three systems. The only difference is that IPOS recommends that you preheat the vacuum forming frame, and they prefer a dry cast. If a wet cast is used, they recommend that an IPOS sheath be pulled over the cast before the thermo-forming. The SFS system recommends a warm, wet mold for Surlyn®. ISNY states no preference. <h3>Frame (Structural Element)</h3> The most variation occurs in the fabrication of the frame. Materials and lay-up have a wide range of variation (<a href="/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg">Table I</a>). <img src="/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg" /> IPOS laminates on the positive model with the flexible socket in place. Carbonacryl, which has been specially formulated to use with carbon fibers (13-1), is laminated over the appropriate layers of nylon stockinette, carbon-glass stockinette, fiberglass matting, and fiberglass stockinette. Total lay-up is seven layers for the average size patient of 120 to 180 pounds. The ISNY system laminates on the positive model with the flexible socket in place. Their recommendation is for 100 percent rigid polyester, acrylics if desired. A polyester lamination is done over the appropriate layers of nylon stockinette, fiberglass stockinette, and 1" and 2" unidirectional carbon tape. The total layup is 26 layers in both directions. In addition, they recommend adding dacron felt "to insure sufficient thickness in strategic areas."<a></a> SFS laminates their frame over the positive model, which has been built up with varying layers of stockinette used as a filler in place of the flexible socket. An acrylic lamination is done over the appropriate layers of nylon stockinette, fiberglass stockinette, and 1" unidirectional carbon tape. Total lay-up at the proximal brim is 25 layers, and 26 layers at the medial brim. In the ISNY and SFS systems care must be taken in the lay-up of the medial/proximal brim where the materials overlay to avoid excessive thickness. <h3>Frame Dimensions</h3> There are some variations in the final trim-lines of the frame. The medial strut on the SFS and ISNY are approximately 2 1/2" and 2 3/4" wide. The medial strut on the IPOS frame extends around the anterior and posterior medial edge by one centimeter. The proximal trimlines on the SFS, anteriorly and posteriorly, are 2/3 the medial/lateral width. The proximal trimlines of the ISNY extend to the anterior and posterior lateral socket corners. The proximal trimlines of the IPOS extend around the anterior and posterior lateral corner by 2 centimeters. In the SFS and IPOS systems, the distal trim-line cups around the lateral distal femur. The ISNY does not. All systems tell you to take care to have an adequate radius on connecting edges between the medial strut and the proximal and distal trimlines. <h3>Comments and Conclusions</h3> The afore-mentioned indicated that there are many questions still unanswered. The varying lay-up design makes for varying flexibility and weight difference in the frames. At Newington, we question why the severe differences in build-up exist and as a result are undertaking a research project with some students at the Engineering Department at the University of Hartford. As a senior research project, they are planning an evaluation of the mechanics and structure of the three strut designs as well as the flexible socket material. It should be noted that if there are severe undercuts on the positive model, removal of the finished strut from the model can cause stress cracks in the frame. Problems have been noted by Newington and others of the flexible socket breaking after delivery to the patient. Care must be taken in fabrication of the socket that all flares are built into the positive mold. This will help reduce the stress in the molding process. Another recommendation to remove the stress from the finished flexible socket is an annealing process. We have yet to evaluate its effectiveness. In conclusion, there has been some confusion as to the different systems. Our purpose here has been to clarify the systems and their differences. As with any new system, questions and confusion are to be expected. It is still a subjective evaluation. As long as the patient benefits, use the system (or combination of systems) with which you are the most comfortable. Footnote Further reference to the SFS system will be as it is fabricated by Durr Fillauer Medical, Inc. *David J. Jendrzejczyk, CP. David J. Jendrzejczyk, CP. is with Newington Children's Hospital, 181 East Cedar Street, Newington, Connecticut 06111. References: <ol> <li>Berry, Dale, CP., "Flexible above knee socket made from low-density polyethylene suspended by a weight transmitting frame," IPOS-Composite Materials for Prosthetic Orthotic Application, April 10, 1985.</li> <li>Berry, Dale, CP., IPOS-Flexible Socket, Case Study and Overview, April 10, 1985.</li> <li>Davis, Roy B., Ill, Ph.D., "Comparison of Inter-face Pressure Distributions, Soft Socket (ISNY/SFS) vs. Hard Socket," presented at an American Academy Orthotics and Prosthetics-New England Chapter Meeting, March, 1985.</li> <li>Giannini, Margaret, M.D., "Transfer of Rehabilitation Research and Development Results into Clinical Practice," Clinical Prosthetics and Orthotics, Volume 8, Number 1.</li> <li>Kay, Hector W. and Newman, June D., "Report of workshop on below-knee and above-knee Prostheses," Orthotics and Prosthetics, Volume 27, Number 4, pp. 9-12, 21, December, 1973.</li> <li><a href="poi/1981_03_129.asp">Koike, K.; Ishikura, Y.; Kakurai, S.; Imamura, T., "The TC double socket above-knee prosthesis," Prosthetics and Orthotics International, 1981, pp. 129-134.</a></li> <li>Kristinsson, Ossur, "Flexible Above Knee Socket made from Low Density Polyethylene, Supported by a Weight Transmitting Frame," Orthotics and Prosthetics, Volume 37, Number 2, pp. 22-27.</li> <li>Lehneis, H.R., Ph.D., CPO; Chu, Don Sung, M.D.; Adelglass, Howard, M.D., "Flexible Prosthetic Socket Techniques," Clinical Prosthetics and Orthotics, Volume 8, Number 1, pp. 6-11.</li> <li><a href="al/1968_02_028.asp">McCollough, Newton, C, III, M.D.; Sarmiento, Augusta, M.D.; Williams, Edward M., M.D.; Sinclair, William F., CP., "Some considerations in Management of the Above-Knee Geriatric Amputee," Artificial Limbs, Volume 12, Number 2, pp. 28-35, Autumn, 1968.</a></li> <li>Pritham, Charles H., C.P.O.; Fillauer, Carlton, C.P.O.; Fillauer, Karl, C.P.O., "Experience with the Scandinavian Flexible Socket," Orthotics and Prosthetics, Volume 39, Number 2, July, 1985.</li> <li>Technical Notes, Artificial Limbs, Volume 13, Number 1, pp. 69-71.</li> <li><a href="poi/1982_02_088.asp">Volkert, R., "Frame type socket for lower limb prostheses," Prosthetics and Orthotics International, pp. 6, 88-92, 1982.</a></li> <li>"A Revolutionary Technique in Fitting AK Amputees," IPOS Flexible Socket Fabrication Manual.</li> <li>"Prosthetic and Sensory Aids Service," Department of Medicine and Surgery, Veterans Administration, Washington, D.C., Bulletin of Prosthetics Research, pp. 227-229, Fall, 1972.</li> <li>"Fabrication Procedures for the ISN Y Above Knee Flexible Socket," January, 1984.</li> </ol> Page Number(s) 27 - 31 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 5 TABLE I http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Flexible Socket Systems Creator An entity primarily responsible for making the resource David J. Jendrzejczyk, CP. * https://staging.drfop.org/files/original/901b570f7984e7d4389bd77bc8b49ab7.pdf 4dc89f03888f81781cc820b1c4281db2 https://staging.drfop.org/files/original/70079561438f68ead76f52fc65dd8527.jpg 9f295a4e4335c10beed8e204bd3902b4 https://staging.drfop.org/files/original/178ecd5991ed2ffe397316d0a4dd0546.jpg 843b4338dc78f6e9769246fa79846425 https://staging.drfop.org/files/original/2b7b51bf9cad86f7ce11a1660d52b387.jpg b0271f700b8d4901edf91d2082d01352 https://staging.drfop.org/files/original/ffaa35ca7b5ac23a6a947d2d3ad255f2.jpg 2fe8351da1a1e6155fb684e2e76de872 https://staging.drfop.org/files/original/f7c3b167230622c735630542cfdca207.jpg 3c649879a171c5ff0e0d93e99308eb76 https://staging.drfop.org/files/original/c4a610256e9b758a37d3623694e2271b.jpg 50f7124cde5cc7ce984f2315ba51fa73 https://staging.drfop.org/files/original/804efb442220a760c2ad6db87361ab61.jpg 373e078a4bb07aaf2eae6726bd391ff6 https://staging.drfop.org/files/original/1e7fab041130f301f034215e0e5b357d.jpg ecae0c1212323fe32a9a5b842bcf28b2 https://staging.drfop.org/files/original/ef3813f645bf9a4a4dd8188a6de82361.jpg 3a0b706d106a04ea3b6e27dcc9b84af6 https://staging.drfop.org/files/original/bb68eabedc0b65835c332efcf81f8201.jpg d34e1f0f082d9b6183dc2c8cee20fa2c https://staging.drfop.org/files/original/ccf65b3120d8051f16e304b8d2ef8f53.jpg 3ef8653b23290da3062586d399ca498b https://staging.drfop.org/files/original/1e94e8303e2979d8bbc043ee1a0e6ee8.jpg abc1ec3d3045264621578c7b7baf7e6e https://staging.drfop.org/files/original/b6daf9f8f83efde86777545189ff48f7.jpg dd96d853a981be0539a39293ad96b1d4 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_04_031.pdf Text Any textual data included in the document <h2>Flex-Frame Sockets in Upper Extremity Prosthetics</h2> <h5>Donald L. Fornuff, CP. <a style="text-decoration: none;">*</a></h5> The development of various new plastic materials has brought about a rapid change in the design and fabrication of lower extremity prosthetic sockets. We can now expect most of these revolutionary developments to overflow into other areas of prosthetics and orthotics. The most natural area next to be influenced is upper limb prosthetics. We at Rusk Institute of Rehabilitation Medicine have been trying various socket frame configurations with all levels of upper limb amputees, from wrist disarticulations to above elbows, including the humeral neck amputation. The following is a brief "technical note" describing the technique we use for fabricating the flex-frame socket for the upper limb prosthesis and a sampling of various socket designs. <h3>Below Elbow Socket</h3> When the below elbow socket model has been modified and smoothed, a flexible socket is made by vacuum molding, using Surlyn or Ethalux polypropylene (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-01.jpg">Fig. 1</a>). A thin socket is then laminated in the conventional fashion, over the flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-02.jpg">Fig. 2</a>). This socket will act as a frame for the flexible socket and will allow for the secure attachment of the forearm extension and wrist unit. Upon completion of the thin laminated socket, the P. V. A. sleeve is removed. The socket is then covered, using strips of 1" masking tape (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-03.jpg">Fig. 3</a>). The forearm extension form, or mold, holding the wrist unit is mounted to the below elbow socket in the correct alignment, position, and length (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-04.jpg">Fig. 4</a>). The wrist unit is taped over to prevent foam from clogging various screw holes. A hole is cut in the forearm extension piece just proximal to the wrist unit. Foam is poured into this hole to form the forearm extension piece. Additional foam may be required to ensure proper shaping of the forearm section. When shaping is completed, the wrist unit is heated slightly and removed. Vaseline® is applied to the remaining foam and socket, and a P.V.A. sleeve is pulled on and tied at both ends (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-05.jpg">Fig. 5</a>). The wrist unit is replaced over the P.V.A. sleeve, held in place by the layers of material to be used in the second lamination. The material is tied off in the usual manner. When the forearm has been laminated, it should be completely removed from the below elbow socket and foam extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-06.jpg">Fig. 6</a>). This removal is relatively easy because of the P.V.A. sleeve applied over the shaped foam forearm section. After the laminated forearm is removed, the foamed forearm section and tape are completely removed from the laminated socket. The laminated and vacuum molded flexible sockets are removed from the model (the model must be broken many times) and the laminated socket frame is cut to its desired shape to allow maximum flexibility of the flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-07.jpg">Fig. 7</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-08.jpg">Fig. 8</a>). The frame socket is placed into the forearm section and trim lines are established. Both sections are then sealed together. The flexible socket is placed in the frame socket and the trim line is established: 1/8" to 1/4" above the edge of the laminated frame socket to minimize the stiffness gradient and to allow a gradual transition from the flexible socket to the rigid frame (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-09.jpg">Fig. 9</a>). Socket designs are many and quite variable (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-10.jpg">Fig. 10</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-11.jpg">Fig. 11</a>). <h3>Above Elbow Socket</h3> All previous steps used in the below elbow prosthesis apply to the above elbow prosthesis until removal of the laminated humeral section with the attached elbow turntable. When the humeral section is removed from the foamed humeral extension, it is set aside (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-12.jpg">Fig. 12</a>), while the laminated above elbow socket is cut out to allow maximum flexibility of the flexible socket. The laminated humeral extension holding the turntable is then re-attached to the flex-frame socket with a rigid plastic resin (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-13.jpg">Fig. 13</a>). Easy removal of the flexible socket will allow for easy access to the elbow friction and attachment nut at the elbow turntable. Again, configurations of both below and above elbow flex-frame sockets are many in design, but must provide attachment areas for harnessing and base plates for proper transition of the cable control system. <h3>Acknowledgments</h3> The author wishes to acknowledge Mr. Steve Szabo's technical assistance. *Donald L. Fornuff, CP. Donald L. Fornuff, CP., was formerly Assistant Director of Orthotics and Prosthetics at Rusk Institute of Rehabilitation Medicine, New York, New York. He is presently Director of Medishare Orthotics and Prosthetics Laboratories, Fords, New Jersey. Page Number(s) 31 - 34 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Flex-Frame Sockets in Upper Extremity Prosthetics Creator An entity primarily responsible for making the resource Donald L. Fornuff, CP. * https://staging.drfop.org/files/original/34801932f31180cf39fb42463e18ca64.pdf b4ff1b0359d2a02dba24114047c1044d https://staging.drfop.org/files/original/6809b2f2afa3773a2820029b18b49a0b.jpg b8e4c1286250c652a53ec2b688db1acb https://staging.drfop.org/files/original/57e50e2a54f0ed529988256cbb6dd943.jpg aaac9f8f9b8b2b5bf8bab18389269d28 https://staging.drfop.org/files/original/69330701385993f53424c16d9fd378d8.jpg 53eb4adca9de07365f0faacc7c1b2bfa https://staging.drfop.org/files/original/f4181d44fd6538734307d9ea8b28ee4d.jpg e62d56cac139627fc1c316f26e860671 https://staging.drfop.org/files/original/d486cbde489421e053211e9332e2c877.jpg 79345ea5bfda40249c1da95de22377db https://staging.drfop.org/files/original/e6f7827c015798b9284c3ad7bce99e38.jpg ff99b290faf944d9eebd1823beba3dee https://staging.drfop.org/files/original/5155ade9bfc40b5ca7f8f0ffd21b75b7.jpg 63ded18f1ee6bf58ba96d15ebbbd68a0 https://staging.drfop.org/files/original/c14fa38126fa67950a300f4f17a45399.jpg 03b0ad5b1d067e9071f0fa40d0d0fd4c https://staging.drfop.org/files/original/23b23cf47b748b0346de8afd3db7a6c1.jpg 50ec8dabc7e88784dc0fc29ba58bfb93 https://staging.drfop.org/files/original/5d0a16bddb915f4ed3e31d89b05da45e.jpg abb09ce6db620b6606f9e0aac650b94e https://staging.drfop.org/files/original/5ac7ebb70decd31ce91601a4ac4da9a3.jpg 04eb1f4faa9d34d5281ad3d69e9e9810 https://staging.drfop.org/files/original/3677c02db76680b30ae38c40228c41b5.jpg 75c09a73c1870f3807933653b49680d3 https://staging.drfop.org/files/original/07dd115ef89f6e6ef005fb07d990dd9a.jpg 7a6534119ecd4981b5a7fb1b7cf37739 https://staging.drfop.org/files/original/0a4c66d644160de8fd4f209c4af5be31.jpg c243901ecf8305a715c919c7ee9e9ca8 https://staging.drfop.org/files/original/284b966aa49d3e57ea60dffeb209a3f4.jpg 34a52cafac6420239a7e937c337dda16 https://staging.drfop.org/files/original/7a18444d44b13d13f4e58b5f7788a592.jpg 7a7490de4b0d6b9ce087c838b433bea6 https://staging.drfop.org/files/original/535a6901340cdd81ec7457c80224e031.jpg c5033dc23af49069a08349ed2d3ef192 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_04_035.pdf Text Any textual data included in the document <h2>New Concepts in Post-Operative Scoliosis Management</h2> <h5>Robert D. Fitch, M.D. <a style="text-decoration: none;">*</a> Carrie Louise Beets, CO. <a style="text-decoration: none;">*</a></h5> As improved surgical techniques and stronger spinal instrumentation are developed, the need for external stabilization post-operatively and the design of post-operative orthotics have also evolved. The purpose of this article is to review the many recent advances in the surgical technique and spinal instrumentation, and the early results of a new management protocol (both surgical and orthotic) in the treatment of selected spinal deformities. <h3>Evolution Of Spinal Stabilization</h3> The goal in the surgical treatment of scoliosis is to correct the deformity and maintain correction until fusion of the spine occurs. It is the surgical technique of fusion that provides long term spinal stability. Until the fusion mass matures, we must rely on stability provided through surgical instrumentation (internal support) and casts or orthoses (external support). If the spine is not stabilized sufficiently internally and externally, then a non-union of the spine will occur similar to that which occurs with inadequate immobilization of long bone fractures. Once a non-union develops, the deformity may gradually recur. Prior to the advent of the Harrington rod, correction of the spinal deformity was obtained through complicated casting techniques. Risser described the turnbuckle in 1927<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-01.jpg">Fig. 1</a>). Later he developed the localizer cast.<a></a> A cast technique similar to this was perfected by Dr. Cotrel of France<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-02.jpg">Fig. 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-03.jpg">Fig. 3</a>). These casting techniques allowed correction of the deformity in the cast. The spine was then operated upon in the corrected position through the cast and the patient was maintained in a cast postoperatively for a period of nine to 12 months. With this form of treatment, there was a high incidence of failure, primarily due to the development of cast complications, or pseudoarthroses.<a></a> Many surgeons advocated routine exploration of the fusion mass six months postoperatively to identify any areas of non-union. <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-01.jpg">Figure 1. Turnbuckle cast as devised by Risser. Patient had to remain in bed for six months. (Photo reproduced with permission from Scoliosis by J.I.P. James, Williams & Wilkins Publishers, 1967.)</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-02.jpg">Figure 2. Localizer cast which extends up over the occiput and mandible. (Photo reproduced with permission from Scoliosis, ibid.)</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-03.jpg">Figure 3. Posterior view of localizer cast showing window through which surgery was performed. (Photo reproduced with permission from Scoliosis, ibid.)</a> In 1960, Paul Harrington reported on the use of a stainless steel distraction rod for the correction and stabilization of spinal deformities.<a></a> The Harrington device has since become the mainstay of surgical treatment for scoliosis. It has shown to be of great benefit in experienced hands and has shortened hospitalization time, avoided the need for preoperative correction with casting, permitted early mobilization of the patient in a well-fitted cast or orthosis, and has markedly decreased the pseudoarthrosis rate following fusion. What it has not accomplished, however, is the ability to provide sufficient internal stabilization to allow the abandonment of external support either by cast or orthosis. There are many instances in which external immobilization is undesirable. These include patients with insensitive skin, spasticity, or respiratory compromise. During the early 1970's, Edwardo Luque, M.D. from Mexico City was faced with many complex spinal deformities similar to those just mentioned. This led him to develop a new form of spinal instrumentation called segmental spinal instrumentation.<a></a> Unlike the Harrington rod, which uses distraction forces and is fixed to the spine at the top and bottom so that all the forces are concentrated at the bone-hook interface superiorly and inferiorly, segmental instrumentation provides corrective forces in a transverse manner at each spinal segment and, therefore, the distribution of forces is spread out over the whole length of the instrumentation. This has been shown to be much stronger biomechanically than the Harrington system and is extremely stable<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-04.jpg">Fig. 4 </a>and <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-04.jpg">Figure 4. X-ray showing Harrington rod system.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-05.jpg">Figure 5. X-ray showing Luque rod instrumentation.</a> Segmental spinal instrumentation has become the preferred method of treatment of complex spinal deformities, especially those associated with neuromuscular conditions such as muscular dystrophy, myelodysplasia and cerebral palsy. However, it has not replaced the Harrington rod for the management of idiopathic scoliosis. This is primarily because of the added neurologic risk that is involved when performing segmental spinal instrumentation. Wires must be passed sublaminarly within the spinal canal at every level to perform this technique. The potential for neurologic complications is related to invasion of the spinal canal with these wires and the potential for vascular compromise to the cord by correction of the deformity, which leads to elongation of the spinal canal and vascular stretch. It must be kept in mind that segmental spinal instrumentation does not take the place of a meticulous fusion, and if fusion does not occur, then instrumentation failure in inevitable. In general, patients who have been treated with segmental spinal instrumentation are not placed in any cast or orthosis post-operatively. This is based on the assumption that the Luque instrumentation is so strong that no external support is needed. However, recently some surgeons have questioned the requirement for external support even with Luque instrumentation. Although the early instrumentation failures have been solved with segmental spine instrumentation, some surgeons have found increased loss of correction over the first few months in patients not treated with orthoses, compared to those who have been treated with orthoses postoperatively. Also, the question of late pseudoarthroses must yet be resolved; and if there is a significant incidence of pseudoarthroses with Luque instrumentation, would post-operative orthotic support decrease this incidence? Because of the added neurologic risk, we have opted not to use segmental instrumentation in dealing with most idiopathic spinal deformities. Rather, we continue to use the Harrington rod with some recent modifications. The modified Harrington rod provides enough internal stability to allow us to use a post-operative orthosis that is comfortable, convenient, and cosmetic. Added stability to the Harrington system has been achieved by a simple modification of the Harrington hooks. This was devised by Dr. Bobechko of Toronto. The new hook has a cam placed inside a slot which allows two hooks, rather than one hook, to be utilized at the upper level. Since most of the early instrumentation failures with Harrington rods have been with the cut-out of the upper hook, two hooks allow the forces to be distributed over a larger surface area, and when the technique is properly performed, corrects that problem. At the bottom end, a specially designed hook with a longer shoe is used to prevent dislodgement of the hook in this area, which can occur when the patient flexes forward. With the degree of stability provided by this method, post-operative cast immobilization is unnecessary. In addition, currently available orthoses such as the Greenville spinal orthosis, the SOS modular orthosis, or the Milwaukee brace also provide more external support than we feel is necessary. This has led us to adopt the use of a posterior plastic shell with corset front and shoulder straps. <h3>Current Management Protocol</h3> This post-operative orthosis is used in two situations: (1) in the patient with idiopathic scoliosis who has undergone Harrington rod instrumentation with modified hooks as described above, and (2) in patients with more complex spinal deformities who have had segmental instrumentation and are at risk for loss of correction or late pseudoarthrosis. Our post-operative regimen consists of taking a mold at the time of surgery. The patient is then mobilized quickly beginning on the first post-operative day. The patient is allowed to stand at the bedside twice a day until the orthosis is ready and applied, usually on the third post-operative day. At that point, the patient is allowed to begin ambulation and sit with the orthosis on. Following discharge, the patient is allowed to doff the orthosis at night and once a day for showering. The orthosis is worn for four months post-operatively. <h3>Orthosis Design</h3> The posterior shell orthosis used at Duke University Medical Center is based on an orthosis design that was originally used at the Texas Scottish Rite Hospital for Crippled Children in Dallas, Texas. At the Scottish Rite Hospital a Surlyn® posterior shell, with a special order Camp corset front riveted to the shell, is used. It is cast and delivered post-operatively, or sometimes on an outpatient basis. At Duke, the design was modified by the addition of shoulder straps for provision of an anti-rotatory movement reminder. The shoulder straps and the corset front are removable for easy laundering. The Duke protocol is for its use as an immediate post-operative orthotic device. <h3>Casting</h3> The Department of Prosthetics and Orthotics at Duke University Medical Center has the advantage of being located on site. This permits close coordination with the physician and his operating room schedule. The dates for which an orthotist is needed in the operating room are known in advance, as well as the time and estimated length of surgery. The surgeon notifies the orthotist as the surgical team prepares to close the case. The orthotist arrives in the operating room while the case is being closed. Adequate time is available to set up splints and water, inspect operative x-rays, and confirm the length of the instrumentation (helpful in determining proximal trimline of orthosis). Following closure of the surgical site, a small temporary sterile dressing is placed over the suture line for protection. The orthotist places a split piece of cotton stockingette over the patient's back and buttocks. Using an indelible pencil, the axillary and proximal trimlines are marked, C-7 is marked for reference, the waist and the gluteal fold and a horizontal line across the top of the gluteal fold are also marked (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-06.jpg">Fig. 6</a>). Six inch wide plaster splints, three layers thick, are applied lengthwise starting with the center back and overlapping towards both sides. Attention is paid to apply the plaster splints as far anteriorly on the patient as possible to make sure the cast impression has been taken to midline or just beyond. If a patient appears large busted or overweight, the sides of the impression can be compressed while the plaster is setting up (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-07.jpg">Fig. 7</a>). This will afford a truer M-L measurement for the patient when standing and sitting. The cast impression is removed (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-08.jpg">Fig. 8</a>) and the post-operative bandages are applied. <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-06.jpg">Figure 6. With the patient still on the operating room table, a split piece of stockinette is placed over the patient's back and landmarks and trimlines are marked.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-07.jpg">Figure 7. If a patient is large busted, the sides of the cast impression can be compressed while the plaster is setting, allowing a truer M-L dimension for when the patient will be sitting and standing.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-08.jpg">Figure 8. Cast impression simply lifts off. Operating room nurses replace temporary bandage, protecting the suture site with a regular post-op dressing.</a> <h3>Fabrication</h3> Any number of thermoplastics can be used to fabricate this orthosis, however, we have found Surlyn® to be sufficiently rigid and cosmetic. The advantage of fabricating with Surlyn® is that the standard practice of pouring, stripping, and modifying a positive model can be completely eliminated. In the fabrication lab, the cast impression is allowed to dry 30 minutes to an hour. The stockinette is then powdered. The impression is placed into an adjustable support to prevent any M-L spreading during the plastic molding. A piece of 3/16" thick Suryln®, large enough to cover the inside of the impression, is placed in the oven and allowed to heat just until it is pliable (about five minutes). The heated plastic is placed in the impression and pressed into the contours of the cast impression (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-09.jpg">Fig. 9</a>). The plastic is then rapidly cooled by a wet towel or air (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-10.jpg">Fig. 10</a>). When completely cooled, the plastic shell is lifted off the cast impression and the stockinette is stripped, exposing trimlines and reference marks made at the time of casting. The plastic shell is set back on top of the cast impression and the trimlines are transferred to the shell (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-11.jpg">Fig. 11</a>). The shell is trimmed and the edges finished (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-12.jpg">Fig. 12</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-13.jpg">and 13</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-09.jpg">Figure 9. Surlyn®, heated just until pliable, is pressed into the contours of the cast impression.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-10.jpg">Figure 10. Surlyn® is rapidly cooled with a wet towel.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-11.jpg">Figure 11. Trimlines are transferred from the cast impression to the Surlyn® shell.</a> Figures 12 and 13. Drape forming the Surlyn® to the cast impression without pouring a positive mold gives excellent contour detail to the resulting posterior shell. The posterior shell is ready for the attachment of the corset front and shoulder straps. We use a standard corset front available from Truform in either a 9", 10", or 12" abdominal length, depending on the patient's stature. Holes corresponding to the corset eyelets are drilled in the lateral edges of the posterior shell and the corset front is laced onto the posterior shell (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-14.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-14.jpg">Figure 14. Finished posterior shell with corset front laced in place and shoulder straps also removable for laundering.</a> The shoulder straps, which are also removable for laundering, are attached to the posterior shell via Velcro® on the ends which double back on themselves after slipping through loops permanently riveted to the posterior shell. The shoulder straps are attached to the shell just proximal to the interscapular level. They cross the shoulders and attach laterally several inches distal to the axillae via a standard corset style hook. Placement of the lateral hooks midway between the axillae and the waistline prevents binding in the axillae when the straps are tightened. Total fabrication time from casting to initial fit is approximately four hours. <h3>Fitting</h3> Though the fabrication of the posterior shell orthosis is fast enough to permit fitting the same day as the cast impression is taken, the orthosis is usually delivered on the third post-operative day. This is done to allow post-operative illeus with accompanying abdominal distention to resolve. If the orthosis is fit too soon, the corset front invariably needs to be altered or the size of the front changed altogether. By the third day, the patient is alert and tolerant of being log-rolled, and the majority of abdominal distention has subsided. The posterior shell is tried for initial fit in bed and the patient is measured for the corset front with the shell in place. The accuracy of the trimlines is noted and the shell is marked if any adjustments are needed. After the corset front is attached, the orthosis is delivered to the patient, along with two pieces of stockinette to serve as in-hospital t-shirts and a written information/instruction sheet which covers care of the orthosis and basic "do's and don'ts." When providing this orthosis for community physicians at nearby hospitals, rather than trying to coordinate with their operating room schedule since travel time is involved, we cast the patient several days post-operatively. The patient is log-rolled in bed to a prone position and the plaster impression is taken the same way as in the operating room. If thick bandages are still over the patient's surgical area, the impression will be slightly deeper than the final product. Trimlines must be adjusted accordingly. The community hospital patient is measured for the corset front at the same time as casting since he can be log-rolled back to a supine position for measuring. The M-L measurement for the corset front is taken midline to midline. The shell is then delivered in 24-48 hours. By either method, the patient is up and walking in the orthosis at four days postoperative and is usually discharged at 6-7 days post-operative. <h3>Summary</h3> As of this writing, the protocol described above had been utilized in 44 patients over a period of 18 months. Diagnoses include adolescent idiopathic scoliosis, myelodysplasia, adult scoliosis, and adult spinal tumor. There has been one occurrence of instrumentation failure in a patient with adolescent scoliosis who had dislodgement of the upper hooks as a result of improper hook placement at the time of surgery. We feel that with the increased internal support provided by the Bobechko hooks in the Harrington rod instrumentation that the modified bracing provided by the posterior shell (versus Milwaukee or Greenville orthosis) has provided satisfactory restriction of gross motions which might endanger the success of surgery. Forward bending and twisting are restricted and the shoulder straps add an upper torso anti-rotatory reminder for the patient. We have had no problems with lack of compliance in brace wearing, even though both the shoulder straps and the corset front are removable. The orthosis has been well received by the patients. It is cooler and more comfortable than many of its counterparts. It is also cosmetically acceptable and is easily donned and doffed. Hygienic maintenance requires minimal time and effort. Finally, it has been well received by both adolescent and adult patients (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-15.jpg">Fig. 15</a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-16.jpg">Fig. 16</a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-17.jpg">Fig. 17</a>, and <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-18.jpg">Fig. 18</a>). Figures 15(above) and 16(below). The orthosis is easily donned by the patient. Figures 17(above) and 18(below). Posterior shell orthosis is very cosmetic. *Carrie Louise Beets, CO. Carrie L. Beets, CO., is formerly of the Department of Prosthetics &Orthotics, Duke University Medical Center. She is presently with the University of Virginia, Department of Prosthetics and Orthotics, 1224 W. Main Street, Charlottesville, Virginia 22908. *Robert D. Fitch, M.D. Robert D. Fitch, M.D., is Assistant Professor at the Division of Orthopaedic Surgery, Duke University Medical Center. References: <ol> <li>Cotrel, Y., "Le corset de platic E.D.F. dass le treatment de la scoliose idiopathegirel," Med. Hyg., 28:1032, 1970.</li> <li>Harrington, P.R., "Correction and internai fixation by spine instrumentation," J. Bone Joint Surg., 42A:1448, 1960.</li> <li>Luque, E.R., "The anatomic basis and development of segmental spinal instrumentation," Spine, 7:256-259, 1982.</li> <li>Ponseti, E.V. and Friedman, B., "Changes in the scoliotic spine after fusion," J. Bone Joint Surg., 32A:751-766, 1950.</li> <li>Risser, J.C., "The application of body casts for the correction scoliosis," Am. Acad. Orthop. Surg., Instructional Course Lect., 12:255-259, 1955.</li> <li>Risser, J.C.; Lauder, CH.; Norquist, D.M.; and Craig, W.A., "Three types of body casts," Am. Acad. Orthop. Surg., Instructional Course Lect., 10:131-142, 1953.</li> <li>Wenger, D.R.; Eurollo, J.J.; Wilkerson, J.A.; Wau-ters, K.; and Herring, J.A., "Laboratory testing of segmental spine instrumentation versus traditional Harrington instrumentation for scoliosis treatment," Spine, 7:265-269, 1982.</li> </ol> Page Number(s) 35 - 42 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-18.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 New Concepts in Post-Operative Scoliosis Management Creator An entity primarily responsible for making the resource Robert D. Fitch, M.D. * Carrie Louise Beets, CO. * 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 <a style="text-decoration: none;">*</a></h5> 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. 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. 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. 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. 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. 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. 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. 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. <a href="/files/original/42f3cf78c258ae2747437e3c837288cc.jpeg">Fig. 1</a>: The controversy illustrated—metal double upright ankle-foot orthosis vs. plastic ankle foot orthosis. 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. 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. 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. 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. 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. 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. 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. References: <ol> <li>Yates, G. ,"A Method for Provision of Lightweight Aesthetic Orthopaedic Appliances," Orthopaedics: Oxford, 1:2, 153-162, 1968.</li> <li>Lehneis, H.R., Ph.D., CPO, "New Concepts in Lower Extremity Orthotics", Medical Clinics of North America, 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" Orthotics and Prosthetics, 36:2, pp.49-55,1982.</li> <li>von Werssowetz, O.F., "The Use and Abuse of Braces in Rehabilitation of Neuromuscular Disorders," Archives of Physical Medicine and Rehabilitation 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," Orthotics and Prosthetics 33:1, pp. 3-10, 1979.</li> <li>Fillauer, C, "A New Ankle Foot Orthosis With a Moldable Carbon Composite Insert," Orthotics and Prosthetics, 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," Physical Therapy, 62:4, pp. 453-455, 1982.</li> <li>Rosenberger, R. and Pritham, C.H., "Instep Strap," Newsletter. . .Prosthetics and Orthotics Clinic, 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," Orthotics and Prosthetics, 3:2, pp. 43-55, 1976.</li> </ol> <div style="width: 400px;">*Joanne A. Klope Shamp, CPO Shamp Prosthetic Center, Inc. Norton, OH </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/760e13aa1dc8e1275a4a9976de2db4cb.pdf 71a8cfac282278de7ae518edde8b0333 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_004.pdf Text Any textual data included in the document <h2>Editorial: Metal vs. Plastic AFO - A Therapist's View</h2> <h5>Donald G. Shurr, LPT, MA <a style="text-decoration: none;">*</a></h5> Ankle foot orthoses are generally prescribed for patients who are able to ambulate without an orthosis, but for whom an orthosis allows a safer, and often more cosmetic, gait. Traditional "bracing" in these cases calls for a combination of metal and leather, often a spring-assisted ankle joint, and a so-called posterior stop, which simulates the motion of ankle dorsiflexion and prevents toe drag during swing phase. More recently, molded plastic ankle foot orthoses have become available. These lighter weight orthoses provide a nearly invisible option to the conventional metal, riveted to the shoe devices. Presently, little agreement exists as to the indications, the timing of the application, or the overall outcome anticipated with the use of plastic AFOs. The physical therapist plays an important function in the team approach to the care of patients with orthotic needs. Because the physical therapist spends considerable time working with these patients, he or she has an opportunity to continuously evaluate the patient's progress. This constancy is critical to the orthotic decision-making process as changes in patient symptoms may well alter orthotic needs. For this reason, it is often the responsibility of the physical therapist to recommend an appropriate orthotic device. In order to do this, the therapist must not only use the current physical findings, but must accurately predict future changes in these data. He/she must choose a device which will not only facilitate early ambulation, but will also meet the patient's future needs. Thus arise the dilemmas of when to fit which device, and whether to use temporary or longer-lasting orthotic devices. In the past, metal AFOs were considered more adjustable and more temporary. These devices were to act as the precursor to the more definitive, more cosmetic, lighter, and therefore "better" plastic AFOs. However, experience with plastic AFOs revealed problems with lack of adjustability, thus necessitating multiple fittings in order to accomodate the patient's changing clinical picture. The therapist must decide how to most effectively provide devices which not only meet the adjustability requirements demanded for early ambulation, but also provide a more cosmetically appealing, definitive device. Questions that need answering are: can an adjustable orthosis be fitted to allow for early ambulation? When should we recommend the more definitive (presumably plastic) devices? How can this be done with a minimum of dollars spent? In 1971, Lehneis and Sarno made the following statement: "It is clear in the function of our clinic that there is no longer any indication for prescription of the conventional double bar BKO." It would be interesting to know if the authors still feel this way despite evidence to indicate that the double bar device is still routinely being fit. The reason for the continued popularity of the bichannel, double upright AFO in our clinic is its adjustability. This allows for medial-lateral control in both swing and stance phase, as well as knee control during stance. The extension moment generated by an anterior pin stop and long foot plate allows good control of knee flexion. Similarly, knee hyperextension can be controlled by adjusting the posterior pin. The timing for the fitting of such a device should allow a sufficient training period so that the patient can be discharged with skills in the proper and safe use of the orthosis. Frequent return visits or home care sessions are necessary to continue to evaluate progress and provide necessary orthotic changes. In many situations, the cost of the orthotic care for the patient is the smallest total dollar amount spent during the rehabilitation phase, yet it seems to receive a disproportionate amount of discussion. In those cases where early ambulation is indicated and expected changes in condition dictate an adjustable orthosis, the device of choice would seem to be the conventional, double adjustable, double upright, metal AFO. Later, as the condition stabilizes and the need for adjustability subsides, a plastic, more cosmetically acceptable AFO may be fitted. Even with the fitting of two devices, the total dollars spent for orthotic care will remain a small part of the overall cost of rehabilitation. This discussion would be incomplete without specific mention of the polypropylene AFO. Since the arrival of the custom-made poly AFO, manufacturers have saturated the market with standard sized, stamped poly AFOs. Many therapists use such devices and compare them with other types of custom-fitted metal and plastic AFOs. If one inspects these devices, it is apparent that they fit very few patients. They do not provide the necessary dorsiflexion assist without a considerable amount of modification, and often never produce the desired effect. Additionally, they provide little knee extension assistance, which is often necessary for many early ambulators. The choice of plastic vs. metal AFOs should be considered with all aspects of the patient's present and expected future condition in mind. The type of orthotic device prescribed should meet all the needs of the patient, with cosmetics being only one element. Multiple plastic or a combination of metal and plastic orthotic fittings can be justified in order to attain early, safe, and independent ambulation. *Donald G. Shurr, LPT, MA Director of Physical Therapy University of Iowa Hospitals and Clinics Iowa City, IA Page Number(s) 4 - 4 Year 1983 Volume 7 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 Editorial: Metal vs. Plastic AFO - A Therapist's View Creator An entity primarily responsible for making the resource Donald G. Shurr, LPT, MA * https://staging.drfop.org/files/original/4e183acf56bb242b877abe71bad0c82c.pdf 2d5fb2193aba4c56fe7e72e3aa738711 https://staging.drfop.org/files/original/f35dbf1ec5058164a5372c266853ed58.jpeg b93e3a485fb5fa30970f58cb3c3f97b4 https://staging.drfop.org/files/original/84f9510431f05aafdee61cf4a63a6e60.jpg 815e14879134606d06e3dec6ad49473c https://staging.drfop.org/files/original/2bf778e75bd7f9b6cdd9a04374f57fee.jpg 0ce17c62d2456956432115616f913c64 https://staging.drfop.org/files/original/bf19e271aafb1c9ff9bb542af0b93338.jpg d3e8c2de5e80c1498f33a82414e7bcb3 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_011.pdf Text Any textual data included in the document <h2>A Modified Hemipelvectomy Socket</h2> <h5>Peter A. Ockenfels, CPO <a style="text-decoration: none;">*</a></h5> This paper is to demonstrate a modified design for a hemipelvectomy type of prosthetic socket, which was designed for an endoskeletal system prosthesis. The patient, a 28-year old white male, while involved in the operation of heavy equipment in May of 1978, experienced severe crushing type injuries. The injuries required a hemipelvectomy amputation on the right side, and due to peroneal nerve injuries, the function of the left lower limb was limited. For the purpose of this paper, however, only the hemipelvectomy socket design, which is different and special due to the presence of a colostomy, which needed to be fitted into the prosthetic receptacle, will be discussed. The patient's first prosthesis was designed in the usual fashion with the colostomy inside the prosthetic socket. This restricted drainage into the colostomy device. The patient needed to remove his prosthetic socket during the day in order to relieve pressure and dispose of the accumulated waste. In considering the design of a new prosthesis, it was felt that an anterior or a lateral opening on the opposite side was inadequate and non-functional since the colostomy opening could not be maintained in one particular area at all times. Thus, a lateral opening was provided on the amputated side. A flexible tongue allows the socket to expand as the patient dons his prosthesis (<a href="/files/original/f35dbf1ec5058164a5372c266853ed58.jpeg">Fig. 1</a>). A single Velcro strap (<a href="/files/original/84f9510431f05aafdee61cf4a63a6e60.jpg">Fig. 2</a>) secures the prosthesis, and the colostomy opening is maintained in a permanent position while standing (<a href="/files/original/2bf778e75bd7f9b6cdd9a04374f57fee.jpg">Fig. 3</a>), as well as sitting (<a href="/files/original/bf19e271aafb1c9ff9bb542af0b93338.jpg">Fig. 4</a>). *Peter A. Ockenfels, CPO American Orthotic &Prosthetic Laboratory, Inc., Columbus, OH Page Number(s) 11 - 11 Year 1983 Volume 7 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-4.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 A Modified Hemipelvectomy Socket Creator An entity primarily responsible for making the resource Peter A. Ockenfels, CPO * https://staging.drfop.org/files/original/dca562c934e6c03968ea74fbd3ff1f31.pdf 573718b9201606fcbfbf62993cef40b0 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_02_001.pdf Text Any textual data included in the document <h2>Cervical Orthoses</h2> <h5>Charles H. Pritham, CPO <a style="text-decoration: none;">*</a></h5> Orthoses are fit for the control of motion about a joint or joints. By extension, cervical orthoses are fit to control motion of the cervical spine. Such orthoses are provided to patients for a wide variety of conditions ranging from the merely inconvenient on one end of the spectrum to the life threatening at the other end. In response to this need, a plethora of devices have been described; a review of the literature and of manufacturers' catalogs will reveal a positive galaxy of orthoses, all described as being of great efficacy and many differing from others in matters of only minor detail. What seems to be lacking is any systematic and quantitative assessment of the various orthoses' merits and a rational scheme for their use. While it may be overstating the case, it seems that most individuals in various parts of the country rely on two rules of three: selecting from the panoply available three orthoses graded as minimally, moderately, and maximally immobilizing; and fit in terms of small, medium, and large. Which orthoses are selected is shaped by local preference, training, and experience among other factors. In contrast to other areas of orthotics, the topic of cervical orthotics can be described as a stepchild or plain shoe. Since the end of World War II, other areas of orthotics have been radically reshaped (lower limb orthotics and spinal orthotics for scoliosis and kyphosis) by the application of new knowledge, new technology, and new philosophies of treatment. Upper limb orthotics occupies the middle ground: it's not that the effort has not been made, just that the results have been less than totally successful. It would, of course, be fallacious to suggest that no effort at all has been made to elucidate in some rational fashion the prescription of cervical orthoses. James D. Harris, D.O., in his review of cervical orthoses in Orthotics Etcetera, 2nd Ed. <a></a> cites a variety of references which used such means of measuring cervical motion as goniometry, cineradiography, and still radiography to assess the immobilizing affects of various orthoses. He further used these references and descriptions of effectiveness in his comparisons of a variety of orthoses. Rollin M. Johnson and his coworkers <a></a> used their original studies for a similar purpose. The impression remains, however, that while useful work has been done, the effects of it have been relatively small scale, and much remains to be done. This point of view is endorsed by the results of a workshop panel convened in 1977 <a></a>. It would seem that there exists a genuine need for research to be conducted comparing the efficacy of various orthoses with an eye towards developing a rational basis for prescription and for the results to be widely disseminated. The contrary point of view can, of course, be argued. Those instances that are truly life threatening are relatively few, usually promptly recognized, and are best managed aggressively with immobilization, confinement to bed and even surgery. For the rest, cervical orthoses are generally prescribed for episodic and short term relief of pain. Even if prescribed with an orthosis that does not perfectly match the need, patients limit their activities in response to pain and if necessary a new orthosis can be prescribed. Under the circumstances a basic measure of common sense illuminated by experience will serve to assess the competing claims of similar orthoses and match a particular orthosis with a particular situation. It would also be fallacious to argue that no improvements in technology have been made. While such developments as the Philadelphia Collar and the S.O.M.I. can be cited, the foremost example is the Halo. Originally a specialized device applied in specialized centers for relatively few indications, it has, in the guise of the Halo-vest, come to be widely used in instances where maximal immobilization and possibly distraction are needed. While intimidating in appearance and implications, the evidence is that the technique is readily mastered, and that the device is well tolerated by patients. However, the possibility of such complications as pin-site infections, penetration of the skull, and loosening do exist. As a result of these reasons and the generally felt need for something less drastic, if equally effective, calls have been made for a non-invasive halo <a></a>. In response, Wilson, Hadjipavlou, and Berretta <a></a> described "A New Non-Invasive Halo Orthosis ..." in 1978. Fundamentally, this is a S.O.M.I. orthosis modified by the substitution of a low temperature thermoplastic skull-cap for the occipital piece. The authors cited experience treating 20 cases of unstable fractures and cineradiographic studies to support their contention that "this orthosis is almost the treatment of choice whenever rigid immobilization of the cervical spine is indicated." In a similar vein, Rubin, Dixon, and Bernkopf <a></a> described in 1978 another modification of the S.O.M.I. In this device the mandibular piece was removed and two pads pressing in under the zygomatic arches where substituted. In addition, a "cranial vertex pad" rigidly fixed to the occipital pad and flexibly connected to the zygomatic pads was added. The authors showed radiographic and photographic evidence of near rigid immobilization of the cervical spine of one subject. However, they cautioned that the device was intended for relatively brief use, specifically for the removal of trauma patients to a hospital by trained paramedics, and they further speculated as to the unknown effects of long-term pressure on the zygomatic arches. Interestingly enough, both Harris <a></a> and Rubin, et al <a></a> refer to a device described by Boldrey in 1945. It is described as a rigid cap encompassing the posterior and lateral aspects of the skull with a forehead strap and sub-zygomatic pads. It was connected by a posterior steel upright to padded thoracic and lumbar bands with over the shoulder extensions and straps. None of these variations are commercially available. One further point needs to be considered: Harris <a></a> cites evidence of Hartman, et. al. that the Guilford Orthosis is 90-95% effective in restricting motion. Therefore, does the need for a non-invasive halo really exist? In any event, it is apparent that the subject of cervical orthotics is one that has received scant attention. What is not so apparent is whether or not such attention is vitally needed. References: <ol> <li>Harris, James D., "Cervical Orthoses," Orthotics Etcetera 2nd Ed., edited by James B. Redford, M.D., Williams and Wilkins, Baltimore, MD, 1980, pp. 100-122.</li> <li>Johnson, R.M.,; Hart, D.L.; Simmons, E.F.; Ramsby, G.R.; and Southwick, W.O., "Cervical Orthoses, A Study Comparing Their Effectiveness in Restricting Cervical Motion in Normal Subjects," JBJS, Vol. 59-A, No. 3, April 1977, pp. 332-339.</li> <li>Johnson, R.M.; Owen, J.R.; Hart, D.L.; and Callahan, R.A., "Cervical Orthoses: a Guide to their Selection and Use," Clinical Orthopaedics and Related Research, No. 154, Jan.-Feb. 1981, pp. 34-35.</li> <li>Edmonson, A.S.; et al., "Report-Panel on Spinal Orthotics" Orthotics and Prosthetics, Vol. 31, No. 4, pp. 67-71, Dec. 1977.</li> <li>Wilson, C.L.; Hadjipavlou, A.G.; and Berretta, G., "A New Non-Invasive Halo Orthosis for Immobilization of the Cervical Spine," Orthotics and Prosthetics, Vol. 32, No. 1, March 1978, pp. 16-19.</li> <li>Rubin, G.; Dixon, M.; and Bernknopf, J., "An Occipito-Zygomatic Cervical Orthosis Designed for Emergency Use-A Preliminary Report," Bulletin of Prosthetics Research, BPR 10-29, Spring 1978, pp. 50-64.</li> </ol> <div style="width: 400px;">*Charles H. Pritham, CPO Durr-Fillauer Medical, Inc., Orthopedic Division, Chattanooga, TN. Editor, Clinical Prosthetics and Orthotics-C.P.O</div> <div style="width: 400px;"> </div> Page Number(s) 1 - 2 Year 1983 Volume 7 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Cervical Orthoses Creator An entity primarily responsible for making the resource Charles H. Pritham, CPO * https://staging.drfop.org/files/original/a4e24d04daaec423ee9b4e3a36bda7ea.pdf 1c53d4c491f0f059b170578f088b4157 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_02_006.pdf Text Any textual data included in the document <h2>Questionnaire: Extra-Ambulatory Prostheses</h2> The following analysis and comments were drawn from responses to a recent questionnaire on extra-ambulatory prostheses. The article, "Extra-Ambulatory Activities and Amputee/' by Drew A. Hittenberger, CP, appeared in the Autumn, 1982 issue of C.P.O. (Vol. 6, No. 4). As of January 25, 1983, five responses had been received to the questionnaire on extra-ambulatory prostheses. This is a very low response and of course no valid conclusions can be drawn from it. In response to question number one, "How many extra-ambulatory prostheses have you made?," four responses said six-15 and one said 16-25. On question number two, "What percent of your patients are involved in some form of physical exercise?," the average response was nine percent with a high of 20%, a low of five percent and one who said he had never thought to ask. When asked, "What percent of your patients ask you about extra-ambulatory prosthetics?," the average response was 11% with a low of two percent and a high of 25%. The respondees were asked to list, in order of occurrence, extra-ambulatory activities in which their patients participate. There were four mentions of swimming, although one was not the first activity listed; there was also one mention of scuba diving. Snow skiing was mentioned three times and water skiing once. Running and racquetball (a running sport) were both mentioned once, as were hunting, fishing, weight-lifting, and horseback riding. The respondees were asked what percentage of patients used their prosthesis for more than just daily activities and the average response was seven percent, with a high of ten percent, a low of five percent, and one who didn't know. As to how many of their patients had one prosthesis for daily activities and one for extra-ambulatory activities, the respondees on the average said four percent, with a low of one percent, to a high of ten percent. All the respondents said that they informed their patients of handicapped sports organizations. One said he had a directory posted, and another said that there were no such organizations in his area. Three of the respondents said that they were not satisfied with the level of prosthetics and its role in extra-ambulatory activities. One said yes, and the fifth said yes, but with reservations. Reasons given for amputees not being more involved were: <ul> <li> lack of interest </li> <li> not involved before amputation </li> <li> non-positive social conditioning </li> <li> fear of injury </li> <li> ignorance </li> <li> embarrassment </li> <li> rejection </li> <li> poor post-operative management </li> </ul> All five said that they would like to attend a seminar on the topic. Several additional comments were received and are listed below. In addition, Carl A. Caspers, CPO, of Minneapolis, Minnesota took the time to write a long, thoughtful letter in response. Parts of it are quoted below. Additional comments: <ol> <li> "Yes—we need better research on different designs of prostheses for different functional activities." </li> <li> "Technical reports detailing alignment and fabrication for these specialized devices [are needed]. I have had to research, design, and devise techniques to create extra-ambulatory prostheses. Also preprinted bulletins with photographs for the patients would offer greater understanding and perhaps desire for these devices." </li> </ol> Mr. Caspers writes, in part: "This letter is in response to Drew Hittenberger's article on extra-ambulatory activities and the amputee in the Autumn issue of Clinical Prosthetics & Orthotics—CPO. I was very pleased to see this article covering this subject as this has been a sadly neglected area for a long time. "Mr. Hittenberger brings up some very good questions regarding the rehabilitation team's capability of maximizing the patient's activity level and more importantly the resultant poor postoperative care and management of the amputee. The vast [majority] are suffering from diabetes or other vascular complications. Obviously, the level of activity and the requirements for these people are going to be considerably less strenuous than those of a younger amputee. I think the problem goes back one step further and does not start with the post-operative care but in the operative management of the amputee. To date, the physician's main concern has been with the medical needs of the patient at that time and very little thought is given to the patient's functional needs after amputation. Such things as myodesis procedures, tibia-fibula stabilization, and lengths of lever arms are all crucial in the long-range function of an amputee. . . . "In the area of limitation, I think Mr. Hittenberger covered this very well. There is an economic limitation that needs to be covered here also. The rehabilitation team's knowledge of extra-ambulatory activities and its awareness of the many extra-ambulatory prosthetic devices is somewhat limited. This thereby creates an economic factor that many amputees are unable to deal with. As has been well documented in the field of prosthetics, there is a need for extra-ambulatory devices and these should be considered in the total rehabilitation, physically, psychologically, and economically. "In the areas of prosthetic design, I think there are a number of things to provide [the patient] the capability of participating competitively or recreationally in extra-ambulatory activities. A sound pain-free residual limb is essential for good function in these areas. A good understanding of bio-mechanics as applied to the amputee is essential for the prosthetist to provide a well designed prosthetic device . . . "In this day and age we have available to us a very sophisticated armamentarium of component parts and space-age type materials that lend themselves extremely well to prosthetic device fabrication, particularly in the specialized limbs geared toward specific physical activities. "In recent times there has been much use of things such as rotational absorbers, Greissinger feet, and multi-axis type ankle joint foot complexes. All of these types of items offer capability to the amputee but should not be applied in a general fashion. There are many activities where a rotator or multi-axis type foot complex is extremely detrimental to the function-ability of an amputee. Any sport which requires rapid directional changes would be a good example where these items should not be used. A person making quick and rapid adjustments in dynamic balance requires immediate response from the floor through floor reaction with his foot. This cannot be accomplished adequately with such items. "In conclusion, I feel that extra-ambulatory activities of the amputee and the resultant prosthetic devices that may be required for his successful participation in these activities is a relatively untouched area. A great deal of input is needed, both from the amputees in this country and the individual prosthetic practitioner, along with the physician and rehabilitation team members. I, myself, have been an amputee for 23 years and have been involved in numerous competitive and recreational activities and sports. I have found there are many areas in which I can participate in a non-handicapped world, and can be very competitive either on a one to one basis or as a team member. I have found this to be extremely fulfilling for myself and feel this is one of the ultimate goals that any amputee would strive to achieve." As regards the question of torque absorbers and use of the more sophisticated ankle foot complexes, Mr. Caspers raises a very interesting question. Certainly many prosthetists hold decided views on the topic and it would be interesting to receive Letters to the Editor on the matter. The Editor Page Number(s) 6 - 7 Year 1983 Volume 7 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Questionnaire: Extra-Ambulatory Prostheses https://staging.drfop.org/files/original/28274e1bdc8b1f42b700c9e81f28597f.pdf c98bd0663a677efb5cc36261b7c4cb7f https://staging.drfop.org/files/original/b6970149668330ce776434d9198152e3.jpeg 731206ce838388691e18855abcf7eb68 https://staging.drfop.org/files/original/a0bf70a49a9e3db596969c11b0c2c69c.jpg 23969c8fa88696d9a5addf89f363da7e https://staging.drfop.org/files/original/8a915c80bd9484bb8ab1b9a594fe6c66.jpg 7494d39a35704017937591467700f667 https://staging.drfop.org/files/original/f5da1243900128485bea8bd5f391499b.jpg beeee6ab4ded6b95b152fb192d126b8d https://staging.drfop.org/files/original/9ecbbc7b6c0294a18f4bb82b168db309.jpg a3cccb644afd639c1fbbc7860f03f802 https://staging.drfop.org/files/original/628b6e300a318be54667478bf7d69ef8.jpg 0ed7a62e1104b47e6adf43049a770bb2 https://staging.drfop.org/files/original/324715b55eb49ed8d385db9eef8fde73.jpg ef08536eda1fad5db1231816539fca86 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_02_009.pdf Text Any textual data included in the document <h2>Bivalved Spinal Orthoses for the Structurally Unstable Spine</h2> <h5>H.R. Lehneis, Ph.D., CPO <a style="text-decoration: none;">*</a> Roger Chin, CPO <a style="text-decoration: none;">*</a> Donald Fornuff, CP <a style="text-decoration: none;">*</a></h5> With the advent of plastics, particularly thermoplastics, and plastics technology, plastic molded spinal orthoses are increasingly used in the orthotics management of the structurally unstable spine for nearly all levels of involvement. Depending on the risk factor involved, they may be used in lieu of surgery, i.e. when the patient is not a candidate to undergo surgery for various physiological reasons, or they may be used in the post-surgical management of the structurally unstable spine. Because of the ability of modern plastics to be intimately contoured to the body, they provide for far safer orthotics management, particulary of the cervical spinal region, than conventional orthoses. Often they are a preferred substitute over casts since these bivalved orthoses can be readily removed, either fully or partially, for hygienic reasons and the orthosis can be kept clean much more easily than a cast. <h3>Orthotics Designs</h3> Two types of bivalved spinal orthoses are described below: <ol> <li> Cervico-thoracic orthosis (CTO) with forehead band. </li> <li> Thoraco-lumbo-sacral orthosis (TLSO). </li> </ol> With slight modifications, various combinations of the above can be designed. The area of injury or surgery usually determines the height and design of the orthosis. The contours of the orthosis aid in maintaining the proper position on the patient. Overlapping edges avoid pinching and allow for some weight gain or loss. The bivalved opening allows for fast removal in case of cardiac or respiratory problems, situations in which access has to be almost immediate. It is also a comfort to the patient, while lying in bed, that either half of the orthosis can easily be removed for short periods of time to give some relief from pressure and for ventilation. CTO with forehead band (<a href="/files/original/b6970149668330ce776434d9198152e3.jpeg">Fig. 1</a>) The cervical region is the most flexible of the spine. Rotation, flexion/extension, and lateral bending are difficult to control using just a cervical orthosis. Stabilization of the thoracic spine is necessary in order to provide the base, or foundation, for control of the cervical spine and head. It is extremely important to appreciate that without proper head control the cervical spine cannot be properly stabilized. Thus, the orthosis must extend posteriorly to cover the occipital area (<a href="/files/original/a0bf70a49a9e3db596969c11b0c2c69c.jpg">Fig. 2</a>), and anteriorly around the forehead, as well as the mandibular area (<a href="/files/original/8a915c80bd9484bb8ab1b9a594fe6c66.jpg">Fig. 3</a>). Inferiorly, it should be noted that the orthosis covers the entire rib cage, including the floating ribs (<a href="/files/original/f5da1243900128485bea8bd5f391499b.jpg">Fig. 4</a>). Thoraco-Lumbo-Sacral Orthosis (<a href="/files/original/9ecbbc7b6c0294a18f4bb82b168db309.jpg">Fig. 5</a>) Orthotics design for structural instability of the thoracic and lumbar spine requires the formation of a sound base inferiorly. In general, this is identical to the trimline used in the Milwaukee brace, or other orthoses for scoliosis. The superior trimlines depend on the level of involvement, but extend from at least the level of the xyphoid process to the inferior border of the clavicle (<a href="/files/original/628b6e300a318be54667478bf7d69ef8.jpg">Fig. 6</a>). The lateral Velcro® closures are of the cross-diagonal type described earlier by Ekus<a style="text-decoration: none;">*</a> to minimize relative vertical displacement between the bivalved sections. <h3>Indications</h3> The orthoses described are indicated either in lieu of surgery if the patient is not a surgical candidate for any physiologic reason, or post-surgically to maintain the desired position of the spine, instead of a plaster cast. Medical indications are: <ol> <li> Fracture and fracture-dislocations, including the odontoid process. </li> <li> Ligamentous rupture or laxity with resultant instability of the spine. </li> <li> Neoplastic disorders with concomitant degeneration of the vertebrae. </li> </ol> Physical indications are: <ol> <li> Lightweight. </li> <li> Hygiene, i.e. ability to clean the orthosis. </li> <li> Removability of either portion of the orthosis for patient hygiene and ventilation. </li> </ol> <h3>Casting Technique</h3> The casting method requires a Stryker frame. It is essential for accurate casting, and is the safest method for the patient. Body movement is limited to transfer in the supine position from bed to frame and back to bed, if the patient is not already in a Stryker frame and in skeletal traction. The patient can be turned from a supine to a prone position by turning the frame, which has been locked to prevent body movement. This method has proven to be the fastest, simplest, and cleanest. With the patient on the Stryker frame in the supine position, bony prominences and areas of relief are marked with an indelible pencil. The patient's anterior half is covered with a separative jelly (K-Y®, petrolatum), except the hair, which is covered with stockinette for casting for the CTO. Approximately 8-10 layers of plaster splints are applied in alternating vertical and horizontal layers to give the anterior shell added strength. With the patient in the supine position, abdominal pressure (which supports the spinal column internally) is built in at the time of casting. When the anterior half has hardened sufficiently to support the body without distortion, the patient is turned to the prone position. Again, bony prominences and areas of relief are marked with an indelible pencil on the posterior side which is then covered with a separative jelly. Approximately 4-6 layers of plaster splints are applied in alternating horizontal and vertical layers. The posterior half does not have to be as strong as the anterior half, as the patient will not be lying in it as in the anterior half. All casts are bi-valved with approximately 5 cm. overlap of the posterior half on the anterior half. A separative jelly is spread over the anterior areas to be covered by the posterior overlap. When the posterior half has hardened sufficiently to be removed, the sections will part easily because of the separative jelly under the overlap. They are then put back together with the overlap providing the key for proper position of the anterior and posterior halfs. The cast is then filled and modified. All bony prominences or areas of relief are built up approximately 2 to 3 cm. while in the soft tissue areas, e.g., abdomen, plaster is removed. <h3>Fabrication</h3> While any thermoplastic sheet material may be used for molding the orthosis, at this institution Subortholen® is preferred. It is a high strength polyethylene which is not only thermoplastic, but can be cold-formed as well. When heated, it can be drape-molded quite easily, and in a cold state, can be hammered similar to light alloy sheet material (e.g., hammered thin to form a hinge or channeled for rigidity or relief). Subortholen® is available in thicknesses of 1 to 6 mm. Sheets are cut to the size needed and placed in an oven heated to 150-160 degrees centigrade (350°F). The material is ready for molding when the sheet has lost its pink color and is almost translucent (<a href="/files/original/324715b55eb49ed8d385db9eef8fde73.jpg">Fig. 7</a>, right). When molding Subortholen®, a half hour oven dry cast or driest possible cast is recommended. The cast should be covered with stockinette to prevent moisture contact to the Subortholen® which, if not done, may cause rapid cooling, bubbling, and an uneven finish on the surface. The posterior half is molded first to extend approximately 5 cm. beyond the lateral midlines. When cooled, the posterior half is removed and cut to the desired trim lines and placed back on the cast. The anterior half is then molded to overlap the posterior half by approximately 5 cm. After the anterior half is cut to the desired trim lines, the orthosis is ready for fitting. <h3>Special Fitting Considerations</h3> Cervico-Thoracic Orthosis with Forehead Band : <ol> <li> Inferior trim line of forehead band should be approximately 1 cm. above the eyebrows. </li> <li> Circumferential pressure adjustability of head band is accomplished by means of a Velcro® strap. </li> <li> Mandibular pressure can be controlled by tightness of forehead band. </li> <li> Inferior trim lines need not extend below rib cage, as not to restrict lateral and posterior/anterior motion. </li> <li> Posterior/superior trim line should extend 3-4 cm. above the apex of the occiput. </li> </ol> Thoraco-Lumbo-Sacral Orthosis: <ol> <li> The orthosis must be keyed in the soft tissue area between the rib cage and iliac crests to prevent vertical displacement of the orthosis. </li> <li> The anterior inferior aspect must be trimmed to avoid sitting problems and pressure on the pubis. The posterior inferior trimline should allow sitting without the orthosis being pushed up from contact with the chair. </li> <li> Depending on the level of involvement, the anterior superior trimline should extend from a point somewhere between the xyphoid process to a level that follows the course of the inferior border of the clavicles. </li> </ol> <div style="width: 400px;">Footnote Ekus L., CO, Cross-Diagonal Closure of Pelvic and Spinal Appliances. Newsletter—Prosthetics and Orthotics Clinic, Vol. 5, No. 1, 2/1981 —Winter/Spring Issue *Donald Fornuff, CP Institute of Rehabilitation Medicine New York University Medical Center New York, NY *Roger Chin, CPO Institute of Rehabilitation Medicine New York University Medical Center New York, NY *H.R. Lehneis, Ph.D., CPO Institute of Rehabilitation Medicine New York University Medical Center New York, NY </div> Page Number(s) 9 - 11 Year 1983 Volume 7 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 7 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-7.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 Bivalved Spinal Orthoses for the Structurally Unstable Spine Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., CPO * Roger Chin, CPO * Donald Fornuff, CP * 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 <a style="text-decoration: none;">*</a></h5> 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. 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. Professionalism demands that a practitioner keep current of the knowledge of his profession by continued reading of technical manuscripts and attendance at seminars. 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. 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. 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. 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. 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. *James Fenton, CPO President, American Board for Certification in Orthotics and Prosthetics, Inc. Fenton Brace and Limb Co., Inc. Miami, Florida 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/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 <a style="text-decoration: none;">*</a></h5> 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. *John H. Harman Legal Counsel, American Board for Certification in Orthotics and Prosthetics, Inc. Coggins, Harman, Lackey and Lowe, P.A. Silver Spring, Maryland 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/13d59df7eaa0bb5ef10ecff3a8fa4fd9.pdf 0247ed6219932127b8f05567d483ea5a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_003.pdf Text Any textual data included in the document <h2>Analysis of the Results From the Questionnaire on Metal vs. Plastic Orthoses</h2> By May 1st, fifty-four (54) responses had been received, considerably more than usual. Fifty-two (52) respondees were certified personnel, one was a physician, and one was an unspecified "other." Interestingly enough, the individual listing himself as other was by far the most negative in his comments. The results were as follow: <ol> <li> Percentage of plastic vs. metal orthoses prescribed: <ul> <li> 100% plastic—17% </li> <li> 75% plastic, 25% metal—61% of the time </li> <li> 25% plastic, 75% metal—13% </li> <li> 100% metal—2% </li> </ul> </li> <li> Percentage of staff trained in plastic: <ul> <li> 100%—74% of respondees </li> <li> 75%—9% </li> <li> 50%—9% </li> <li> 25 %—7% </li> </ul> </li> <li> Most significant advantages: <ul> <li> lightweight—43% </li> <li> cosmesis—28% </li> <li> versatility—26% </li> <li> correction increased—17% </li> <li> other—11% </li> <li> total contact—9% </li> </ul> Many individuals checked more than one. </li> <li> Most significant disadvantage, most commonly indicated factors (actual numbers): <ol> <li> Inability to adjust dorsiflexion/plantarflexion—20 </li> <li> Fluctuating edema—7 </li> <li> Fitting a proper shoe and heel height—5 </li> </ol> </li> <li> Durability of plastic and hybrid orthoses vs. metal orthoses: <ul> <li> more durable, less maintenance—40% equal—30% </li> <li> less durable, more maintenance—22% </li> </ul> </li> <li> Do you agree with Mr. Shurr's arguments for the use of traditional metal upright orthoses? <ul> <li> yes—69% </li> <li> no—30% </li> </ul> </li> <li> Do you share Mr. Shurr's skepticism regarding prefabricated plastic AFO's? <ul> <li> Yes—83% </li> <li> No—13% </li> </ul> </li> </ol> This seems to be one issue about which considerable unanimity exists within the profession. Questions one and two seem to indicate that plastic plays a major role in the practice of many orthotists and that most of them are versed in its usage. The response to question 5 indicates that most practitioners are not experiencing significant problems with durability, probably as good an indication of good fabricating technique as any. In looking at questions 3, 4, 6 and 7, it appears that most respondents understand the role of plastic in orthotics and its advantages and disadvantages. In light of this unanimity of opinion it is interesting that the question of plastic vs. metal should excite enough interest to spark so large a response, particularly as plastic orthoses have now been in use for over ten years. It may be that orthotists still confront the need to defend plastic orthoses and justify their use. Contrarily it may be that enough individuals have enough experience with plastic that they feel comfortable responding to the issue. Additional responses: The following samples are chosen somewhat at random as examples of differing opinions: Comments on question 4: <ol> <li> It is my firm belief that the fixation of any joint will have the result of severe atrophy and eventual fusing of the joint. The long term results of the use of the (non-jointed) plastic AFO are not known. Putting it simply: What's the use of working toward recovery of use of an extremity (and that return gradually takes place) when the 'treatment' by an orthotic device has created other problems that the degree of recovery is not able to overcome? </li> <li> I feel there has been an overemphasis on plastic AFO/prefab AFO used by R.P.T.'s which have a limited application, and may be used with some success on geriatric patients in convalescent areas. They do make damned good night splints and that's about all. If used on hilly terrain or streets the patient usually ends up on his butt or smashes his face. </li> <li> How anyone could argue the cause for plastic AFO's is unreal. Any amount of comparisons with the traditional AFO reveals less durability and limited function. Seven out of 10 patients have disabilities necessitating metal over plastic, numerous modifications [to plastic] are a must, and medial lateral support is nil. In my experience, I have found that very mild cases necessitate the use of a plastic AFO when drop-foot (only) is the reason for bracing. Instability in the M-L plane is often accompanied by drop-foot, thus ruling out the plastic AFO. </li> <li> I feel that the plastic AFO is definitely a more desirable type of orthosis for all the reasons mentioned in question #3. However, not every patient is a candidate for a plastic AFO, especially if the patient has edema or needs adjustability at the ankle. </li> <li> Most students coming out of schools at this time only know how to make plastic AFO's and are not proficient or comfortable in making conventional orthoses. These "students" who usually possess degrees never spend sufficient time working in the lab to become bench technicians and most, when handed a pair of bending irons, are in jeopardy of hurting themselves. </li> <li> I agree with Mr. Shurr, but only from the standpoint of a therapist. Adjustment of plastic AFO's requires more than just a general knowledge of thermoplastics. During patient rehabilitation, minor changes in the degree of dorsi or plantar flexions that the orthosis is set in can make a drastic change in patient function. In clinical settings, this should always be done by the orthotist. However, physicial therapists working with patients wearing AFO's may not have accessibility to an orthotist whenever they want to "experiment" with different ankle settings. I can therefore understand Mr. Shurr's interim preference. This is, however, no comparison between the superiority of plastic systems over metal. Orthotists should be involved with any change made to their patients orthotic system. </li> </ol> In response to question 6: Therapist adjustment syndrome (TAS) is not a valid RX criterion. General Comments: Far more important than durability is the ability to provide superior fit alignment and function. Improperly fitting plastic orthoses, by their very nature, are far more obvious and as a result more nearly considered unacceptable than the traditional Brace—which by its very nature masks improper fit and alignment and of course results in improper braces being worn. In 1980, we introduced a policy of providing all necessary repairs and adjustments without additional cost for the life of any plastic orthosis. This policy specifically excludes traditional metal/leather braces. Page Number(s) 3 - 4 Year 1983 Volume 7 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Analysis of the Results From the Questionnaire on Metal vs. Plastic Orthoses https://staging.drfop.org/files/original/2a26fa46a936952d7346630a4fddeb3b.pdf 9bf1d7ad81311e350ca58227aa8ef3e4 https://staging.drfop.org/files/original/fd60ab108fc04d3ee3243e19fd78a73d.jpeg 12316de41cb85404fa07f030884d0bbd https://staging.drfop.org/files/original/b22d12eeac67c882c1a6ee06ab860780.jpg 5c959a25cd8c901d6983309deb9ae306 https://staging.drfop.org/files/original/7555fd7f9d24bef41fe4b95c8c319ccf.jpg aa82aa97958a91904276e94a5b918415 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_005.pdf Text Any textual data included in the document <h2>Some Comments on Cervical Orthoses</h2> <h5>Augustus A. White, III, M.D. <a style="text-decoration: none;">*</a></h5> The following was received past the deadline for the Spring C.P.O., for which it was intended. Because of the interest in the subject it addresses, we are printing these comments here. Anyone wishing to respond to the points the author raises may do so through letters to the editor. Our thanks to Dr. White for submitting his editorial. The Editor <h3>Introduction</h3> A classic history on the development of orthopaedic appliances, including some interesting material on cervical orthoses, has been written by J. W. Edwards (1952). A reading of this work quickly illustrates that many orthotic devices bear a striking resemblance to components of medieval armor. Particularly prominent in cervical orthotics is the work of Hugh Owen Thomas. This ingenious, chain-smoking, nineteenth century inventor developed a number of useful orthopaedic appliances, and is credited with the basic design of the cervical brace used today and known as the Thomas cervical collar. <h3>Functions of Cervical Orthoses</h3> Any cervical orthosis is really a device designed to apply forces to the cervical spine in order to control it in some way. The goal of that control is usually support, rest, immobilization, protection, or correction. The application of the forces restrains the normal or abnormal patterns of movement or alignment of the cervical spine. When the goal is to rest the spine, the device must assist or substitute for stabilizing muscle action. For example, a cervical collar may be used to prevent extension into a range that is painful or irritating to the patient. In another instance, the purpose of the orthosis may be to protect the vital spinal cord or nerve roots. This would be required when the spine has been rendered unstable by tumor, disease, surgery, or injury. A cervical orthosis can also function simply as a reminder and psychological "support." When the patient moves, he or she is made aware of the brace and therefore voluntarily restricts motion. In addition, the orthosis may provide warmth and physical support that is reassuring to the patient. After the physician makes a diagnosis, and elects to treat a particular problem with a cervical orthosis, it is helpful to identify the specific mechanical functions that are to be achieved with the orthosis (see Table I). Is the goal to support (rest), immobilize (protect), or correct the spine? It is helpful for the clinician to go through the process of determining which of various motions of the spine must be controlled. Is it flexion, extension, lateral bending, axial rotation, or some combination of these? By thinking through these questions, a more rational and precise orthotics selection can be made. Table I. Systematic Analysis for the Selection of Orthoses <h3><img src="/files/original/fd60ab108fc04d3ee3243e19fd78a73d.jpeg" h3="" width="418" height="327" />Orthotics Evaluation Studies</h3> Before discussing examples of cervical orthotics, it is helpful to review briefly the experimental work upon which we base our clinical recommendations. In-vivo cineradiography studies by Hartman and colleagues evaluated the effectiveness of immobilization of various orthotic devices on the cervical spine (Hartman et al. 1975). These studies compared five different cervical orthoses (Findings are shown in Table II). The investigators concluded that the motion that was most difficult to restrain was that between the occiput and C2. Table II. Effectiveness of Cervical Spine Orthoses in Immobilization* <img src="/files/original/b22d12eeac67c882c1a6ee06ab860780.jpg" p="" width="568" height="192" /> An evaluation of cervical braces by Johnson and colleagues placed normal subjects in different orthotic devices Johnson et al. 1977). Photographs and radiographs were used to determine differences in range of motion with and without the subjects wearing various orthoses (Findings are shown in Table III). It was found that by increasing the vertical length and the rigidity of a given cervical orthoses, there is improvement in its ability to control motion. In general, it was found that controlling lateral bending and axial rotation is more difficult than controlling flexion/extension. The most effective conventional braces are able to restrict C1-C2 flexion extension by only 45% or normal. The halo apparatus restricts the motion by 75%. Table III. Efficiency of Cervical Braces in Immobilization* <img src="/files/original/7555fd7f9d24bef41fe4b95c8c319ccf.jpg" p="" width="422" height="254" /> In summarizing this experimental data, the following generalizations are valid. The soft collar does little in the way of immobilizing the cervical spine. The rigidity of the components at the chin and the occiput are the main elements in restricting motion. As one adds shoulder or thoracic fixation to the various conventional cervical collars, the immobilizing capacity of the orthosis is increased. When the added chest support is actually fixed to the thorax, the immobilizing efficiency is further improved. <h3>Clinical Review of Some Specific Cervical Orthoses</h3> To follow is a review of the major types of cervical orthoses. They are categorized on the basis of effectiveness of control. Thus, we have divided cervical orthotics into minimum, intermediate, and most effective control (Table III). Minimum Control: The basic Thomas collar and numerous variations of it are examples of minimum control orthoses. These collars vary in height, contour and rigidity. They may be worn either forwards or backwards to increase or decrease the amount of flexion/extension possible. Generally, they are to be worn so that the chin rest, which is a convexity in the collar that points downwards, is anterior. However, some patients find it more comfortable to reverse this position, and certainly in cases where one is more interested in restricting extension than flexion, a reversal of this position will block extension more effectively. In other words, if a high portion of the collar is worn posteriorly there is relatively less extension. Although these collars probably do little or nothing in the way of immobilizing the spine, they do provide warmth as well as psychological comfort and support. They can be helpful to the patient in the treatment of a broad variety of conditions including some whiplash injuries, minor sprains and strains, cervical spondylosis, and some stable postoperative surgical constructs. Intermediate Control: There are a number of orthotics that are appropriately classified in this group. The Philadelphia collar is a beefed-up version of a Thomas collar. It is more rigid, has an anterior and a posterior plastic reinforcement, a rigid chin support, and a significantly developed extension block posteriorly to support and restrict the occiput. In order to achieve a greater level of immobilization, some extension of the orthosis down into the shoulder and/or thorax is required. This lengthening of the orthosis provides a more effective anchoring, purchase, and immobilization. There are several braces that fit into this category, most notably the four-poster brace, the Duke brace, the Guilford brace, and the SOMI brace. The SOMI is the most effective immobilizer in this group. These orthoses are probably more effective in the standing and sitting positions. In the supine, prone, or side lying positions, relaxation and rotation of the shoulders and thorax minimize the effectiveness of these orthoses. We should also note that if we wish to prevent anterior displacement of C1 or C2 in a rheumatoid patient we cannot rely upon a soft cervical collar, a Philadelphia collar, a four-poster brace, or even a SOMI brace (Altoff and Goldie 1980). Most Effective Control: If there is a clinical problem involving significant loss of clinical stability, the cervical orthosis hould provide the maximum amount of immobilization, unloading of the spine, and protection. Major control is needed in all of the parameters of motion. Depending on the particular clinical situation, it may be more important to control some particular motion or combination of motions. One option in this situation is a significantly more rigid version of the Thomas collar. The Minerva cast incorporates the concepts of extending the brace down towards the thorax and immobilizing the chin and occiput. This cast extends from the forehead down to the pelvis. The goddess Minerva was born by popping from the head of Jupiter, fully armored. From this Roman myth the cast has taken its name. This device, although not used very much currently, can be useful, especially in the protection of irresponsible patients. It should be kept in mind, however, that even with a well-applied Minerva cast, a few degrees of cervical spine motion are possible. Most of the motion occurs at the occiput-C1 region. The cast has to be open enough to allow an adequate range of motion for the mouth so that the patient can talk and chew. This same range of motion allows for motion at the occiput-C1-C2 joint complex. Thus, when your patients are in a Minerva cast but can talk and chew, you must be aware that they can move C1-C2. In difficult clinical situations, where there is extensive disease or surgery, or an injury has rendered the cervical spine unstable, use of a halo apparatus should be considered. This device is fixed to the skull with pins and is attached either to an individually molded plaster jacket or to a prefabricated jacket which comes in several sizes. Experimental studies generally agree that this device is the most effective immobilizer of the cervical spine. One should be aware that use of this device carries the risk of several complications. These include: penetration of the skull by fixation pins, brain abscesses, abducens, glossopharangeal and facial nerve palsy, and the development of cervical spondylosis. Facial complications can be recognized during the first few days after application by requesting patients to smile, roll their eyes, and stick out their tongue. If the patient is unable to do any of these three activities, careful neurological evaluation is indicated. <h3>Resume</h3> A rational approach to the use of cervical orthotics may be taken by posing several questions. What is the clinical condition of the spine? What are the therapeutic goals to be achieved by the brace? Is the goal to protect the spine, or to rest it? In what way should the mechanics of the spine be changed to achieve that goal? What kinds of forces are necessary in order to achieve these therapeutic aims? In the cervical spine, the standby orthosis for minimal immobilization is the Thomas collar. If one needs a high level of control, then an intermediate zone orthosis, such as the Philadelphia collar or any variety of collars that involve thoracic attachments, can be employed. The SOMI brace is the most effective in this intermediate group. If the therapeutic goal is to obtain maximum control and immobilization of the cervical spine, a halo apparatus with an individually molded plaster jacket is required. One should be aware that this apparatus carries the liability of exposure to complications. These complications can be minimized by diligent care techniques and follow-up evaluation. References: <ol> <li>Altoff, B. and Goldie, I.F.: Cervical collars in rheumatoid atlauto-axial subluxation. A radiographic comparison. Annals of the Rheumatic Diseases 39: 485, 1980.</li> <li>Edward, J.W.: Orthopaedic Appliances Atlas. Vol. I, Ann Arbor, Michigan, American Academy of Orthopaedic Surgeons, 1952.</li> <li>Hartman, J.T., Palumbo, F., and Hill, B.J.: Cineradiography of the braced normal cervical spine. Clinical Orthopaedics 109: 97, 1975.</li> <li>Johnson, R.M. et al.: Cervical orthoses. A study comparing their effectiveness in restricting the cervical motion in normal subjects. Journal of Bone and Joint Surgery 59A: 332, 1977.</li> <li>O'Brien, J.P.: The halo-pelvic apparatus. A clinical, bio-engineering and anatomical study. Acta Orthopaedica Scandinavica 163 (supplement), 1975.</li> <li>Victor, D.I., Bresnan, M.J., and Keller, R.B.: Brain abscess complicating the use of halo traction. Journal of Bone and Joint Surgery 55A: 635, 1973.</li> <li>White, A.A. and Panjabi, M.M.: Clinical Biomechanics of the Spine, Philadelphia, J.B. Lippin-cott, 1978.</li> </ol> *Augustus A. White, III, M.D. The Department of Orthopaedic Surgery Beth Israel Hospital and Harvard Medical School, and the Charles A. Dana Research Institute, Beth Israel Hospital, Boston, Massachusetts <div style="width: 400px;"></div> Page Number(s) 5 - 7 Year 1983 Volume 7 Issue 3 Figure 2 TABLE II http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 TABLE III http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-3.jpg Figure 1 TABLE I http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-1.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 Some Comments on Cervical Orthoses Creator An entity primarily responsible for making the resource Augustus A. White, III, M.D. * https://staging.drfop.org/files/original/cafa9b743d894ef8ac329dd049105439.pdf c5c3c6f8570f5611fb7f6c5a42f9907f https://staging.drfop.org/files/original/da8d8abfb620ef2e663567dd50bcc654.jpeg 1a03a7488c0c4c3a9df9bdbc0366fc44 https://staging.drfop.org/files/original/3f58c60474774ff9e63168d5ae29a02e.jpg 815138367afbe230364d1322051cddfe https://staging.drfop.org/files/original/3144aa6cc1e6fdbd0b6a2114007d029c.jpg 5b636b99ef116d0e221fdb299ac85bb1 https://staging.drfop.org/files/original/5d13bc560af79f59d4201f44574589b8.jpg c266285611b6774216497b8f21a83e26 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_008.pdf Text Any textual data included in the document <h2>Technical Note: Wrist Flexion Unit Modification</h2> <h5>Peter A. Ockenfels, CPO <a style="text-decoration: none;">*</a></h5> Several years back we learned that a wrist flexion unit, be it the Homser FM 500, 300, 200, or the Pope Easy Flexion Wrist PW 4-6, has little value for bilateral above elbow or bilateral shoulder disarticulation amputees. The patient involved, a right true shoulder disarticulation and left humeral neck amputee, had been successfully fitted with bilateral prostheses. The term "successful" can only be used in terms that the patient felt comfortable, was able to flex his elbows to 90 degrees and 135 degrees, and able to open the terminal device with extended elbow 100 percent of full opening elbow flexion of 90 degrees, 80 percent, and at elbow flexion of 135 degrees, 50 percent. Both prostheses were harnessed with leg loops and the usual elbow lock controls. Wrist units were prescribed and incorporated into both forearms, but proved to be quite useless due to the fact that the patient was unable to activate the wrist units. To rectify the situation, the following modification was constructed. The trigger bar that activates the wrist flexion units is located medially on either wrist unit; therefore, an activating lever was designed and incorporated into the forearm (<a href="/files/original/da8d8abfb620ef2e663567dd50bcc654.jpeg">Fig. 1</a>), so that the patient can trigger wrist flexion by pushing against a chair, his leg, or any other object (<a href="/files/original/3f58c60474774ff9e63168d5ae29a02e.jpg">Fig. 2</a>). Extension of the wrist unit is achieved using the legs (<a href="/files/original/3144aa6cc1e6fdbd0b6a2114007d029c.jpg">Fig. 3</a>). The trigger lever (<a href="/files/original/5d13bc560af79f59d4201f44574589b8.jpg">Fig. 4</a>) is made of 1/8" aluminum and pivots on a 3/16 half-threaded rod, mounted in the sides (ant. and post.) of the forearm wall. The patient no longer uses his right SD prosthesis and has been converted to a special chest harness. The wrist flexion trigger mechanism has proven to be very successful, and the patient would not be able to accomplish many tasks of daily care without it. *Peter A. Ockenfels, CPO American Orthotic & Prosthetic Laboratory, Inc. Columbus, Ohio Page Number(s) 8 - 8 Year 1983 Volume 7 Issue 3 Figure 2 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Wrist Flexion Unit Modification Creator An entity primarily responsible for making the resource Peter A. Ockenfels, CPO * https://staging.drfop.org/files/original/e1690cf1890c573375cb787032399988.pdf 87ee8a5abed800c76c98156dc2200899 https://staging.drfop.org/files/original/eabe930fc32847ec7e0d92434e7bc45f.jpeg b3f9edfdc10e1b362dba27c588c54d35 https://staging.drfop.org/files/original/4c55a6f8fb1adae4dd686d30f0e72e98.jpg 7ea898f965eb05a136608fe7f0fa85db https://staging.drfop.org/files/original/972fd80c1ddfa050d6812e2062ddeca8.jpg 3019cc6d45434da220cde813c997c009 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_010.pdf Text Any textual data included in the document <h2>Technical Note: A Cervical Orthosis Modification</h2> <h5>Paul Trautman, CPO <a style="text-decoration: none;">*</a> George Varghese, MD <a style="text-decoration: none;">*</a></h5> Recommending or prescribing the best possible cervical orthosis for a patient whose cervical vertebrae require support is a difficult task for an orthotist or physician. In recent years the plastazote® (Philadelphia) cervical orthosis has become a highly prescribed device for several reasons (<a href="/files/original/eabe930fc32847ec7e0d92434e7bc45f.jpeg">Fig. 1</a>). Most importantly, the orthosis limits flexion and extension of the cervical spine as well as rotation between C-3 and C-7 and patients find it reasonably comfortable and accept wearing it. This is due, to some extent, to the fact that the low temperature, and easily moldable plastazote® conforms in time to the patient's contours. The better distribution of pressure and comfort for the patient may provide more relaxation of the para-cervical spinal Secondly, the Philadelphia cervical orthosis is relatively inexpensive compared to more rigid appliances. Thus, it is less costly to replace when it becomes contaminated or spoiled beyond cleansing. A third important feature is the ease of selecting and donning the device. Only two measurements, the length of the neck and the circumference of the neck are required. The orthotist is able to provide the item to the patient readily, and it is not necessary to maintain a large, costly inventory. In the Neurosurgery Intensive Care Unit of the University of Kansas' Bell Memorial Hospital, this cervical orthosis has become the orthosis of choice for treating head trauma patients. The posterior half of the collar can be slipped behind the patient's supported head and neck with a minimal amount of need to move the patient. The anterior half is easily put into place to complete the fitting. Since a number of ICU patients have required a tracheotomy it became necessary to modify the Philadelphia cervical orthosis. The design modification created by staff orthotist Wallace Whitney, CO is seen in <a href="/files/original/4c55a6f8fb1adae4dd686d30f0e72e98.jpg">Fig. 2</a> and <a href="/files/original/972fd80c1ddfa050d6812e2062ddeca8.jpg">Fig. 3</a>. Since we do this modification fairly regularily we have made a plaster cast to preform the low temperature plastic (K-splint® or Orthoplast®) reinforcement piece. The original anterior strap is cut in the center, folded over and riveted to the plastic reinforcement piece and the collar. A hole (1 1/4 inch) for the tracheotomy tube is cut through the collar. A side effect is that the collar is made slightly more rigid which is often desirable for those patients. *George Varghese, MD Associate Professor, Department of Rehabilitation Medicine University of Kansas College of Health Sciences and Hospital Kansas City, Kansas *Paul Trautman, CPO Director of Orthotics/Prosthetics University of Kansas College of Health Sciences and Hospital Kansas City, Kansas   <div style="width: 400px;"></div> Page Number(s) 10 - 11 Year 1983 Volume 7 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: A Cervical Orthosis Modification Creator An entity primarily responsible for making the resource Paul Trautman, CPO * George Varghese, MD * https://staging.drfop.org/files/original/d387177f1743b2d3eb2e5fd8a7efd4c6.pdf 5152d646cade58bf58af3b450a7b5ac2 https://staging.drfop.org/files/original/cf533beb527fcd368a66e40b0251877b.jpeg 746bfce96a05847c161f7f8919e43c51 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_04_001.pdf Text Any textual data included in the document <h2>S-N-S Knees and the Bilateral A/K Amputee</h2> <h5>Gustav Rubin, M.D. <a style="text-decoration: none;">*</a></h5> We have under our care at VAREC eleven adult male bilateral A/K ambulators. Ten of these use Swing and Stance (S-N-S) knees and one, a missionary to a remote area in Africa, was fitted with single axis knees because of the obvious need for simplicity in his special circumstances. Eight of our S-N-S users are active individuals, but two are household and limited community ambulators. As would be anticipated, all of our above-knee amputee ambulators are in good physical condition and strongly motivated. These were important aspects in prescribing prostheses. The S-N-S knees provided the amputees with the smooth gait characteristic of hydraulics, greater security, improved ease in reaching the sitting position, improved opportunity to recover from sudden stops or potential stumbles, better control when descending stairs, and the ability to lock one or both knees for negotiation of stairs. We have also found the S-N-S to be the sturdiest of the hydraulic units. <a href="/files/original/cf533beb527fcd368a66e40b0251877b.jpeg">Image</a>: A.H., an active bilateral A/K ambulator. No one of our amputee veterans demonstrates the potential of S-N-S knees better than A.H., injured in Vietnam at 21 years of age. A. H. was initially evaluated by the VAREC Clinic Team over one year later on Sept. 24,1970. A.H. sustained bilateral A/K amputations. The right A/K stump was eight inches in length and multiply scarred. The left A/K stump, partially covered by healed split thickness skin grafts, was seven and one-half inches in length. A.H. also sustained partial amputations of the fingers of both hands. The index and middle fingers of the left hand were amputated; on the right hand, the proximal phalanges of the fourth and fifth fingers and the first metacarpal of the thumb were retained. A.H. demonstrated that he was capable of grasping crutches with both residual hands. On the right he could come within an inch of opposing the first metacarpal to the fourth and fifth proximal phalangeal stumps. Opposition could be achieved on the left. A.H. was in excellent physical condition, very well motivated, without hip contractures, and with good muscle power of the trunk and residual extremities. He had been working out in his garage, which he had converted to a gym. When seen, he weighed 160 lbs. and indicated that his pre-amputation height was 6 feet, 1-1/2 inches (a height that was subsequently successfully reachieved at his request). The VAREC Clinic Team decided to prescribe bilateral A/K partial suction quad sockets with waist belt, rigid uprights and band, multiplex knees (to allow trial of several knee units "in the rough"), and, finally, a trial with first SACH feet, and then single axis feet. The S-N-S knee units and single axis feet were selected on the basis of A.H.'s performance with them. On May 13, 1971 A.H. walked to VAREC without a cane or crutches. After a subsequent trial with total suction and silesian belts he had to be returned to his original prescription, due to stump scarring. A.H. had been an accomplished skier prior to amputation and, on January 25, 1974, requested prostheses with which he could ski again. The clinic team notes of that date follows. "He has been informed that skiing will be dangerous. Nevertheless, he is anxious to try it, and, because of the morale factor and the intensity with which this patient wishes to ski, plus the fact that he was a skier prior to his leg amputations, the prostheses have been ordered." Outrigger ski poles with special adjustments for the hand grips were also prescribed. The first prescription was determined after another bilateral A/K skier was invited to visit the clinic team with his prostheses. That concept was copied and prostheses were supplied to A.H. with solid knees fixed at 45 degrees and correspondingly dorsiflexed feet. They were rejected shortly thereafter by A.H. since they allowed him to slide down only low slopes. The prostheses with S-N-S knees and single axis feet however, did allow him to actively ski. It is noteworthy that the most efficient position of his stumps, since he required strong abductor power for skiing, was found to be in sockets set up in almost twenty degees of abduction. Since the neutral position of the feet was more efficient for skiing the feet were not out-toed. A.H. proved his proficiency on skis (<a href="/files/original/cf533beb527fcd368a66e40b0251877b.jpeg">see photo</a>) by winning the handicapped Olympics in Norway in 1982. He has competed in numerous events in the U.S. and overseas and he reports that he can negotiate 40 slalom gates in 60 seconds. He has not been trouble free, however. The most serious of his problems occurred when a spur was removed from his left stump and overlying soft tissue breakdown occurred. Although this healed secondarily, the clinic team advised that the area be covered by adequate soft tissue. This was done and the amputee had no further difficulty. A.H. continues to be active and, in addition to skiing, sails his own boat. Not all amputees, however, follow the same road to successful ambulation. At one time, the clinic team believed they had two patients who had the potential and motivation to ambulate. The team provided prostheses but the patients became obese and gave up the effort. The rehabilitation of one, a triple amputee (BE on one side) was, unfortuntately, a notable failure. *Gustav Rubin, M.D. FACS Chief, VAREC Special Clinic Team   Page Number(s) 1 - 2 Year 1983 Volume 7 Issue 4 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_04_001/1983_04_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 S-N-S Knees and the Bilateral A/K Amputee Creator An entity primarily responsible for making the resource Gustav Rubin, M.D. * https://staging.drfop.org/files/original/c1dcd8002daf073f875a014ab93e6d77.pdf 9f6846fc84195173da86b474bf524650 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_04_003.pdf Text Any textual data included in the document <h2>Hydraulics and Above-Knee Prosthetics</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration: none;">*</a></h5> Some of the highlights in the history of the use of hydraulic systems in artificial legs might be useful in understanding the present status and influencing the future application of hydraulic principles in lower-limb prosthetics. One of the prime objectives of the designers of artificial legs for above-knee amputees is control of the knee joint, and, thus, the shank to provide the amputee with the means to stand and walk safely, efficiently, and gracefully. Sporadically since 1918, and possibly before, hydraulic principles were proposed as a means for locking or braking the knee to enhance safety, but none of these ideas seem to have reached a practical stage until after World War II. When the National Academy of Sciences (NAS) initiated a research program in limb prosthetics in 1945 at the request of the Surgeon General of the Army, surveys of amputees indicated that the above-knee amputees felt that their greatest need was a knee lock that would prevent stumbling. This "finding" prompted a number of designs in the United States that used hydraulic systems to provide knee locking or braking on demand. Concurrently, a team in Germany, Ulrich Henschke, a physician, and Hans Mauch, an engineer, developed a leg prototype that used a hydraulic lock activated by motion of the abdominal wall. After Dr. Henschke and Mr. Mauch moved to the United States at the invitation of the United States Air Force, they were encouraged by their host to continue development of their design, and they became active in the NAS Artificial Limb Program. During the 1940's, Mr. Jack Stewart, an AK amputee and inventor, devised, to meet his own needs, an above knee leg which used a hydraulic system to not only provide knee locking, but also to provide shock absorption at the heel, co-ordinated motion between knee and ankle joints, and adjustability of the height of the heel. Swing phase control was provided by hydraulic fluid being forced through a single orifice, a serendipitous sort of circumstance. About 1951, leaders in the research program came to the conclusion, based on data developed at the University of California, that perhaps, more important than control in the stance phase, is control during the swing phase. Mr. Mauch was requested to give high priority to the design of a mechanism that would provide control of the knee during swing phase so that the amputee could vary cadence without changing the friction control setting. At about the same time, it was recognized that the characteristics of a fluid flowing through an orifice had the possibility of providing automatically the change in resistance to knee flexion and extension needed to compensate for changes in the walking cadence. Using many of the same parts designed for the stance-control system as well as data provided by the University of California Biomechanics Laboratory concerning knee movements during swing phase, Mr. Mauch produced a unit with a number of orifices arranged to provide changes in resistance to rotation at the knee corresponding to the "normal." This design, known as the Model "B," after some years of testing and field use, was combined with the stance-control system to produce the Model "A," which when modified was marketed as the Henschke-Mauch S'n'S (Swing and Stance) knee unit. During the development of the Henchke-Mauch units several less complex hydraulic and pneumatic units were also developed by others and marketed commercially with some degree of success. During the early 1950's 18 units of the Stewart design known as the Stewart-Vickers Hydraulic Leg were evaluated by a team at New York University, who found good amputee acceptance, and recommended that the locking feature be eliminated since the cost could be reduced appreciably and the test subjects didn't seem to make use of that feature. This recommendation was followed by Mr. Stewart, who a short while later sold all rights to U.S. Manufacturing Co., who manufactured and marketed it as the Hydra-Cadence Leg. The Hydra-Cadence Leg has been a commercial success, but in spite of a great deal of experience, no one can be sure of the relative importance of its many features. The development of hydraulic mechanisms for artificial legs has been plagued by leakage and breakage, which is only natural in an effort that tries to arrive at the optimum compromise between cost, weight, and function. Whether or not this optimum has been achieved is not yet known. We do know, however, that active above-knee and hip-disarticulation amputees appreciate the swing-phase control function afforded by hydraulic mechanisms and that the present day costs are not prohibitive for a substantial number of amputees. No definitive studies have been made that would delineate the efforts of the various factors and features involved, singly or in combination. With the availability of 4-channel 24-hour physiological surveillance systems and other sophisticated instrumentation, such studies seem to be quite feasible now and certainly should be considered. For at least thirty years the need for voluntary control of the knee joint has been recognized, but until the advent of the microcomputer it was difficult to conceive of a practical method to accomplish this. When microcomputers became available, the first reaction of some designers was simply to add the microcomputer to present hydraulic systems, but these efforts failed most probably because the systems available were not designed for control by computer. At any rate, it would seem that the weight alone of present systems would make voluntary control impractical, and thus any project in this area should begin anew. At present, very little work seems to be going on in the area of voluntary control systems. Some work at the Massachusetts Institute of Technology has been reported for nearly a decade. More recently, the REC at Moss Rehabilitation Hospital started a project where pattern recognition techniques are used to obtain subconscious control of a knee mechanism by EMG signals about the hip joint, which shows a good deal of promise. Perhaps what we need most at this point is more information concerning the contribution of each variable, such as swing-phase control, stance-phase control, ankle action, weight, and weight distribution, singly and in combination, for designers of the next generation of above-knee legs. With the technology now available to us, this appears to be possible as well as practical. *A. Bennett Wilson, Jr., B.S.M.E. Assistant Director, Rehabilitation Research and Training Center Dept. of Orthopaedics and Rehabilitation University of Virginia Medical Center Charlottesville, Virginia 22908. <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1983 Volume 7 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 Hydraulics and Above-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/ea5cb965d7cc12d8d6b0c436964b44d9.pdf e5e3dd0a8d1c47e6d18a93f0e7dde31d https://staging.drfop.org/files/original/eb8ca65bd9a979fad277a91a57b0e631.jpeg 43dae3e86044e9e9337edfa12f8d523c https://staging.drfop.org/files/original/b99d31ef707acfb4cb39459306f929ae.jpg 1f0a63be299196ddf613145c782f8bb2 https://staging.drfop.org/files/original/fac91bdfc7e7039cf0393d7300667e49.jpg 4f4ff35f2fa8689775893928003e2f4d https://staging.drfop.org/files/original/17601e26a1ee85e6b6d571785e2d2278.jpg b0ffbc512dbf96e101590a70c9834f21 https://staging.drfop.org/files/original/3c565e3e3e82d1e16dd0bc2c8487a402.jpg edc1b0783e1722653e72676e255cecdc https://staging.drfop.org/files/original/f60360f716924225bb6b1b92e24d5971.jpg ccb584ca57daf2499edbf1d0c9c55314 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_04_004.pdf Text Any textual data included in the document <h2>Physical Therapy and Hydraulic Knee Units</h2> <h5>Bernice Kegel R.P.T. <a style="text-decoration: none;">*</a></h5> Without a thorough understanding of the principles of operation and functional benefits engineered into the sophisticated hydraulic knee mechanisms, the therapist will be unable to help the amputee gain maximum benefits and use the system effectively. It is important that the prosthetist ascertain that the therapist knows what adjustability is incorporated into the prosthesis. Much of the adjustment will be done during dynamic alignment at the prosthetic facility, but modifications will need to be made as the patient gains confidence and his ambulation pattern improves. An understanding of the fundamental differences between hydraulic control and mechanical friction will help in training the amputee to take full advantage of the flexibility of hydraulic mechanisms. Amputees can walk over a wide range of cadences instead of being limited as with mechanical friction. There are two reasons for this. First, hydraulic friction increases with speed to balance the increase in kinetic energy of the prosthesis while mechanical friction remains essentially constant. The programmed hydraulic characteristics give little frictional resistance during initial extension and flexion but build to a peak at terminal flexion and extension. This helps to provide a natural appearing gait regardless of cadence. The stability of hydraulic systems permits alignment nearer the trigger point and thus results in less energy expenditure required for walking. If a patient has previously used a mechanical knee, he needs to be reminded that no exaggerated residual limb motion is necessary to gain adequate flexion and extension of his hydraulic prosthesis. For purposes of brevity, I will limit my discussion to gait training with one knee unit-the Mauch S-N-S (Fig. 1). The Mauch S-N-S knee unit can be set to provide 3 functions: <a href="/files/original/eb8ca65bd9a979fad277a91a57b0e631.jpeg">Figure 1</a>. Cutaway diagram of the Mauch Unit <ol> <li> Swing and Stance phase control. </li> <li> Swing phase control only. </li> <li> Manual knee lock. </li> </ol> A stirrup shaped lever near the top of the piston rod operates as a selector switch. When the lever is in the down position, swing and stance control are both operative. This would be the adjustment chosen for normal walking. The major advantage of stance control is that it offers the patient stumble recovery. If the prosthetic knee buckles, it will give way slowly enough that the patient should be able to regain his balance before falling. When training a patient with a conventional knee unit, he is taught to forcefully contract his hip extensors late in swing phase to accelerate the shank forward (with resulting terminal impact) to ensure extension of the knee at heel strike. Amputees wearing fluid-controlled mechanisms need not do this. The amputee should be instructed to swing his thigh forward, decelerate it, and end the movement with the residual limb pointing to the point on the ground where the heel should strike. The shank, aided by the built-in extension bias will swing forward smoothly, and at heel strike will be in full extension. With the stance phase control engaged, the prosthetic knee will be stable in the initial portion of stance phase without forceful extension of the hip musculature being necessary. The feature makes gait training markedly easier. It is extremely important during the end of stance phase on the prosthetic side that the hip be ahead of the knee and weight on the ball of the foot. This hyperextension moment is necessary to disengage the stance phase control momentarily and allow the knee to bend freely in swing phase. If the amputee does not exert this hyperextension for 1/10th of a second, he might experience difficulty in flexing the knee to begin swing phase. When walking on soft ground, it is even more important to exert this hyperextension moment. The benefits of stance control are also used when walking down stairs and ramps in a step-over-step manner. This ability to walk down steps in a step-over-step manner rather than one step at a time or by jack-knifing is one of the key advantages of the Mauch knee unit. The patient needs to be taught to place his prosthetic heel on the lower step with the forefoot extending beyond the edge of the step (Fig. 2). He is then told to flex his hip forward while simultaneously putting weight on the prosthetic leg. This will cause a controlled bending of the prosthetic knee. As the prosthetic knee yields, the sound leg is brought forward and placed on the lower step. If the patient has to wait for the prosthetic knee to bend, then stance phase resistance is too high and should be reduced. This activity is probably the most difficult to teach an amputee, especially if he has used a conventional knee unit in the past. This same technique is used for going down ramps. When walking up steps and ramps the same techniques are used as in conventional training. <a href="/files/original/b99d31ef707acfb4cb39459306f929ae.jpg">Figure 2</a>. Correct placement of the prosthetic heel When sitting down in a chair, the patient can either use the weight bearing resistance of the S-N-S unit to control the rate of sitting, or release the stance phase control and use the sound leg to control sitting rate in the same fashion as with a conventional knee unit. How quickly the knee bends under weight is determined by the stance adjustment screw, which is turned with a 22mm Allen wrench (Fig. 3). The adjustment is extremely sensitive with a range of only 120 degrees. Slowest bending and maximum stability is obtained with a full clockwise adjustment. Most patients like to start with a high degree of stability. <a href="/files/original/fac91bdfc7e7039cf0393d7300667e49.jpg">Figure 3.</a> Allen wrench inserted into the stance adjustment screw To eliminate stance phase control the patient is told to stand with his prosthetic leg behind his sound leg. With weight on the toe of his prosthesis, he pulls the selector switch lever up (Fig. 4). This mode would be used for bicycling and other activities needing a free swinging leg. Swing resistance is adjusted by moving the serrated cap. The verticle black line under the serrated cap is the extension resistance marker. When the black line is all the way to the right (4 o'clock) extension resistance is lowest, and all the way to the left (8 o'clock) is the maximum setting. A good resistance for beginning walking would be at 5 o'clock (Fig. 5). <a href="/files/original/17601e26a1ee85e6b6d571785e2d2278.jpg">Figure 4</a>. Eliminating the stance phase control. <a href="/files/original/3c565e3e3e82d1e16dd0bc2c8487a402.jpg">Figure 5</a>. Good resistance settings for beginning walking. The same serrated cap that adjusts extension resistance also adjusts flexion resistance. When the "H" in the word HYDRAULIC is over the line marker (regardless of the position of the line marker), flexion resistance is lowest. "K" over the marker indicates maximum resistance. A good resistance for beginning walking is at the "D" position (as shown in Fig. 5). To engage the knee lock, the selector switch is pulled into up position with the knee flexed and bearing no weight (Fig. 6). The knee may now be extended from this flexed position, but increased flexion is not possible. <a href="/files/original/f60360f716924225bb6b1b92e24d5971.jpg">Figure 6</a>. Engaging the knee lock. A right-legged amputee might choose to lock the prosthetic knee while driving and pressing the pedal by a forward motion of the hip. For standing at work for any length of time or while standing on a bus, the amputee could be taught to lock his knee. The Mauch S-N-S units have also been successfully used by bilateral amputees. The two units are likely to be adjusted differently because different residual limb lengths call for different resistance settings. The patient should be taught that the hydraulic unit may require servicing every one to two years. He should also be told that small amounts of air in the hydraulic system are no reason for concern. An automatic selfbleeding feature will eliminate the air after he walks a few steps, or if he bends the knees several times before applying the prosthesis. The leg should be stored upright with the knee fully extended so that air does not enter the hydraulic spaces. References: <ol> <li>Kegel, B., Byers, J.L., "Amputee's Manual-Mauch S-N-S Knee." Medic Publishing Co., P.O. Box 1636, Bel-levue, WA 98009, 1977.</li> <li>Lewis, E.A., "Elements of Training with the Mauch S-N-S System for Above-Knee Amputees." Research and Development Division, Prosthetics and Sensory Aids Service, Veterans Administration, 252 Seventh Avenue, New York, New York 10001.</li> <li>Lewis, E.A. and Bernstock, W.M., "Clinical Application Study of the Henschke-Mauch Model A Swing and Stance Control System." Bulletin of Prosthetics Research Fall, 1968.</li> <li>Mauch, H.A., "Stance Control for Above-Knee Artificial Legs-Design Considerations in the S-N-S Knee." Bulletin of Prosthetics Research, Fall 1968.</li> <li>Knee Prostheses, Mauch Laboratories, Inc., 3035 Dryden Road, Dayton, Ohio 45439, January 1974.</li> <li>Murphy, E.F., "The Swing Phase of Walking with Above-Knee Prosthesis." Bulletin of Prosthetics Research, Spring 1964.</li> <li>Staros, A. and Murphy, E.F., "Properties of Fluid Flow Applied to Above Knee Prostheses." Bulletin of Prosthetics Research, Spring 1964.</li> </ol> *Bernice Kegel R.P.T. Seattle, Washington Page Number(s) 4 - 7 Year 1983 Volume 7 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-5.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/1983_04_004/1983_04_004-6.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 Physical Therapy and Hydraulic Knee Units Creator An entity primarily responsible for making the resource Bernice Kegel R.P.T. * https://staging.drfop.org/files/original/d1fa99c68ccb7ad17715ef0dc1dd6825.pdf 2673ebe4132713a88e1fc6bbbefeea96 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_04_007.pdf Text Any textual data included in the document <h2>Hydraulic/Pneumatic Knee Control Units A Prosthetist's Point of View</h2> <h5>Charles H. Pritham, CPO <a style="text-decoration: none;">*</a></h5> As Mr. Wilson has demonstrated, the use of hydraulic and pneumatic control units had its genesis in the post World War II R & D effort. The objective, of course, was to fit the returning veteran AK amputee with the best prosthesis technology could provide. Such amputees were young and physically fit, prime candidates to benefit from the advantages of advanced control units. The prime advantage, usually cited, is cadence responsiveness. As the patient walks at different rates, the control unit automatically adjusts to control heelrise and terminal swing impact. Constant friction knees can not duplicate this feature. All hydraulic and pneumatic units provide this feature and one, the Mauch S-N-S, provides stance phase control as well. This means that the unit provides enhanced knee stability in the early portion of stance phase to increase the patient's safety. In this mode, the S-N-S unit can be said to function in a fashion analogous to that of a conventional safety knee. In another mode, the function of the S-N-S can be likened to that of a simple manually locking knee. Two other knee control units, variants of Kingsley's Hydranumatic and USMC's Dynaflex, function in a similar fashion. The Hydracadence, in addition to swing phase control, also provides heel height adjustability and toe pick-up. Otto Bock has recently introduced a modular knee that includes a hydraulic swing phase control. As can be seen then, these are just a few of the variations available to the prosthetist and his patient. The principal advantages claimed for such control units are enhanced cosmesis and performance, and lower energy expenditure. Against these advantages, the disadvantages must be weighed. Bulk, size, and weight of some of the units preclude their use by many patients. The considerable expense of most, if not all, hydraulic and pneumatic control units rules out others. Moreover, the control units have been shown to be unreliable. Some patients derive satisfactory service from their units while other patients using the same brand unit are constantly having them replaced and repaired. As most of the units need to be factory serviced, the delay and expense of maintaining a unit under such circumstances can engender considerable frustration. Given these circumstances, the pool of available amputees for whom such advanced control units are suitable is a small proportion of the total AK population, and most closely resembles the patients for whom they were originally developed: young traumatic males; i.e. veterans. It must be borne in mind that this pool today represents a less important proportion of the amputee population than it did some 25 years ago. Statistics demonstrate that the majority of civilian amputees in the Western World are geriatrics who lose a leg due to arteriosclerosis and are as often as not female. Indeed, the very amputees who were originally provided hydraulic units by the VA are not getting any younger. The day will come for each of them when they, and the clinic teams who attempt to address their needs, must make a reappraisal of their prescription. So, the use of hydraulic/ pneumatic control units for a considerable portion of the amputee population can be ruled out. Not only that, but it is possible to be very skeptical in considering the suitability of such units for patients for whom it is theoretically ideally suited. Young, active traumatic amputees are probably, children aside, the hardest on their prostheses. Given the expense of purchasing and maintaining such a unit, does it make sense to fit an amputee with one if he is going to have more than average maintenance problems? Can he afford the time lost from work, interruptions in his daily life, and expense of repairs? Given the disproportionately rising cost of health care today, can society? Gait studies demonstrate that AK amputees walk slower than normal subjects and BK amputees because of increased energy expenditure. If this is so, is the prime advantage cited for hydraulic/pneumatic units, cadence response, relevant and worth the additional expense and problems? In another vein, given the aging nature of the population should further effort and money be devoted to developing newer and more sophisticated knee control units? In any event, it can be said that a prosthetist in attempting to formulate a solution to his patient's problems is confronted with a number of questions and a wide variety of devices all intended to perform the same function. It is also true that the prosthetist has little more than personal experience, hearsay, and the competing claims of the manufacturers to aid him in making his decision. The natural tendency on the prosthetist's part is to provide his patient with the most sophisticated unit possible, for all of us gain considerable satisfaction from doing so and from working with such units. The patient also wants the best prosthesis possible. The fact remains, however, that such tendencies must be resisted and both prosthetists and patient must make a realistic appraisal of the situation and logically weigh the pros and cons. *Charles H. Pritham, CPO Technical Coordinator Durr-Fillauer Medical, Inc. Chattanooga, Tennessee Editor, C.P.O. <div style="width: 400px;"></div> Page Number(s) 7 - 8 Year 1983 Volume 7 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 Hydraulic/Pneumatic Knee Control Units A Prosthetists Point of View Creator An entity primarily responsible for making the resource Charles H. Pritham, CPO * https://staging.drfop.org/files/original/c14dfe270bafb90a2b20c29025446a0e.pdf ea4783b10f5c3a4d12c12442901d6cfc https://staging.drfop.org/files/original/e1c5e0817e16709456d081f6f415e65f.jpeg 25f2e057c93d0e69803ff76ac02699cb https://staging.drfop.org/files/original/b41bc35c2793e59d83d08621281b2157.jpg d5bfa6e4244d4b75c3af3ee1a2a68fca https://staging.drfop.org/files/original/38a21614eba81d206bc337aeb5d6e7fd.jpg b15d554896978844d9a1ee39e912bc50 https://staging.drfop.org/files/original/ab1b7ad80230fb3c67ffc6ab3131818b.jpg 382f8f76e28b2dde663fe0ef853f6e34 https://staging.drfop.org/files/original/4b05615aa03be409c03076b58f01516d.jpg d8571f4ee65ef85e91ebdfa64c11a806 https://staging.drfop.org/files/original/d44602f704718bd80028a10a39ab8557.jpg e1ed3363899743fe273d87b37d17f806 https://staging.drfop.org/files/original/aaeef9fb5c5bb12a4dd59e22be53a3c9.jpg 0f490c5304c88163f508047e5ba454cb https://staging.drfop.org/files/original/e0754e5e8e0d5cf1482166067833d458.jpg a89802e08f0b5c0fc15a0c44adff5e94 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_01_001.pdf Text Any textual data included in the document <h2>Scoliosis: Orthotic Management Concepts</h2> <h5>Edward P. Van Hanswyk, CO. <a style="text-decoration: none;">*</a></h5> The orthotic management of idiopathic scoliosis (<a href="/files/original/e1c5e0817e16709456d081f6f415e65f.jpeg">Fig. 1</a>) over the years has employed a number of different orthotic systems. Included among them have been the Milwaukee and modified cervico-thoracolumbosacral orthoses (C.T.L.S.O.) as well as various prefabricated, modular, and custom fabricated thoracolumbosacral orthoses (T.L.S.O.). The prescription of any of the systems is dependent upon a number of variables, including the level and degree of curvature, the degree of rotation, the age and physical condition of the patient, and the degree of patient cooperation expected. No matter which system is selected, and no matter which set or combination of variables is present, there exists a number of orthotic management principles for consideration. The purpose of this paper is to outline these principles and theories, the similarities and differences presented by scoliosis, and orthotic management systems employed. In order to present these relationships, a number of somewhat original, and perhaps not so original, orthotic management concepts and theories are discussed. The theories include: 1. the reasons for reducing lumbar lordosis; 2. the idea and employment of a "righting reflex," both sagittal and coronal; 3. the concept of "costal distraction"; 4. the importance of axial alignment; and 5. a theory concerning the deviations of scoliosis, the creation of forces, and the force systems necessary for their control and correction. <h3>Lumbar Lordosis</h3> Historically, there has been an emphasis over the years on the reduction of lumbar lordosis (<a href="/files/original/b41bc35c2793e59d83d08621281b2157.jpg">Fig. 2</a>) in the orthotic management of the spine, especially in the orthotic management of scoliosis with the C.T.L.S.O. and the T.L.S.O., for a number of reasons. <ol> <li> In the orthotic management of a lumbar or thoraco-lumbar scoliosis, flexion of the lumbar spine has a positive effect on scoliosis. The distraction that occurs between the thoracic spine and sacrum reduces lumbar scoliosis. The reasons presented for this "correction" include the release of the hip flexors and resultant pelvic tilt, and the stretch of the posterior longitudinal ligaments; the net result being an improvement of the lumbar scoliosis. </li> <li> When managing a lumbar curve in an orthosis with a corrective force from the posterior lateral direction in an attempt to reduce scoliosis and vertebral rotation by compressing of muscle bulge, it is necessary to provide an anterior counter-force to prevent an increase in lordosis. </li> <li> Recognizing that the thoracic and lumbar spine are interrelated, efforts to control lordosis with encasement and stabilization of the pelvis produce an opportunity for leverage and corrective forces, both inductive and direct, to be applied to the thoracic spine. </li> </ol> <h3>"Righting Reflex"</h3> The "righting reflex" (<a href="/files/original/38a21614eba81d206bc337aeb5d6e7fd.jpg">Fig. 3</a>) is an example of an inductive force. When producing flexion of the lumbar spine, the kyphotic posture of the thoracic spine accentuates a forward flexion of the shoulder and head. The body's natural tendency to right itself over the center of gravity produces an extension or reduction in thoracic kyphosis. This sagittal plane reflex can be utilized in the orthotic management of Scheurmann's kyphosis and idiopathic scoliosis. Another "righting reflex" force developed is in the coronal plane. In double curves, thoracic and thoracolumbar, when the lumbar curve is reduced, causing a lateral shift of the head and shoulders, the body's natural tendency to right itself results in a reduction in thoracic scoliosis as well. In the orthotic management of scoliosis in a C.T.L.S.O., the "righting reflexes" can be planned as an adjunct to the direct counter-lateral and anti-rotational forces of the thoracic pad. In a T.L.S.O., this inductive extension is aided by a fulcrum created by the superior trim line of the orthosis. In theory, even though the length of the lever arm superior to the apex of the thoracic curve does not appear adequate for a significant force to be applied, the planned instigation of "righting reflex" forces is used to augment a lesser, direct force. <h3>Axial Alignment</h3> The encasement and stabilization of the pelvis provides the counter-force and leverage for direct force application to the thorax as well. Because of the rotational component present in scoliosis, axial alignment of the body, rib cage and pelvis is necessary. The direct force created by symmetric alignment of the pelvic and thoracic surfaces of the orthosis results in a direct anti-rotational corrective force. This is particularly applicable in the orthotic management of a thoracic curve in a T.L.S.O. Since the rotational component present in scoliosis is one variable that may preclude the use of a T.L.S.O., management of rotation in this system can be viewed as critical. <h3>"Costal Distraction"</h3> Another direct force advantage created by the encasement of the pelvis is "distraction." Stabilization of the pelvis and the "total contact" encasement of the lower rib cage in a T.L.S.O. produces an opportunity to maximize the distance between the pelvis and the rib cage, resulting in a distraction of the lumbar spine. The flattened abdominal surface induces lumbar flexion and also increases the intra-abdominal pressures, augmenting this force. The resultant costal-pelvis distraction is another planned, direct force in the orthotic management of lumbar scoliosis in a T.L.S.O. <h3>Orthotic Management Goals</h3> The concepts and theories presented might now be viewed in relation to orthotic management goals relative to scoliosis, specifically the evaluation of the various scoliosis deviations and the corrective forces available in the orthotic management system employed. In the normal spine, the muscles act antagonistically on either side to maintain a straight, neutral spine. The spine, rib cage, and pelvis are symmetrically related and supported by the musculature. In the scoliotic spine, as the vertebrae rotate and move laterally, the muscles lose their lever-arm advantage, and the spine, rib cage, and pelvis lose their symmetry. The orthotic management goals then become: <ol> <li> repositioning of the vertebrae, not only by direct forces, but also by inductive reflex forces. </li> <li> re-establishment of muscle levers and re-establishment of symmetry of the rib cage and between the rib cage and pelvis. </li> </ol> <h3>Thoracic Scoliosis (Two Deviations)</h3> In identifying the orthotic system to be used, the differences in scoliosis deviations should be recognized. Thoracic scoliosis (<a href="/files/original/ab1b7ad80230fb3c67ffc6ab3131818b.jpg">Fig. 4a</a>) is seen as a two-deviational deformity, 1. a lateral deviation, the curve, 2. a rotational deviation, the rib prominence. Theoretically a three-directional force system is necessary for management of these deviations. The choice of C.T.L.S.O. or T.L.S.O. force systems depends, of course, on the variables outlined previously. In the three-directional force system C.T.L.S.O. (<a href="/files/original/4b05615aa03be409c03076b58f01516d.jpg">Fig. 4b</a>), the forces include, 1. the counter-lateral force of the thoracic pad, 2. the anti-rotational force of the thoracic pad, and 3. the distractive force of the pelvic base opposed by the occipital portion of the neck ring. Certain thoracic curves can be managed also in a T.L.S.O. system: The two-deviational deformity of thoracic scoliosis managed with the lateral and anti-rotational force of the axially aligned surfaces of the orthosis, augmented by the righting reflex inductive forces, coronal and sagittal. <h3>Lumbar Scoliosis (Three Deviations)</h3> Thoraco-lumbar and lumbar curves (<a href="/files/original/d44602f704718bd80028a10a39ab8557.jpg">Fig. 5</a>) are seen as a three-deviational deformity (<a href="/files/original/aaeef9fb5c5bb12a4dd59e22be53a3c9.jpg">Fig. 6</a>). In addition to the lateral and rotational deviations there is usually a tendency toward lordosis. The asymmetry and loss of muscle levers and the shape of the lumbar vertebrae allow hyper-extension which contributes to a third deviation. It becomes necessary to incorporate a four-vector force system to manage this three-deviational deformity. The four-vector force system T.L.S.O. (<a href="/files/original/e0754e5e8e0d5cf1482166067833d458.jpg">Fig. 7</a>) contains: 1. anti-lordotic, 2. lateral, 3. anti-rotational, and 4. costal distraction forces, all described earlier. In summary, understanding of the concepts and theories presented is necessary to provide the orthotic management system reflecting the re-positioning and forces required for appropriate correction. References: <ol> <li>Van Hanswyk, Edward P., Hansen, Yuan, and Eckhardt, Wayne, A., "Orthotic Management of Thoraco-Lumbar Spine Fractures with a 'Total-Contact' TLSO," Orthotics and Prosthetics Journal, Vol. 33, No. 3, pp 10-19, September, 1979.</li> <li>Van Hanswyk , Edward P. and Bunnell, William P., "The Orthotic Management of Lumbar Lordosis and the Relationship to the Treatment of Thoraco-Lumbar Scoliosis and Juvenile Kyphosis," Orthotics and Prosthetics Journal, Vol. 32, No. 2, pp 27-34, June, 1978.</li> </ol> <div style="width: 400px;">*Edward P. Van Hanswyk, CO. Instructor, Department of Orthopedic Surgery, University Medical Center, SUNY, Syracuse, New York.</div> Page Number(s) 1 - 4 Year 1981 Volume 5 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Scoliosis: Orthotic Management Concepts Creator An entity primarily responsible for making the resource Edward P. Van Hanswyk, CO. *