11 20 371 https://staging.drfop.org/files/original/cc46ad414ca9f0d932c9c1bd427dabc4.pdf 497441a68e5f2a4eef555521963106c4 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_010.pdf Text Any textual data included in the document <h2>The New Revolution</h2> <h5>Timothy B. Staats M.A., C.P. <a style="text-decoration: none;">*</a></h5> The recent development and proliferation of advanced and precision fitting techniques in prosthetics have caused many prosthetists to reevaluate those principles which were held sacred for the past twenty years. In the last three years in particular, both below-knee and above-knee prosthetics have undergone tremendous changes. Many progressive practitioners recognize that the term "Patellar Tendon Bearing (PTB)" is no longer considered descriptive of a well designed below-knee socket and use the term only in a historical sense. The term Total Surface Bearing better describes what has superseded PTB philosophy. In above-knee prosthetics, a greater revolution is in the offing. Now the CATCAM (Contour-Adducted-Trochanteric-Controlled Alignment Method) socket is shaking the underpinnings of the Quadrilateral above-knee socket design. For those of us who are "dyed-in-blue-and-gold-UCLA-Quad-socket" prosthetists, it is both difficult and exciting to see the development and confusion a rival design causes throughout the profession. I am sure that thirty years ago the "wood-socket-plug-fit" prosthetists shared a similar feeling when the quadrilateral socket and later the introduction of plastics caused their world to turn upside down. The point is that change and improvement are inevitable. You can fight it and it will flow over you like a river, or you can go with the flow and learn to adapt to new techniques. I have been asked repeatedly what I think about the use of multiple check socket fittings, CATCAM, alginated check sockets, and the Flex-Foot. The list goes on and on. American prosthetists in particular must understand that we are in the midst of a full blown revolution and the results of this revolution will set the path we follow for the next couple of decades. Rather than question what is right or wrong without really having proof of either, I have chosen a path as the director of a prosthetics education program of "pouring fuel on the fire." What better time or place for controversy than at UCLA, where the first school was started over thirty years ago. Is all this extra precision and care really necessary to accurately fit an artificial limb? The answer is quite simple, and if you are an amputee the question is repulsive. If superior techniques that can improve the quality of the care provided to amputees are available but are not used, it is nothing less than criminal. There are those who would question: how much of a good thing is enough? That is a question that the patient must answer and the prosthetist must decide based on knowledge and education. The fact that many of the newer techniques and fitting regimes demand more time and effort than methods which have been in use for twenty years is entirely a separate issue. While it may not be possible to provide these services for the reimbursements, which are now received from payment sources, this does not mean that the techniques do not work or are wrong. It only means that the third party payers are ignorant of changes which have occurred in our profession and must be introduced to the benefits of new procedures. This same principle applies to prescribing physicians. It is totally fair to say that a physician who took his prosthetics-orthotics training over five years ago is now out of date. The same is true for practitioners who have not upgraded their practices through educational opportunities during this period. It is always uncomfortable when you begin to wonder whether you are doing the best you can for your patient. It is even more uncomfortable when you know you are not. We should never be satisfied with our work and never doubt that a better job can be done. With such a philosophical upheaval running rampant through our profession, the time for learning is now. Are you satisfied with application of outdated techniques, or are you willing to enter a new era of prosthetic and orthotic practice? The choice is yours. *Timothy B. Staats M.A., C.P. Timothy Staats, M.A., CP., is Adjunct Assistant Professor and Director of the Prosthetics &Orthotics Education Program at UCLA, Rehabilitation Center, 1000 Veteran Avenue, Rm 22-41, Los Angeles, CA 90024. <div style="width: 400px;"></div> Page Number(s) 10 - 11 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The New Revolution Creator An entity primarily responsible for making the resource Timothy B. Staats M.A., C.P. * https://staging.drfop.org/files/original/b3a2c7a0584c7b41faa78f8463cf4268.pdf f252ffd28bf2d19a88c0995299dca5af Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_004.pdf Text Any textual data included in the document <h2>An Advanced Approach Toward Improved Prosthetic Fittings</h2> <h5>David F.M. Cooney, R.P.T., C.P.O. <a style="text-decoration: none;">*</a> Keith E. Vinnecour, C.P.O. <a style="text-decoration: none;">*</a></h5> The importance of amputation surgery and dedicated follow-up cannot be underestimated by those clinicians who deal with the amputee population. A prosthetist who receives a patient with a residual limb that is of the optimum configuration to receive a prosthesis and permits the lowest energy cost with maximum unilateral weight bearing comfort, is too often the exception. A concerted effort by all professionals involved—physicians, nurses, physical and occupational therapists, psychologists, social workers, and prosthetists—is required for truly successful rehabilitation. <h3>Delineation Of Level</h3> Successful primary healing in patients who have experienced a trauma related amputation is not as great a concern since the average age of this group is much younger than the dysvascular amputee. For the majority of patients who require prosthetic care due to vascular insufficiency, predictions for successful healing, and therefore level of amputation, is a critical consideration and of primary address here. The following discussion and techniques employed, however, can apply to all prosthetic fittings. In the dysvascular patient, the correct assessment of tissue viability and level of limb amputation is paramount to successful rehabilitation. Correct assessment also serves to reduce the length of the hospital stay and, therefore, costs. Patient morbidity and mortality are also reduced.<a></a> A number of methods are employed to determine amputation level. Absolute determinants include ischemia and necrosis. Skin temperatures, absence of hair, sensory deficits, and peripheral pulses are also clinical tools of relative, though unreliable, demarcation. A less direct way of determining level of amputation is the condition of the underlying tissues and skin bleeding during surgery.<a></a> Objectively defined methods are being used to more accurately determine surgical level. Doppler pressure measurements use systolic pressure differentials between the level of concern and brachial pressure. The literature cited offers relative values for prediction of successful healing,<a></a> but also points out the Doppler method's fallibility.<a></a> Two other non-invasive tests, segmental systolic pressure readings and pulse-volume recordings, can provide a reasonably valid prediction of primary wound healing, but should not be used as the sole indicators for amputation site.<a></a> Thermography has been used to estimate the optimal site of amputation. Infrared emissions from the involved extremity are displayed on a screen to show temperature differentials. One study claimed a 96 percent success rate with amputation levels recommended via thermography<a></a>. Skin blood flow by the Xenon-133 clearance techniques to predict primary healing levels in amputation surgery have shown positive results. A 100 percent primary amputation healing is claimed by these authors for surgeries where recommendations according to their standards were followed.<a></a> The choice of any of the above methods rests with the abilities of the institution. Though most non-invasive means are available throughout the medical community, invasive techniques using radioactive isotopes, like Xenon-133, require the availability of a nuclear medicine department. Clearly, not all facilities have this capability. Once the level of tissue viability and surgical healing have been determined, operative procedures commence. A residual limb offering optimal function should be a "well muscled, durable stump of effective length with a pliable skin cover that has adequate sensation." The means to this end requires careful attention to the handling of the bone, nerves, and soft tissues.<a></a> <h3>Surgery</h3> Subsequent to determining the amputation level is the actual surgical technique, which is an important adjunct to successful rehabilitation of the amputee. Handling of the bone requires close attention to the residual cortical shaping, and in standard practice it should be beveled to prevent sharp margins and potential socket problems.<a></a> The reaction of the bone to surgical handling of the periosteum is not fully understood, but when dealing with tissues that are compromised initially, one cannot fault a "kid-glove" approach to dissection and ligation. Delicate handling may avoid subsequent spurring along the bony margins.<a></a> It has generally been considered that fibular length should be less (approximately 2.0 cm.) than the length of the tibia.<a></a> The authors feel that fibular length should be equal to or no more than 5 mm. shorter than the cut tibia. It is felt that this improves prosthetic medio-lateral stability, provides greater distal bulk, and serves to prevent mature conical shaping and increase total tissue contact and weight-bearing. In the procedure described by Ertl,<a></a> the lengths of the two bones are equal. A bony bridge, or periosteal flap, is then created to afford an end bearing residual limb. This synostosis also prevents any relative motion of the two bones. The tibiofibular osteoplasty closes the open medullary canals and can recreate the normal conditions of direct weight bearing pressures and circulation in the long axis of the bone. This can help prevent degeneration in the joints proximal to the amputation.<a></a> It would seem that this procedure should warrant greater attention in appropriately selected patients (especially in light of the much improved fitting techniques now available). Establishing stabilization in the distal musculature at the selected site of amputation is important to provide a more physiologically effective residual limb. Where surgically feasible, the muscles should be sutured to each other as well as to the periosteum and/or bone without excessive tension or laxity. This allows for a well contoured and generally less prosthetically troublesome limb.<a></a> Nerve tissue should be handled meticulously to avoid residual problems once prosthetic wear is initiated. Each nerve should be individually dissected and have adequate traction applied. Severing of the nerve with traction maintained will cause it to retract far enough up into the soft tissue so as to be well protected and less threatened by weight bearing pressures.<a></a> Prosthetically crucial are the smaller sural and saphenous nerves, as they are sometimes neglected in lieu of the more major posterior tibial, deep and superficial peroneal nerves.<a></a> Redundancy of soft tissues should be avoided, but adequate coverage of the remaining structures is a must in order to provide a good limb for weight bearing. Closure of the wound should include careful suturing and handling of the already compromised tissues and care should be taken to avoid traction at the suture line so as to prevent contractures of the joint.<a></a> It has been shown again and again that immediate post-surgical fitting procedures can improve residual limb viability, reduce pain and edema, and prevent contractures.<a></a> Rigid dressings are common practice in immediate post-surgical fittings, but variations on this theme include the use of pneumatic devices that can also afford the advantages of their more rigid counterparts.<a></a> More tenuous situations that may not allow for early weight bearing and ambulation, secondary to healing problems, can be approached through the use of Una boot dressings<a></a> and an innovative removable rigid dressing technique.<a></a> Invariably, the independent and/or conjunctive use of any one of these methods can enhance the post-operative management of even the most difficult rehabilitation patient. By improving a patient's physical and mental status and by providing mobility through this approach, the clinical team can increase a patient's rehabilitation potential.<a></a> <h3>Prosthetic Evaluation</h3> Little has changed in the physical aspects of evaluation. Standard anthropometric measures are still used to provide an objective record for modifications and fabrication, and for comparative purposes related to future changes. Accurately determining the anatomical joint range of motion (both in the involved and uninvolved limb) and strength/stability can provide criteria for prescription and serve to mediate problems during fitting. One new tool in the evaluative process is Xeroradiography®. Xeroradiography® is a process that yields an x-ray image on an opaque background. The picture records are easier to store than their x-ray counterparts and provide a clear definition of both the bony anatomy and soft tissue. Evidence of bone spurring, vessel calcification, and presence of vascular surgery staples is readily observed. Measurements are also easy to glean. The use of this information in the treatment of the amputee is obvious and can significantly improve and objectify the prosthetist's skills and, ultimately, improve patient management.<a></a> <h3>Casting</h3> Adopting a "hands-on" technique in the quest of obtaining an anatomical replica of the residual limb should be the goal of the prosthetist. A careful volume study of the involved limb can serve to optimize the definitive results. The growing use of static and dynamic test sockets, and the information provided by them, has yielded a twist on the time tested practices utilized by many prosthetists. The technique of automatic build-ups over sensitive areas has been found to be less than necessary. Reversing this thought process to promote negative model modifications over areas of weight bearing can provide better total-contact, total-weight bearing sockets. Doing this in the molding process can reduce the amount of relatively educated guesswork necessary in cast modification by producing better initial cast molds. Methods which have been developed to aid in this pursuit include vacuum casting<a></a> or a three to four stage alginate casting technique.<a></a> Another method to improve fit from the initial casting is to work toward a more dynamic casting method. As the casting is predominantly done under non-weight bearing conditions, working toward more "dynamic" casting methods which equalize the weight bearing pressures is warranted consideration. Where an Ertl procedure has been performed, distal weight bearing casting is preferred to achieve maximum results. The same intent should be attempted with the non-Ertl distal end as well. Ultimately, the better the quality of the cast and the less initial modification guesswork, the better the test socket fitting. <h3>Test Socket</h3> Use of clear test sockets for improving fit is well documented in the literature cited. Though the technology for transparent test sockets has been available since the 1950's, the current practice of direct weight bearing modifications to the socket are relatively new.<a></a> During the initial static weight bearing period, areas of the residual limb are demarcated according to weight distribution and, therefore, load. This is evidenced by varying degrees of blanching or redness. The goal of a total tissue bearing socket is then pursued to decrease areas of excessive pressure (blanching) and to increase areas of inadequate loading (redness). This goal can be met through either static or dynamic test socket volume changes, or cast model modifications. Under weight bearing conditions, loose areas are marked by redness, and tension analysis is accomplished via "poking" the tissue through holes made in the socket. Various injectable materials (glycerine, alginate, pour-a-pad) are then added to equalize weight bearing pressures. Areas of excessive weight bearing, if not relieved by the weight borne by the newly injected materials, are either relieved in the socket or modified on the master mold. By achieving a careful stump-socket interface tension analysis as described, greater confidence in he ultimate result and an optimum fit is possible. Difficulty of fit dictates the number of check socket fittings. Unfortunately, fittings are also affected by the reimbursement source. The fact is undeniable, however, that a transition to the use of transparent test socket fittings can increase the level of prosthetic expertise and elevate the profession to a higher plateau of fitting success. <h3>Dynamics</h3> Advancements in prosthetic componentry and gait analysis techniques, when used in conjunction with improved evaluation tools and fitting methods, provides a greater arsenal for the prosthetist seeking to optimize his patient's abilities. An exciting variety of new techniques are surfacing throughout the country which not only render prosthetics more professionally demanding to the practitioner, but also challenging to the patient. Different socket styles and theoretical bends are adding to current thought and practice. The above-knee amputee now has a variety of alternatives in not only socket material and construction, but in functional design as well. The Swedish flexible socket offers a lighter weight, more "natural" feeling socket to the AK amputee. It also allows for greater transmission of heat via the polyethylene or Surlyn® material, and therefore a cooler feeling. The flexibility of the socket also encourages physiological muscle activity and provides sensory feedback through the thin material.<a></a> Contoured Adducted Trochanteric Controlled Alignment Method (CATCAM) is an exciting new above-knee socket design. Proponents claim it increases comfort secondary to total soft tissue weight bearing, because the ischial tuberosity is no longer on the "seat" of the conventional quadrilateral design, but contained within the socket. The CATCAM also allows for more natural muscle activity by virtue of both the flexible design (a la Swedish flexible socket) and inherent socket mechanics. By improving the socket's purchase on the femur, whereby the ischium, trochanter, and adductor longus tendon are in essence "locked-in," stabilization increases, which then decreases the Trendelenberg tendencies experienced by many above-knee amputees. By obtaining a definite position of adduction of the femur, one can take advantage of the muscle stretch of the gluteus medius and therefore increase pelvic control with unilateral weight bearing.<a></a> Ultralight weight components continue to be preferred in the above-knee prosthesis. The availability of titanium, carbon graphite, and higher density plastics in the manufacturing of the pylons, joints, and attachment plates allow for lighter weight limbs and, ultimately, decreased energy costs for the amputee. The below-knee amputee has a varied repertoire of options. A greater array of suspension methods—latex rubber, neoprene sleeves, total suction prostheses—are now available. The Flex-foot prosthesis<a></a> utilizes a sleeve suspension and is comprised of a carbon graphite and fiberglass pylon and a heel that is very strong, light weight, waterproof, and energy cost effective. The Flex-foot design provides "stored energy" upon weight bearing that "propels" the amputee forward, mimicking "normal" muscle activity in gait. This can also be used for the above-knee amputee. The Flex-foot is proving to be a great advance toward increasing the abilities of the athletic amputee and shows great promise for the elderly and less physically challenged. New liner materials have also provided alternatives for the below-knee amputee, with greater comfort as a result. Silicone gel and leather liners,<a></a> Ipocon gel,<a></a> and injection molded silicone gel liners<a></a> offer the amputee who has minimal tissue coverage and/or scarring the benefit of shock absorption and a "new skin" type feel. The active, athletic below-knee amputee also captures the benefit of the gel system and suffers less trauma as a result. Prosthetic feet, such as the Seattle<a></a> foot and S.A.F.E.<a></a> foot, appear to offer better gait characteristics and function, and also allow for increased activity by virtue of their functional, flexible designs. Ancillary methods of evaluating and improving gait performance are making their way into the more aggressive practices. John Sabolich, C.P.O.<a style="text-decoration: none;">*</a> in Oklahoma City has been utilizing a bio-feedback device with his above-knee patients in an attempt to re-educate the gluteus medius muscle during gait training. Utilizing the system in a dynamic fashion, i.e. patient ambulating with the electrodes over the targeted muscle, provides the patient audible feedback of muscle activity. Use of a video tape camera also provides patients with optimum benefits during the alignment and gait training period.<a></a> Careful analysis of the saggital and frontal views provides the practitioner with a better opportunity to critically analyze and improve his patient's gait. Improved problem-solving subsequent to delivery is also a benefit of this technique. The film serves as a learning tool for the new amputee and the practitioner, and also serves as a record of a patient's progress and delivery status for ironing out future fitting problems relative to gait induced complaints. The Computer Aided Design, Computer Aided Manufacturing (CADCAM) technique<a></a> is presently available for use in designing below-knee prosthetic sockets and will soon be available for design of above-knee prosthetic sockets as well. Measurements are taken from the residual limb and entered into the program. A screen display then allows for modifications to be made relative to the entered data and design scheme. Once the design is created, the information is transmitted to a computerized milling device that then carves out a model of the residual limb. From this model a socket is fabricated from polypropylene. In the future, "shape-sensing" will allow for modifications from the sensed data rather than the standard methodology. The ability to draw from the digitalized information of Computerized Axial Tomography (CATSCAN) or x-rays is also in the offing. This system is also an excellent, accurate record keeping tool. The potential to "sense" size and shape, store the information, recall, modify, or duplicate as desired is an enticing prospect. Further research is both warranted and forthcoming. <h3>Conclusion</h3> With the advent of better technology and methods, a concomitant increase in prosthetic professionalism occurs. Improved education must also follow. Industry-wide attention to continuing the trend will help prevent our field from lapsing into the mundane. The practice of this increased professionalism and improved techniques also commands a higher cost. Jan Stakosa, C.P.'s<a style="text-decoration: none;">*</a> method of using a wide variety of componentry per patient during the fitting and alignment phases in order to optimize function not only serves to improve the patient's quality of life, but carries with it an increased time commitment and cost. Due to this increased input and component variability, thorough education of the public and professionals per the costs involved is required. Ultimately, third party payers and the government will also have to be addressed. Until such time as these practices and advancements become standard, there will not be reimbursement for them.<a></a> How do you value human needs in a marketplace in which the trend is toward price reduction? The reality is that all these advances will increase the cost of prosthetic care. Prosthetists, the public, third party payers, and the government will need to be willing to improve the quality of life for this sector of the population, who deserve to be rehabilitated to the maximum and be allowed to perform as well as any able-bodied individual. It is our hope that the prosthetic industry will take up the challenge to advance the profession and invest the time in testing preferred methods and improvements. Equally important is the quest to participate in their creation. Through improved knowledge of the mechanics of amputation surgery and the variables of follow-up care, combined with mutual professional dialogue, we can better serve the amputee population. References: <ol> <li>Barnes, R.W.; Shanik, G.D.; and Slaymaker E.E., "An index of healing in below-knee amputation: Leg blood pressure by Doppler ultrasound," Surgery 79(1):13-20, 1976.</li> <li>Bonner, F.J. and Green, R.F., "Pneumatic airleg prosthesis: Report of 200 cases," Archives of Physical Medicine and Rehabilitation, 63:383-385, 1982.</li> <li>Burgess, E.M., "General principles of amputation surgery," Atlas of Limb Prosthetics: Surgical and Prosthetic Principles, St. Louis, MO, Mosby, Ch. 2, p.p. 14-18, 1981.</li> <li>Burgess, E.M., "Postoperative management," Atlas of Limb Prosthetics: Surgical and Prosthetic Principles, St. Louis, MO, Mosby, Ch. 3, p.p. 19-23, 1981.</li> <li>Burgess, E.; Hittenberger, D.; Forsgren, S.; and Lindh, D., "The Seattle foot," Orthotics and Prosthetics, 37(1):25-31, 1983.</li> <li>Campbell, J. and Childs, C, "The S.A.F.E. Foot," Orthotics and Prosthetics, 34(3):3-16, 1980.</li> <li>Cary, J.M. and Thompson, R.G., "Planning for optimum function in amputation surgery," Atlas of Limb Prosthetics: Surgical and Prosthetic Principles, St. Louis, MO, Mosby, p. 28, 1981.</li> <li>Ertl, J., "Uber amputationstumpfe," Chirurg., 20:218, 1949.</li> <li>Gibbons, G.W.; Wheelock Jr, F.C.; Hoar Jr, CS., et al, "Predicting success of forefoot amputations in diabetics by noninvasive testing," Archives of Surgery, 144:1034, September, 1979.</li> <li>Graves, J., "Selectively placed silicone gel socket liners," Orthotics and Prosthetics, 34(2):21-24, 1980.</li> <li>Hanak, R., "Fabrication procedures for the ISNY above-knee flexible socket (instruction manual)." Course at New York University, Post-Graduate Medical School, Prosthetics and Orthotics, January, 1984.</li> <li>Henderson, H.P. and Hackett, M.E.J., "The value of thermography in peripheral vascular disease," Angiology, 29:65-71, 1978.</li> <li>Hittenberger, D.A. and Carpenter, K.L., "A below knee vacuum casting technique," Orthotics and Prosthetics, 37(3): 15-23, 1983.</li> <li>Ipocon Silicon Liner Technical Manual. IPOS, Lune-berg, West Germany.</li> <li>Kerstein, M.D., "Utilization of an air splint after below-knee amputation," American Journal of Physical Medicine and Rehabilitation, 53(3): 119-126, 1974.</li> <li>Koniuk, W., Personal communication. San Francisco Prosthetic-Orthotic Service, Inc., San Francisco, 1985.</li> <li>La Noue, A.M., "More on Ertl tibiofibular synostosis," Newsletter . . . Amputee Clinics, (V)4:3-4, July, 1973.</li> <li>Leal, J., "The Flex-foot prosthesis" (instruction manual). Presented at UCLA Prosthetics Education Program, Advanced Below Knee Prosthetics Saturation Seminar, October, 1984.</li> <li>Loon, H.E., "Below-knee amputation surgery," Selected Articles from Artificial Limbs, January 1954 - Spring 1966. Huntington, NY, Krieger, p.p. 305-318, 1970.</li> <li>Malone, J.M.; Leal, J.M.; Moore, W.S.; et al., "The Gold Standard for amputation level selection: Xenon-133 clearance," Journal of Surgical Research, 30:449-455, 1981.</li> <li>Malone, J.M.; Moore, W.S.; Leal, J.M. and Childers, S.J., "Rehabilitation for lower-extremity amputation," Archives of Surgery, 116:93-98, January, 1981.</li> <li>Mehta, K.; Hobson II, R.W.; Jamil, Z; et al., "Fallibility of Doppler ankle pressure in predicting healing of transmetatarsal amputation," Journal of Surgical Research, 28:466, 1980.</li> <li>Mooney, V. and Snelson, R., "Fabrication and application of transparent polycarbonate sockets," Orthotics and Prosthetics, 26(1):1-13, 1972.</li> <li>Moore, W.S.; Henry, R.E.; Malone, J.M.; et al., "Prospective use of Xenon Xe 133 clearance for amputation level selection," Archives of Surgery, 116:86-88, January, 1981.</li> <li>Pike, A.C. and Black, L.K., "The orthoglas transparent test socket-an old idea, a new technology," Orthotics and Prosthetics, 36(4):40-43, 1982-83.</li> <li>Pollack Jr, S.B. and Ernst, C.B., "Use of Doppler pressure measurements in predicting success in amputation of the leg," American Journal of Surgery, 139:303, 1980.</li> <li>Reger, S.I.; Letner, I.E.; Pritham, CH.; et al., "Applications of transparent sockets," Orthotics and Prosthetics, 30(4):35-39, 1976.</li> <li>Sabolich, J. and Guth, T., "The C.A.T.C.A.M. above knee prosthesis pilot course" (instruction manual). Course at UCLA Prosthetic Education Program, March, 1985.</li> <li>Saunders, C.G., "Computer-aided socket design: A computer-aided design and manufacturing package for fitting below-knee amputees with sockets," Medical Engineering Resource Unit, Shaughnessy Hospital, Vancouver, BC, Canada, March, 1984.</li> <li>Saunders, C.G. and Fernie, G.R., "Automated prosthetic fitting." Proceedings of the 2nd International Conference on Rehabilitation Engineering, Ottawa, 1984.</li> <li>Schmitter, E.D., "Surgical principles and practice: Lower Extremity amputations." Lecture-Prosthetics and Orthotics Course for Physicians and Therapists. Provided by Prosthetic-Orthotic Education Program, School of Medicine, Department of Surgery (Orthopaedics). University of California, Los Angeles, April 5-9, 1982.</li> <li>Staats, T.B., "Advanced prosthetic techniques for below knee amputations," Orthopedics, 8(2):249-258, 1985.</li> <li>Stakosa, J.J., "Prosthetics for lower limb amputees," Vascular Surgery: Principles and Techniques, Norwalk, CT, Appleton-Century-Crofts, p.p. 1143-1162, 1984.</li> <li>Sterescu, L.E., "Semirigid (Una) dressing of amputations," Archives of Physical Medicine and Rehabilitation, 55:433-434, September, 1974.</li> <li>Varnau, D.; Vinnecour, K.E.; Luth, M.; and Cooney, D.F., "The enhancement of prosthetics through Xerora-diography," Orthotics and Prosthetics, 39( 1): 14-18, 1985.</li> <li>Whipple, L. and Stakosa, J., "The not so simple ABC's of high technology," Disabled USA, Washington, D.C., July, 1983.</li> <li>Wu, Y.; Keagy, R.D.; Krick, H.J.; et al., "An innovative removable rigid dressing technique for below-the-knee amputation," Journal of Bone and Joint Surgery, 61-A(5):724-729, 1979.</li> </ol> <div style="width: 400px;">Footnote Jan Stakosa, C.P. is Director of the Institute for the Advancement of Prosthetics, Lansing, Michigan. John Sabolich, C.P.O., is Vice-President of Sabolich Orthotics-Prosthetics Center, Oklahoma City, Oklahoma. </div> <div style="width: 400px;">*Keith E. Vinnecour, C.P.O. Keith E. Vinnecour, C.P.O., is owner and president of Beverly Hills Prosthetics Orthotics, Inc., Beverly Hills, California. *David F.M. Cooney, R.P.T., C.P.O. David F.M. Conney, R.P.T., C.P.O., is a senior vice-president at Beverly Hills Prosthetics and Orthotics, Inc. </div> Page Number(s) 4 - 9 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Advanced Approach Toward Improved Prosthetic Fittings Creator An entity primarily responsible for making the resource David F.M. Cooney, R.P.T., C.P.O. * Keith E. Vinnecour, C.P.O. * https://staging.drfop.org/files/original/502cd24e05dc13685ce6c563d104b2cb.pdf c70c27a74e2e66b798440e7ec879a61c https://staging.drfop.org/files/original/3035cab4876d5e39dab2d7edc8f4280b.jpg 951d63ffb5182b95b09608292e446731 https://staging.drfop.org/files/original/317321434223dd65228f625d548145c2.jpg 33aef1d70d11bb5ffc3b46cab9f52066 https://staging.drfop.org/files/original/0d927e9043f66bd3e3af11041dbd3773.jpg a042157b9df13bf8aaf8981539c337b1 https://staging.drfop.org/files/original/0aec22109bbbab540a2b674c0f7b5c6d.jpg 69bbd64c5529d66b42bce4a5ccfd1632 https://staging.drfop.org/files/original/c4eabe665ad4dd8ea652e3ce8c3d13c2.jpg 4beac600d40f940220fb8267dc991693 https://staging.drfop.org/files/original/ecbbc4f77a47d1d78ba3db33d9c2c0bd.jpg e7c5d8fea44a345fc700a7ae696bd459 https://staging.drfop.org/files/original/a0c06126276a088136acdb56cfd72933.jpg 6eed0cb3b76b3a15c24cc44ef909fc88 https://staging.drfop.org/files/original/9b71e91d2b0275c07dda585373e86535.jpg 7777d3cc087d37eafb6b05901bd25113 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_02_019.pdf Text Any textual data included in the document <h2>Swedish Attempts in Using CAD/CAM Principles for Prosthetics and Orthotics</h2> <h5>Kurt E.T. Oberg, M.D. <a style="text-decoration: none;">*</a></h5> This paper was presented for the American Academy of Orthotists and Prosthetists Annual Meeting and Scientific Seminar, San Francisco, January 30-February 1, 1985. <h3>Swedish Cat/Cam History</h3> In the mid-70s, James Foort and some of his colleagues began to investigate the use of CAD/CAM principles in prosthetics and orthotics. Others had also started to work in biostereo-metrics. Some colleagues of mine in Sweden and I had initiated investigations in order to find modern technology which could be used in prosthetics and orthotics. Reports on this subject had already been published and showed promising possibilities for new techniques to be used. Interest in CAD/CAM, however, was very low in Sweden at this time. Prosthetists and orthotists were very skeptical of the value of this kind of technology as applied to the improvement of prosthetic and orthotic technique. Therefore, further attempts in developing CAD/CAM technology for prosthetics and orthotics in Sweden were dropped. This skepticism was understandable because at that time the new technique could not possibly give us as good quality results as was already possible with the traditional techniques. <h3>The Ispo World Congress In London</h3> During the 1983 ISPO World Congress in London, it became clear to Swedish prosthetists and orthotists who attended the congress that CAD/CAM techniques really had something to contribute to the field. The exhibition showed hardware such as measuring equipment and a milling machine which gave an example of the automated socket fabrication technique. As a result of the London Congress, the interest in CAD/CAM for prosthetics and orthotics became quite high in Sweden. <h3>Swedish Attempts</h3> There is now a definite interest in Sweden and Scandinavia to implement CAD/CAM techniques into the prosthetic and orthotic field. The large company, LIC, which provides over 60 percent of the prosthetic and orthotic service in Sweden, and which also has started service in other countries, has a clear intent to adapt CAD/CAM techniques to their work. The first area to be involved will be the orthopaedic shoe service. Another large prosthetic and orthotic service company, Een-Holmgren Orthopaedic Inc., is also following the work that is going on around the world in this field. There are some counties in Sweden that run prosthetic and orthotic services themselves and they, too, are very interested in following and adapting CAD/CAM techniques. They have decided to seek co-operation with the work that is done by the College of Health and Care in Munksjöskolan, Jönköping, Sweden. My intention is now to present the research and development activities in Jönköping. <a href="/files/original/3035cab4876d5e39dab2d7edc8f4280b.jpg">Fig. 1</a>: College of Health and Care Jönköping, Sweden <a href="/files/original/317321434223dd65228f625d548145c2.jpg">Fig. 2</a>: Relevant Laboratory Resources for CAD/CAM <a href="/files/original/0d927e9043f66bd3e3af11041dbd3773.jpg">Fig. 3</a>: Criteria on CAD/CAM in Prosthetics and Orthotics <h3>Competence And Educational Considerations</h3> The college runs the prosthetic and orthotic education programs for Sweden, Denmark, and Iceland. There are regular programs for orthopaedic engineers (2 1/2 years), prosthetic and orthotic technicians (two years), and orthopaedic shoe technicians (two years). Various types and lengths of special courses are also offered at the school. The educational program is connected to research and development activities and divided into three laboratories. One laboratory is called the Unit for Applied Orthotics and is testing and evaluating orthotic appliances for the Swedish Handicapped Institute. Another laboratory is the Orthotics Laboratory, which has been involved in the development of prosthetic and orthotic devices for more than 14 years. The newest laboratory is the Biomechanics Laboratory, which I started two years ago. There will be considerable consequences for a prosthetic and orthotic educational program when a technique like CAD/CAM is introduced into the orthotic and prosthetic field. The question for us is whether we should be passive and follow the development of techniques in different laboratories around the world, or whether we should be active in developing these techniques ourselves. The decision has been made that with regard to the resources and the competence we have in laboratories connected to the school, we should be active in development. There already are some relevant resources available at the laboratories. At the Biomechanics Laboratory there is equipment such as computers, digitizers, image processing equipment, and lasers. There is also experience with digital measuring technique, computer programming and prosthetic and orthotic biomechanics. The Orthotic Laboratory has a machine shop and design office experienced in prosthetic and orthotic development and the development of various instruments. <h3>Cad/Cam Philosophy Of The Biomechanics Laboratory</h3> The philosophy of CAD/CAM in prosthetics and orthotics at the college and at the Biomechanics Laboratory can be expressed by the following criteria: <a href="/files/original/0aec22109bbbab540a2b674c0f7b5c6d.jpg">Fig. 4:</a> The Principal Parts of the CAPOD System <a href="/files/original/c4eabe665ad4dd8ea652e3ce8c3d13c2.jpg">Fig. 5:</a> Specification of the Measuring Equipment <a href="/files/original/ecbbc4f77a47d1d78ba3db33d9c2c0bd.jpg">Fig 6:</a> Computer <ol> <li> The complete system should be available for each prosthetic and orthotic service shop. The alternative is a centralized organization where central units are put in place for the fabrication of the prosthesis from data and measurements taken at the clinics and sent to the central workshop. With this kind of centralized organization, the whole advantage of the CAD/CAM technique cannot be fully utilized. Patients change for various reasons and it is important to use the CAD/CAM system when there are changes or when modifications are necessary. This can increase the effectiveness of the service quite a lot. It also enables the prosthetist and orthotist to have a better control of the whole process when making a device. </li> <li> The system should require moderate investment. This criterion is only a consequence of the first criterion. </li> <li> Equipment of a very high specification (able to work to extremely close tolerances) should be avoided. Very high specification is generally not needed, but if it does not increase costs, it usually does no harm. However, machines or computer programs which are too generalized (that works to too coarse tolerances) can increase the cost of the system tremendously and consequently should be avoided. </li> <li> Individual 3-D shape sensing should be the basis for control of the numerically controlled (NC) milling machine. This is necessary in order to allow for individual variations that might occur, instead of working from more standard shapes, which is a simple but less effective way to work. </li> </ol> <h3>Objectives Of The Capod System</h3> There are potential possibilities for the use of CAD/CAM techniques in the whole prosthetic and orthotic field and the development that has been initiated at the Biomechanics Laboratory in Jönköping therefore uses the name CAPOD as an acronym of Computer Aided Prosthetic and Orthotic Design. The objective of this project is to develop a CAD/CAM system which fulfills the criteria mentioned above. The objectives of the CAPOD system are as follows: <ul> <li> To develop a CAD/CAM-system for prosthetics and orthotics as one complete unit based on a micro computer. </li> <li> The cost of the system should remain within the range of US$30-40,000. </li> <li> To allow commercially available video image processing equipment to be adapted for 3-D shape sensing. </li> <li> To encourage the development of a specially designed NC milling machine, costing less than US$12,000. </li> </ul> <a href="/files/original/a0c06126276a088136acdb56cfd72933.jpg">Fig. 7:</a> NC-Milling machine for CAPOD System <a href="/files/original/9b71e91d2b0275c07dda585373e86535.jpg">Fig. 8:</a> Principal Parts and Cost of the NC Milling Machine <h3>Technical Specifications And Project Status</h3> The principal parts of the CAPOD system will be a micro computer that controls both the measuring of the limb shape and also the NC milling machine by means of a measuring program, a CAD program, and a control program. Almost all these computer programs must be custom written. The fabrication cost of the whole system is estimated to be about $35,000. The principle of the shape sensing scheme is generally the same as that developed at the West Park Hospital in Toronto. The plan is to take a video recording of a laser illuminated contour of the limb at increments of one one-hundredth of a turn. The videogram will then be transferred to the computer via the MicroSight image processing system. The software in the computer then takes care of data reduction and will define the surface of a limb as a set of digital coordinates. The custom made CAD program will then modify the shape as specified by the practitioner in a manner that corresponds to the plaster cast rectification process that he does today. At present, a Victor micro computer from Victor Technologies, Inc. is being used. This computer is equipped with an Intel 8088 processor and has an internal memory of 256 Kb, which can be expanded to 896 Kb. It has 2 x 1, 2 Mb Floppy Disk, but a Hard Disk of 10,6 Mb is more likely to be used in the future. The monitor is 12" and has a graphic resolution of 800 x 400 pixels. It has been found that commercially available numerically controlled milling machines are not suitable in this application. They are too over-specified for our purpose and the objectives of the CAPOD system cannot be fulfilled with such machines. Early on it became quite clear that for our purposes, a specially designed milling machine had to be developed. After some investigations, a design proposal, as illustrated by the schematic drawing, has been developed. The cutting is controlled by the same type of coordinates as were used during the measuring procedure, i.e., the model will rotate in steps of one one hundredth of a turn. The X and Y coordinates of the cutter are then controlled by coordinates corresponding to the X and Y coordinates of the measured and modified contour. The travel of this stroke is such that models of torsos and whole legs can be made. An important feature of the machine is the high speed which has been achieved through the use of stationary motors. By using stationary motors and transmissions to power the cutter, the moving parts have quite low mass, which gives a low inertia and allows high speed. It would be possible to cut a model of about 30cm in length in two minutes. It is estimated that the fabricating cost of such a machine would be $10,000-11,000. Fifty percent of that cost is commercial parts—for instance, the control electronics for the stepper motors and the complicated transmissions. There are a few custom made parts, the whole chassis and assembling of the machine, which make up the other half of the cost. The specification of the system has been worked out in co-operation with the orthopaedic technical departments in Gothenburg and Boras. They are also deeply involved in the educational program. The development work has come into a practical and detailed phase, and the whole team is very enthusiastic and anxious to fulfill the objectives and make the CAPOD system a successful system. *Kurt E.T. Oberg, M.D. Dr. Oberg is Director of the Biomechanics Laboratory Jönköping City Council, Munksjöskolan, Box 1030-S-551, Jönköping, Sweden. 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Oberg, M.D. * https://staging.drfop.org/files/original/ae236bfbb39982337feabb0733c52902.pdf e72d5cf575ee14ceefaff511308e621b https://staging.drfop.org/files/original/666c4f3f407ef42ef96a9eeb30cba2cc.jpg ef072ec1bc27f9dcd672375601a67a9e https://staging.drfop.org/files/original/da001445312603a0ab4a223ff85c38d1.jpg 4f8a28f1624ff2e04786d747684a2057 https://staging.drfop.org/files/original/a32c142193dc07186843945607ee7c09.jpg 79706ff74b7376718ec3c1c01ef15ca3 https://staging.drfop.org/files/original/d6cf3cf6ad5b9329cdf3ac01b1190266.jpg f251a6a6b93993eeba8075a00dd5ac91 https://staging.drfop.org/files/original/41e3f04ea2dcb2b15a38233a0196d63c.jpg 9d90b7c57aaad093cb21238b39211ddc https://staging.drfop.org/files/original/c70f240f5eef716b30961b9ae75c899e.jpg 1e4183be00d6bedb3cc92fad6389248d https://staging.drfop.org/files/original/f4d46e9d44ec0b8a2fd85babdfade006.jpg f7682f94bed1b0ccc9e390612c5dafdf https://staging.drfop.org/files/original/d5207f95412f40949c9a0abdcc8f179f.jpg 35b4aa1ad815d9578b088cbbfd993f91 https://staging.drfop.org/files/original/dd41c84673e88dc6270e962c77261651.jpg 117eda80e9303ed50d584b0ee204d8f9 https://staging.drfop.org/files/original/4575504d9fda222439f290f7163145af.jpg 423c40aa07471e5f2cf3e718ae770e6b https://staging.drfop.org/files/original/91b675186e820e21469468d77ca70551.jpg 5afe9e85b461d2b3d97106de870921a2 https://staging.drfop.org/files/original/ac9d622bf611e960cead91b85bba30b1.jpg d785d4c25a39f7ab31ae8d5fc4053ed2 https://staging.drfop.org/files/original/554280c049e6a114db8463eaeefec20f.jpg e79e156f8cb8fe7c9dd123eec6027222 https://staging.drfop.org/files/original/c767acc60d993ecbc9a2dea3fdceafb5.jpg eaa08643ef0c977a0f9e9974a26262f3 https://staging.drfop.org/files/original/9696814c90d3a127b31bdde25d16906a.jpg 1d2ed620db67e11602f865d0cbca66a1 https://staging.drfop.org/files/original/11e6648c1da2da4e863cf22ff6b27e92.jpg 7979974fd7a2d61065ebd35791b01993 https://staging.drfop.org/files/original/0be90617be2197739e9b7215c50adcc4.jpg 761099b39d2853060144d43fd50bce9e https://staging.drfop.org/files/original/cdf2e11044f459004d4cc3bea3571520.jpg b18f89555cc3b064d9679377782bc8d8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_02_007.pdf Text Any textual data included in the document <h2>Passive Mobilization: An Orthotist's Overview</h2> <h5>Dwain R. Faso, C.O. <a style="text-decoration: none;">*</a> Mel Stills, C.O. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> The application of passive motion in orthopedics has brought a new dimension to an old concept for the treatment of musculoskeletal problems. It is now recognized that the adverse effects of immobilization such as joint stiffness, poor articular cartilage nourishment, and collagen loss can be reversed by prolonged passive mobilization. R.B. Salter demonstrated significant results with his experimental work in the healing of osteochondral defects in rabbits subjected to continuous passive motion. R.D. Courts followed with clinical experiences of improved range of motion after total knee replacements. The indications for passive motion have since broadened to include knee ligament reconstructions,  joint injuires, fractures, dislocations, joint sepsis, and many others. The orthotist is often consulted for the evaluation of passive motion devices, their set up, adaptation, and implementation with fracture orthotics, external fixation, and traction. This article will provide an overview of passive mobilization as a supplement to the practitioner's database and present a variety of clinical situations encountered in the Dallas area at a large trauma and reconstruction center. <h3>Background</h3> For centuries, the clinician has vacillated between the uses and benefits of rest versus motion in the management of various disorders and injuries involving body joints. Rest or motion have been the most prescribed forms of non-operative treatment, yet the controversy of indication, duration, and value of each is far from being resolved. In the teaching of Hippocrates, the injured body was to be at 'rest and lie up.' His use of splints in musculoskeletal injuries assured rest. With the impregnation of bandages with plaster of Paris in 1852 by Flemish surgeon Antonius Mathijsen, immobilization took on a new form. The use of plaster casts in treating trauma and injury unquestionably assured the concept of immobilization by orthopedic surgeons for the next 130 years with little examination of the potential damage to articular tissue. Additional support of the rest concept was led by the British surgeon Hugh Owen Thomas. His doctrine of rest was to be complete, prolonged, uninterrupted, and enforced. This was accomplished through the use of splints of his own design, many of which are still in use today with minor modifications. Thomas' immobilization techniques routinely included uninjured joints above and below the fracture site. The mobilization concept found its roots in the Aristotelian teaching that movement is life. In the late 1900's, a school of mobilization took on a significant form through its advocate, Dr. Lucas-Champonniere. This French surgeon supported the use of massage and motion as a means of preventing muscle atrophy and joint contracture during the management of fractures and joint injuries. He believed that motion helped to relieve pain rather than to aggravate it. The use of balanced skeletal traction for fractures involving joint surfaces, initiated by Professor George Perkins, emphasized active motion in the realignment of fragments and prevention of stiffness. In the 1950's, the 'movement is life' principle found a resurgence under the guidance of the Association for Osteosynthesis (AO). They coined the term "fracture disease" for the chronic edema, joint stiffness, muscle atrophy, and disuse osteoporosis found in the treatment of fractures with immobilization. The AO group's technique of open reduction, rigid internal fixation with compression, and no casting encouraged early mobilization and provided a significant aggressive treatment. Apley, Dehane, and more recently Mooney and Sarmiento advocated the closed functional treatment of fractures through the use of cast bracing. Although these two methods vary, both preserve joint motion and encourage early function. <h3>Continuous Passive Motion</h3> The human body has evolved and developed into an organism that needs to move in order to maintain optimum efficiency. When the body is immobilized, the overall physical fitness declines rapidly: the heart rate decreases, and cardiac output no longer rises sufficiently during even mild activity; the upright position is poorly tolerated; the nervous system response slows; calcium is released by the immobilized skeleton and is excreted in urine, reflecting the extent of bone loss; muscle atrophy occurs with the reduction of fiber size, thereby resulting in the decline of tensile strength and energy absorption capacity; and the immobile body loses three percent of its original strength per day in a linear fashion for the first seven days, after which little strength is lost. The joints of the body are especially susceptible to immobilization. The articular cartilage layers depend on synovial fluid for nutrition. Motion makes for constant interchange of fluid between the layers of articular cartilage and synovial fluid. Joint motion causes alternating cartilage compression and distension. The absence of these pressure fluctuations causes a stagnation of intercellular fluid and a decrease in nutrition. Surprisingly, the adverse effects of immobilization on the human body generated little interest for evaluation. In the 1960's, Salter began investigation on the effects of immobilization versus mobilization on articular tissue in rabbits. His studies produced significant laboratory evidence that continuous passive motion offered startling benefits in the articular repair process in knee joint injuries compared to the routine care of immobilization. Salter's conclusions for his first 12 years of experimentation are: <ul> <li> Continuous passive motion (CPM) is well tolerated and seems to be relatively painless. </li> <li> CPM has a significant stimulation effect on the healing of articular tissue, including cartilage, tendons, and ligaments. </li> <li> CPM prevents adhesions and joint stiffness. </li> <li> CPM does not interfere with the healing of incisions over the moving joint. </li> <li> The principle of rest for healing tissue is incorrect. </li> </ul> Evidence for the clinical effectiveness of continuous passive motion on the process of healing is both subjective and objective. In various studies, Dr. Richard Courts demonstrated that there is a reduction in postoperative pain and an increase in post total knee joint range following the use of continuous passive motion for several weeks. The decrease in pain experienced may be caused from the rhythmic joint movement providing competitive interference to retard the pain-spasm reflex and alleviate pain at the source. The increase in range of joint motion reported may be due to the improved orientation and strength of collagen fibers formed, preventing adhesions which would limit range without disturbing or causing damage to adjacent uninvolved normal structures. Clinically, Salter has indicated CPM use immediately postoperatively for the management of open reduction internal fixation (ORIF) of the ankle, knee, hip, and elbow with usage ranging from one to three weeks. Decreases in wound edema, joint effusions, pain medications, and an increase in patient comfort and shorter hospital stays are documented as compared to non-CPM patients. Schnebel and Evans found that while active flexion is acquired earlier in CPM patients, there was no statistical difference in active flexion in late motion studies between CPM and non-CPM total knee arthroplasty patients. <h3>Design</h3> Continuous passive motion machines can be categorized into three groups by design: mattress-mounted, bed frame mounted, and single joint units. Clinical use of continuous passive motion has primarily been utilized for mobilization about the knee and hip joint due to the mechanical design of the majority of motion devices, i.e. the mattress-mounted units. These machines are similar in that the patient lies supine with thigh and calf held in the unit, and the knee and hip are mobilized simultaneously. (In these units the patient is unable to move about in the bed or make significant posture changes.) Ankle movement may also be provided. Some mattress-mounted machines and their suppliers are: <blockquote> Autoflex, Chattanooga Corp. CAPE System, Zimmer CK-7 Passive Motion Knee Exerciser, OEC Danni-Flex, Danniger Medical Technology Kinetec Passive Leg Exerciser, Richards Powerflex 3000, Biodynamic Technologies of Florida Stryker Leg Exerciser, Stryker Sutter CPM 2000, Sutter Biomedical </blockquote> The bed frame mounted units attach to standard overhead Bulkin frames and provide the versatility for mobilizing multiple joints. These systems are: <blockquote> CPM K-10, Sutter Biomedical Passive Mobilizer, 3D Orthopedic Inc. </blockquote> Single joint units address specific joints of the body only. These are: <blockquote> Miami Ankle Motion Machine, Zoya Orthopaedic Kinetec Elbow Exerciser, Richards CPM-5000, Sutter Biomedical CPM Mobilimbs L1-A, Toronto Medical Corp. </blockquote> Functional features of all systems vary from: microswitching to torque sensing, mechanical range setting to computer programmed, 110 volt to battery operated, patient-controlled cycles to programmed cycles, and one speed to variable speeds. Yet all systems have been developed more from subjective than objective data. The questions of how much force, optimum speeds, duration of cycle, direction of pull/push/lift to the joint, control of joint motion, or should the joint be loaded or unloaded need to be addressed in order to quantify CPM and avoid the potential dangers of this modality. Dangers exist when these systems are utilized by those unfamiliar with mechanical systems and/or the expectant results they are trying to obtain. The level of knowledge required varies, i.e. the mattress-mounted units are limited in application and therefore are relatively simple. The multiple joint systems would require more expertise because of the increased options of use, the mechanical advantages gained with the use of pulleys and springs, and the variations of movements occurring about the anatomic joints. These systems tend to be more cost-effective since their various uses can be applied to a greater patient population. <h3>Two Year Experience</h3> In our experience at a major trauma hospital, the need for versatility, ease of use, and reliability were of utmost importance. We utilized five machine designs over a two year period: Sutter K-10, CPM Mobilimb L1-A, Richards Passive Leg Exerciser, 3D Passive Mobilizer, and a home-grown unit. All systems functioned very reliably. The Mobilimb unit had a rechargeable battery powered system which, for our use, proved to be the least practical. The mattress mounted units were limited to mobilizing knees and hips, especially in cases of joint replacement. The trays to these units were cumbersome to housekeeping. The staff would take the tray off the bed to change linens, causing frequent malalignments when setting it back on the bed, usually due to fear of reapplying and/or the lack of understanding how the system functioned. Patient comfort was a major concern. If the patient was not comfortable in the system due to the physical design of the system or improper positioning in the unit, the staff would turn off the machine, thereby reaping no benefits. The tray would not fit properly if the patient was above or below the average height of five foot ten inches. These systems did not provide a recorder to document how long the patient had the system on or how many cycles the limb experienced. Lack of full extension and flexion became another concern in our use of any of the units utilizing the tray that the leg simply laid in. Although the tray would indicate full extension, the leg would still be flexed, and usually abducted and externally rotated (<a href="/files/original/666c4f3f407ef42ef96a9eeb30cba2cc.jpg">Fig. 1</a>). Because of these reasons and the need to be able to utilize traction, cast braces, and rehabilitative orthotics with passive motion, we began using a homegrown version utilizing the Sutter K-10 without the mattress mounted tray. Through the use of dynamic suspension, we could achieve full extension with the assistance of gravity, mobilize a patient in traction, maintain abduction and adduction, and set up bilateral limbs with only one machine. This variation enabled the patient to move about in bed and provided easier bed pan use and overall more comfort. It won favor with our ancillary staff because there was nothing in their way to be moved or replaced (<a href="/files/original/da001445312603a0ab4a223ff85c38d1.jpg">Fig. 2</a>). In March 1984, we began using the Passive Mobilizer by 3 D Orthopedic Inc. This system had incorporated many of the features of our homegrown unit with some significant improvements. The system provides a linear pull rather than the rotating arc of the Sutter K-10 so that flexion and extension limits are more easily controlled and eliminates the potential hazard of the rotating arm (<a href="/files/original/a32c142193dc07186843945607ee7c09.jpg">Fig. 3</a>). Also, the unit includes a cycle counter to document how many cycles the patient has experienced. These two additional features were found to be very useful in our practice. <a href="/files/original/da001445312603a0ab4a223ff85c38d1.jpg">Figure 2.</a> Home grown unit using Sutter K-10 motor and control system. <a href="/files/original/a32c142193dc07186843945607ee7c09.jpg">Figure 3.</a> Patient with a right acetabular fracture with 30 lbs. of tibial traction in continuous passive motion (3D Passive Mobilizer). Hip flexed 0-90° and kept abducted. The use of passive mobilization should begin as soon as possible. The earlier the application, the better the results that can be anticipated. In the case of elective procedures, such as total joint replacements, the passive mobilization system should be set-up before surgery to familiarize the patient with the machine and its operation. At our center, the majority of the cases are trauma related and of a fracture variety. Patients are placed in passive motion postoperatively in the O.R., recovery room, or when transferred to the orthopedic floor. The unit is set to allow 30-40° of motion initially post-op with the rapid increase of range of motion to tolerance. In this two year experience, we have had 168 cases involving the use of continuous passive motion. These are broken down into three major categories: <dl> <dt></dt> </dl> Articular Fractures Knee—79 Hip—17 Elbow—4 Ankle—3 Joint Replacement Knee—14 Hip (Cup)—8 Other Knee Problems Sepsis—20 Lig. Repair—12 Edema Control 6 Continuous passive motion was also applied to mobilize the cervical spine (in halter traction post soft tissue trauma), the shoulder (post manipulation or rotator cuff repair), and the lumbar spine (post laminectomy or decompression). These were not listed because the applications are still under evaluation. Our goal in utilizing the modality of continuous passive motion is full range of motion. Initially we target for 0-40° of motion the first day, cycling the limb approximately one complete cycle per minute. Increase in ROM is aggressively addressed daily to pain tolerance. Since time minimums in CPM have not yet been established, patients are kept in passive motion except during meals, physical therapy, or bathroom use. The goal established for ROM of the knee and hip is 90+°. It was felt that if the joint could go through a passive 0-90 +° range pain free, and prior to discharge 0-90+° active range, that normal knee and hip motion could be achieved on an out-patient basis with aggressive physical therapy. Many factors influenced the outcome. Patient compliance and willingness to participate in this treatment plan is a major factor. Competent application and training in the use of continuous passive motion is also critical to the outcome. <h3>Cases</h3> Case 1 A twenty-nine year old male sustained a high caliber gunshot wound to the left knee (<a href="/files/original/d6cf3cf6ad5b9329cdf3ac01b1190266.jpg">Fig. 4</a>), traversing the lateral femoral condyle through the joint space and through the lateral tibial plateau. Open reduction internal fixation (ORIF) and ligamentous repairs were made. Postoperatively, the patient was placed in a standard cast brace due to the inability to provide adequate medial-lateral stability of the knee surgically (<a href="/files/original/41e3f04ea2dcb2b15a38233a0196d63c.jpg">Fig. 5</a>). The cast brace was attached to a continuous passive motion dynamic suspension system to restore and maintain motion (<a href="/files/original/c70f240f5eef716b30961b9ae75c899e.jpg">Fig. 6</a>). At the time of the initial cast bracing, the patient had considerable soft tissue edema about the knee. The use of passive motion quickly reduced that swelling to the point where the cast brace provided little support. After one week, the cast brace was reapplied with the addition of a varus producing strap (<a href="/files/original/f4d46e9d44ec0b8a2fd85babdfade006.jpg">Fig. 7</a>) and the patient began ambulation training and was discharged. (If atrophy or swelling should continue, the varus producing strap can be easily adjusted to maintain force on the knee and another cast change would not be required). Case 2 A twenty-five year old female sustained a fracture dislocation of the left knee (<a href="/files/original/d5207f95412f40949c9a0abdcc8f179f.jpg">Fig. 8</a>). The fracture and ligaments were internally fixed, and the patient was placed in a continuous passive motion dynamic suspension system utilizing a Mobilizing Brace (3 D) and a bootie (<a href="/files/original/dd41c84673e88dc6270e962c77261651.jpg">Fig. 9</a>). The patient achieved 0-90° of motion in two days and was maintained in passive motion for five days until she could achieve the same range of motion actively without excessive pain. The patient was then cast braced for increased medial-lateral stability, received gait training, and was discharged from the hospital. Case 3 A nineteen year old male sustained a distal fracture with a split condylar fracture to the right leg (<a href="/files/original/4575504d9fda222439f290f7163145af.jpg">Fig. 10</a>) and a lateral condyle fracture on the contralateral side (<a href="/files/original/91b675186e820e21469468d77ca70551.jpg">Fig. 11</a>). Fractures were stabilized, but were not internally fixed at time of admission because of emergency vascular repairs being required. Three days post injury, the patient underwent ORIF of his fractures (<a href="/files/original/ac9d622bf611e960cead91b85bba30b1.jpg">Fig. 12</a> and <a href="/files/original/554280c049e6a114db8463eaeefec20f.jpg">Fig. 13</a>). The right leg was placed in a free knee Mobilizing Brace and the left leg was placed in the rehabilitative free knee orthosis. A continuous passive motion dynamic suspension system was placed on the lower right extremity (<a href="/files/original/c767acc60d993ecbc9a2dea3fdceafb5.jpg">Fig. 14</a>). The lower left extremity had normal pain free motion following surgery. The patient was kept in passive motion for five days and achieved 0-100° of pain free motion. A cast brace was applied on the right extremity; the patient received gait training and was discharged. Case 4 An eighteen year old male sustained bilateral femur fractures and bilateral patella fractures. The patient underwent bilateral closed inter-medullary (IM) rodding of the femur and the patellas underwent bilateral ORIF (<a href="/files/original/9696814c90d3a127b31bdde25d16906a.jpg">Fig. 15</a> and <a href="/files/original/11e6648c1da2da4e863cf22ff6b27e92.jpg">Fig. 16</a>). The patient was placed in a free knee Mobilizing Brace on the left leg and attached to a continuous passive motion dynamic suspension system immediately postoperatively. The right leg was maintained in a straight position and in a denotation boot to prevent the fractured femur from spinning on the IM rod. In two days, the left knee had 0-90° of pain free passive motion. Active motion on the right lower extremity was limited to 0-15° of motion. At that time, the patient's right leg was placed in a free knee Mobilizing Brace and bilateral passive motion began (<a href="/files/original/0be90617be2197739e9b7215c50adcc4.jpg">Fig. 17</a>). Right leg motion progressed to 0-90° passive motion in four days, while the left leg was maintained in the 0-90° range. (This passive motion device, providing bilateral application from one power source, can be adjusted for varying degrees of motion independent of each other by varying the tension on the attachment lines.) Ambulation training began utilizing the bilateral Mobilizing Braces with drop locks in position (<a href="/files/original/cdf2e11044f459004d4cc3bea3571520.jpg">Fig. 18</a>). The patient was fully ambulatory with this system, achieved full range of active motion in ten days, and was discharged. Passive motion was maintained for a longer period than normal due to the degree of articular damage to the patellas. <h3>Summary</h3> Passive range of motion has proven itself as a useful treatment modality for increasing or maintaining range of motion of the hip, knee, ankle, shoulder, and elbow. Clinically, we have observed improved wound healing and reduction of edema. Septic joints that are or have been opened and drained appear to clean up sooner than joints treated with only incision and drainage (I & D) and daily whirlpool. Patients are comfortable with reduced requests for pain medications. Patients also seem happier and this may be due to the fact that something is being done to help them get better on a continuous basis. Therapy time can now be devoted to improving muscle control and independent activity levels rather than painful ROM exercises. Of the 168 cases presented in this paper, all but two patients did or would have benefited from passive mobilization. The degree of success depended to a large extent on patient compliance. All patients who cooperated with this treatment modality improved their motion and reduced their hospitalization with two exceptions. One patient had undergone total knee replacement and was placed in CPM in the recovery room. Approximately 20° of motion was achieved initially. All attempts to increase her motion failed in that the 3D device would stall at a given point and reverse itself. The referring physician was contacted in order to report the difficulties. It was learned that the patient, some 40 years earlier, had undergone a spontaneous hip fusion probably due to infection. Conventional CPM can not be utilized for ROM of the knee if the hip is immobilized. The second failure was with a young sickle cell disease patient also having severe sepsis of the knee. All attempts of passive mobilization were painful and limited to less than 30° of flexion. The patient underwent arthrodesis of the knee and was later discharged with granulating wounds. Patients with fractures involving articular surfaces of the knee have done well with 0-90° of pain free active motion obtained in generally less than ten days. Depending on the degree of internal fixation or patient compliance, a cast brace was applied prior to discharge. As stated earlier, cast bracing and passive mobilization is a common treatment modality. References: <ol> <li>Burks. R.. Daniel. D,. and Losse. G.. "The effect of continuous passive motion on anterior cruciate ligament reconstruction stability." Amer. J. Sports Med., 212:323, 1984.</li> <li>Coutts, R.D., Toth C., and Kaita J.H., "The role of continuous passive motion in the rehabilitation of the total knee patient." Total knee arthroplasty-a comprehensive approach. Hungerford D. ed.. Baltimore: Williams & Wilkins, pp. 126-32. 1983.</li> <li>Dehne. E., Torp, R.P., "Treatment of joint injuries by immediate mobilization," Clin. Orthop. 77:218, 1971.</li> <li>Frank, C., Akeson, W.H., Woo, S.L.Y., Amiel, D., and Courts. R., "Physiology and therapeutic value of passive joint motion." Clin. Orthop., 100:113-125, 1984.</li> <li>Korcok, M., "Motion, not immobility, advocated for healing of synovial joints," J.A.M.A., 246:2005, 1981.</li> <li>Lynch, J.A., et al., "Continuous passive motion: A prophylaxis for deep venous thrombosis following total knee replacement," Scientific paper 143, AAOS 51st. meeting, 1984.</li> <li>Muller, "Influence of Training and of Inactivity on Muscle Strength." Arch. Phys. Med. Rehab., 51:449, 1970.</li> <li>Mooney, V., and Ferguson, A.B., "The influence of immobilization and motion on the formation of fibrocarti-lage in the repair granuloma after joint resection in the rabbit." J. Bone Joint Surg., 48A:1145, 1966.</li> <li>O'Driscoll, S.W., Kumar, A., and Salter, R.B., "The effect of continuous passive motion on the clearance of a hemarthrosis from a synovial joint: An experimental investigation in the rabbit," Clin. Orthop., 176:305-11, 1983.</li> <li>Perry, C.R., Evans, L.G., Rice, S., Fogarty, J., and Burdge, R.E., "A new surgical approach to fractures of the lateral tibial plateau," J. Bone J. Surg., 66A:1236, 1984.</li> <li>Richardson, W.J., and Garrett, W.E., Jr., "Clinical use of continuous passive motion," Contemp. Orthop., 10:75-79, 1985.</li> <li>Salter, R.B.: Presidential address, Canadian Orthopaedic Association, Halifax, N.S. J. Bone Joint Surg. 64B:251, 1982.</li> <li>Salter, R.B., and Hamilton, H.W., "Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: A preliminary report of a feasibility study," J. Orthop. Research, 1:325-342, 1984.</li> <li>Schebel, B.E., and Evans, J.P. "The use of continuous passive motion in the rehabilitation of total knee artho-plasty," Scientific poster, AAOS 52nd meeting, 1985.</li> <li>Steinberg, F.U., The Immobilized Patient, New York, Plenum, 1980.</li> <li>Strang, E.L., and Johns, J.L., "Nursing care of the patient treated with continuous passive motion following total knee arthoplasty," Orthop. Nursing, 3:27-32, 1984.</li> </ol> *Mel Stills, C.O. Mel Stills, CO., Instructor, Orthopedics, South Western Medical School, 5323 Harry Hines Boulevard, Dallas, Texas 75235. *Dwain R. Faso, C.O. Dwain R. Faso, CO., Manager, Research and Development, 3D Orthopedics, 11126 Shady Trail, Dallas, Texas 75229. Page Number(s) 7 - 19 Year 1985 Volume 9 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Passive Mobilization: An Orthotist's Overview Creator An entity primarily responsible for making the resource Dwain R. Faso, C.O. * Mel Stills, C.O. * https://staging.drfop.org/files/original/8a9d698b5aa9a88b1d78cca1010c8eea.pdf 19dc4e493a77c65d2001e424e6222098 https://staging.drfop.org/files/original/99962c094bd59683119343ed583b5ef4.jpg 39cc66fe8bd0fa42c218e04d12f792fa https://staging.drfop.org/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg 342634e484594f8c0b6ec6fe1e681ed9 https://staging.drfop.org/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg a24f4347ad26657b24aa89700949a9fc https://staging.drfop.org/files/original/8722aae75627f1d176b8d9a189158028.jpg e972a1cac03927a2aafa9101a7ca1f5c https://staging.drfop.org/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg bdd02cd537217663f89754a8cbf9e89e https://staging.drfop.org/files/original/bdccea442ad3ab930b10461937bd5371.jpg be9a619d33b72a6e85e028985e907098 https://staging.drfop.org/files/original/e625aaa21e9345136d836397f35f4a25.jpg a7924af794fc40802662208fcc8abc16 https://staging.drfop.org/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg f673166d26b71b65d9dc04bd19d51530 https://staging.drfop.org/files/original/35e4a19292bc235080a381e346afc9df.jpg 2d9d56f7b3531d006b2ab2c40616d544 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_02_003.pdf Text Any textual data included in the document <h2>Orthotic Correction of Blount's Disease</h2> <h5>Terry J. Supan, C.P.O. <a style="text-decoration: none;">*</a> John M. Mazur, M.D. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> Infantile tibia vara is the result of abnormal growth in the proximal tibial epiphyseal late of the tibial plate. Blount<a></a> first identified the condition as osteochondrosis deformans tibialis in 1937. Clinically, tibia vara presents itself as a severe bowing of the proximal tibia, without the associated bowing of the tibial shaft or the femur, which is evident in physiological bowleg. On radiological examination of the child with tibia vara, a beaking of the medial aspect of the tibia metaphysis is noted. In 1964, Langenskiold and Riska<a></a> developed a grading system for chronologically staging the development of Blount's disease. Mitchell, et al.<a></a> advocated the use of the epiphyseal metaphyseal angle (E-M angle) as a simple quantitative measurement for Blount's disease in 1980. This method is useful to determine the severity of the disease and monitor treatment. Historically, the use of orthotic management in the correction of Blount's disease has not proven to be as successful as hoped. The lack of correction and increased laxity of the joint capsule of the knee have been the main reasons for not continuing with orthotic management. To this point, the treatment of choice for individuals with Stage IV or an E-M angle of greater than 30° has mandated that the child undergo one of several types of tibial osteotomies. Because of the high incidence of complications<a></a> and the recurrence of the condition, the authors felt that a new orthotic approach should be investigated. The result of that investigation has been the development of a knee-ankle-foot orthosis. This orthosis has successfully been used in seven cases of Blount's disease. <h3>Orthotic Design</h3> Previous orthoses used in the treatment of Blount's disease have been either a KAFO with a medial side bar only, or a KAFO with bilateral side bars. The medial side bar KAFO incorporated a varus corrective knee pad. The bilateral side bar orthosis is essentially a passive device to maintain the existing condition and to prevent it from getting worse. Neither system has proven to be completely successful in the treatment of Blount's disease. The design criteria established for the development of the knee-ankle-foot orthosis consists of the following: <ul> <li> The design must correct the varus deformity of the tibia. </li> <li> The medial joint capsule should not be distributed by the orthosis. </li> <li> Forces should be applied directly to the tibia and not the full length of the limb. </li> </ul> Because the patient is a growing child, it must be adjustable for growth as well as easily cleaned by the parents. The knee-ankle-foot orthosis which the authors have developed has met all of these criteria. Stress to the medial joint capsule was prevented by using an inversion of the supracondylar suspension technique used for below knee prostheses.<a></a> By having a medial thigh section extend beyond the joint space to the area of the medial tibial condyle, we were able to reduce the possibilities of applying stress to the joint space itself (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Fig. 1</a>). <a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Figure 1</a>. Bilateral KAFO's for Blounts with stainless steel medial side bar, thermoplastic femural section, and elastic tibial strap. Femural section protects the knee joint while the elastic applies maximum force to the apex of the tibial curve. A dynamic system was used to apply corrective forces to the tibia. The use of an elastic material to provide dynamic forces has been well documented.<a></a> A six-inch wide elastic gusset material with velcro closures provided an adjustable and continuously applied force to the tibia (<a href="/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg">Fig. 2</a>). The maximum force applied to the limb with the elastic material is at the apex of the curve (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Fig. 1</a>). This allows the maximum amount of correction with minimum amount of force. The velcro allows easy removal for laundering. All orthoses are provided with two sets of elastic straps. <a href="/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg">Figure 2</a>. Cross section of leg and orthosis at mid-tibial level. The relationship of the sidebar, elastic, velcro, and limb are shown. The orthosis needed to be strong and adjustable because these children are growing and extremely active. The side bars are made of stainless steel which overlap for growth adjustment only between the knee and ankle (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Fig. 1</a>). The knee-ankle-foot orthosis was not made adjustable proximal to this area in order to maintain the tibial extension of the thigh piece in its proper relationship to the tibial condyle. The patient's foot is maintained in a high top shoe which is attached to the medial side bar by means of a free ankle stirrup. <h3>Prescription Criteria</h3> The E-M angle is used to determine whether the patient meets the criteria for orthotic management of the Blount's disease. The E-M angle is measured on an anterior/posterior x-ray of the knee. To construct this angle, a line is first drawn through two points on the base of the proximal tibial epiphysis, selecting the first point at the base of the normal lateral side of the epiphysis and the second medial point as far away from the lateral side as possible, but at the base of the normal non-depressed epiphysis. Next, determine the midpoint at the base of the epiphyseal center, then draw a second or metaphyseal line from the medial tip of the metaphyseal peak to the midpoint of the epiphyseal center (<a href="/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg">Fig. 3</a>). If this E-M angle is equal to or greater than 20°, then orthotic intervention is recommended. Mitchell et al. determined that the mean E-M angle for normal children was 3°-11°. Orthotic management is maintained for a minimum of nine months and at such time as the E-M angle is less than 15°. If the child is over eight years of age, orthotic correction will not be achieved. Based on our experience, orthotic management in stages I through III tibia vara can be effectively corrected with orthotic management. Aggressive treatment is necessary to achieve these results. Stages IV and V Blount's Disease and children over eight years of age need surgical treatment. <a href="/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg">Figure 3</a>. Method of measuring the E-M angle. <h3>Case Study</h3> A white male, age 3, was presented at the orthotic clinic by his parents because of bowing of his right lower extremity (<a href="/files/original/8722aae75627f1d176b8d9a189158028.jpg">Fig. 4</a>). Clinical examination showed bilateral tibia vara. Bilateral standing AP radiograms were obtained. The E-M angle determined on these radiograms was 20° bilaterally (<a href="/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg">Fig. 5</a>). The child was fitted with the bilateral KAFO's (<a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Fig. 6A</a>) and a new set of standing AP radiograms was obtained which showed no difference in the E-M angle at that time (<a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Fig. 6B</a>). <a href="/files/original/8722aae75627f1d176b8d9a189158028.jpg">Figure 4.</a> Clincal appearance of B.D. at age 3 with bilateral Blounts Disease. <a href="/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg">Figure 5</a>. Standing A/P radiograms show E-M angles of 20° bilaterally. <a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Figures 6A (top) and 6B (bottom).</a> B.D. fitted with bilateral KAFO's. X-rays show no change at time of fitting. For the next six months, B.D. wore his bilateral KAFO's 23 hours a day with the knee joints in the locked position during weight bearing. After one week's wearing time, the patient no longer objected to wearing the devices and adapted his lifestyle accordingly. No restrictions were placed on the child concerning his daily activities. At his six-month checkup, new radiograms, both in and out of the KAFO's, were obtained. The E-M angle at that time was determined to be 15° bilaterally. Clinically, the child appears to have less bowing of his tibia as well. It was determined at that time that the side bars needed to be lengthened, which was done. It was decided that the parents could then allow the child to use the orthoses in the unlocked position during the daytime, but to return to the locked position at night. Because of growth of the child's feet, a shoe change was necessary. At nine months, the patient was again presented to the clinic. Once again the orthoses were lengthened (<a href="/files/original/e625aaa21e9345136d836397f35f4a25.jpg">Fig. 7</a>). New standing AP radiograms were also obtained, showing no significant alterations from the previous exam at six months (<a href="/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg">Fig. 8</a>). Day use of the KAFO was discontinued. <a href="/files/original/e625aaa21e9345136d836397f35f4a25.jpg">Figure 7.</a> Sidebars were lengthened twice during the treatment period. One shoe transfer was also completed. <a href="/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg">Figure 8.</a> Radiogram taken after 9 months of treatment show an E/M angle of less than 15° as well as less bowing of the tibial shaft. The patient returned for a twelve-month evaluation. No significant changes had occurred clinically in the patient's extremities (<a href="/files/original/35e4a19292bc235080a381e346afc9df.jpg">Fig. 9</a>), thus use of the orthoses was discontinued. <a href="/files/original/35e4a19292bc235080a381e346afc9df.jpg">Figure 9</a>. Orthotic treatment discontinued after 12 months. Clinical examination shows normal lower limbs. <h3>Summary</h3> This successful use of orthotic management in the early stages of Blount's disease has been proven at Southern Illinois University School of Medicine. An orthosis was designed to specifically meet the established criteria of correcting the tibial deformity, reducing the stress on the medial joint capsule, and allowing adjustability for growth. The device has been used in seven cases of tibia vara with excellent results in all cases. The E-M angle of the affected tibias have been reduced to less than 15°. Aggressive treatment in the early stages of Blount's disease will reduce the necessity of tibial osteotomies with their significant level of complications. References: <ol> <li>Blount, W.P., "Tibia vara osteochondrosis deformans tibia," J. Bone Joint Surg., 19, 1-29, 1937.</li> <li>Langenskiold, A.N., Riska, E.B., "Tibia vara osteochondrosis deformans tibia: a survey of seventy-one cases," J. Bone Joint Surg., 46-A, 1405-1420, 1964.</li> <li>Mitchell, E.I., Chung, S.M.K., Dask, M.M., Greg, J.R., "A new radiographic grading system for Blount s disease," Orthopaedic Review, Vol. 9, No. 9, 27-33, 1980.</li> <li>Steel, H.H., Sandral, R.E., Sullivan, P.D., "Applications of tibial osteotomy in children for genu varum or val gum," J. Bone Joint Surg., 53-A, 1629-1635, 1971.</li> <li>Marschael, K., Nitschke, R., "Principles of the patellar tendon supracondylar prostheses," Orthopaedic Appl. Journal, Vol. 21, No. 1, 33-38.</li> <li>Clancy, J., Landseth. R.E., "A dynamic orthotic system to assist pelvic extension: A preliminary report," Orthotics and Prosthetics, Vol. 29, No. 1, 3-9, March, 1975.</li> </ol> *John M. Mazur, M.D. John M. Mazur, M.D., Associate Professor, Department of Surgery, Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine. *Terry J. Supan, C.P.O. Terry Supan, C.P.O., Instructor, Department of Surgery; Director, Orthotic/Prosthetic Service, Southern Illinois University School of Medicine, Room 102, 707 North Rutledge Street, Springfield, Illinois 62702. <div style="width: 400px;"></div> Page Number(s) 3 - 7 Year 1985 Volume 9 Issue 2 Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-06.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-09.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-02.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-07.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthotic Correction of Blount's Disease Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * John M. Mazur, M.D. * https://staging.drfop.org/files/original/a9f10fd556c1a92dcd99130f4c4c7fb4.pdf 471c56da3d5a2d6cbb3f53fef609568e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_02_002.pdf Text Any textual data included in the document <h2>The Nature of Contractures</h2> <h5>Justin Alexander, Ph.D. <a style="text-decoration: none;">*</a></h5> When orthotic devices are supplied to a patient, it is generally in the hope that function can be enhanced. If this expectation is to be realized, joint mobility or range of motion should be within normal limits. Unfortunately, there are many patients where a significant deficit in freedom of movement occurs. It is essential to realize that the causative factor for such limitation is varied, so that one may develop a reasonable treatment approach. Impedence to free motion can result from injury or malfunction of the skin overlying a joint, muscles or tendons surrounding or crossing joints, the joint capsule, or the joint surfaces. In many instances joint disturbances can be avoided by timely intervention such as correct positioning; active, assistive or passive exercises; or stretching and joint mobilization. Unfortunately, even when meticulous care is provided, limitations of movement can occur. Once tightness has been allowed to develop, it becomes more difficult and painful to restore normal function. A variety of mechanical devices designed to minimize the danger of developing contractures, or to overcome them, have been described in the literature. Surgical intervention may be attempted in carefully selected instances as well. A common sequela to prolonged inactivity is loss of flexibility due to shortening of muscle fibers and connective tissue. In an otherwise healthy individual this does not cause a serious problem and one can expect that with resumption of normal activity, muscles will regain length and flexibility. If, however, a limb is immobilized because of injury or disease, tissue repair involves replacement of muscle fibers with scar tissue which consist of collagen. Early, persistent, and careful physical therapy usually produces satisfactory restoration of movement. Delay in starting therapy or placing the responsibility for performing a prescribed regimen completely on the patient or family member, without assurance that the program is understood and that it will be performed, is prone to produce serious impedance to normal mobility. It is important to note that when a distal joint is immobilized, the more proximal joints are not utilized as much as under ordinary conditions and secondary joint limitation may develop. Some common examples are the concommitant tightness of hip flexors and knee flexors, or the limitation seen in the shoulder and elbow of the patient who has sustained a Colles fracture of the wrist. Immobilizing a part in a resting position does not necessarily produce limitation of movement, provided there is physiological rest.<a></a> On the other hand, if a part is immobilized and there is active muscle contraction to prevent the muscle from being elongated or the joint moved, muscle tightness can be invariably expected. When a person expects that motion might be painful, such as during the acute phase of Rheumatoid Arthritis or during severe and prolonged periods of ischemia, a "protective spasm" can be anticipated and frequently results in "irreversible contracture." The term "irreversible" must be used tentatively, since, if given enough time, the contracture may be relieved through ordinary activity.<a></a> In most instances, therapy cannot be provided or justified for the long period required to ameliorate the situation. In several instances, we have observed changes occuring over two years or longer following initial insult. Extravasation of fluid into tissue surrounding the joint, which may be observed following repeated trauma. This could be a result of stretching which is performed too enthusiastically, or after episodes of bleeding in an individual with hemophilia. It will invariably result in deposition of collagen and may continue to permit calcification of the capsule. This could end in heterotopic bone formation. Heterotopic ossification presents a difficult problem to manage. While there have been some reports of spontaneous remission over time, others have reported recurrence after surgical excision. Repeated insults to the integrity of the joint itself can lead to complete blockage of the joint, either as ankylosis of the capsule or due to fusion of the joint surfaces. Depending on which joint is involved, total or partial joint replacements have been very successful in restoring function and almost completely eliminating pain. The management of the patient with contractures is complicated and if it is to be successful, close collaboration between physician, therapist, orthotist, and the patient and family is imperative. In the presence of contracture, the application of an orthotic device can be wrought with danger. If too much tension is applied in order to gain motion when the patient is walking, protective spasms may counteract any stretching effect. It is also possible that excessive pressure can result in a fracture, especially if the patient has ben inactive for some time and if osteoporosis is present. The chances of successfully reducing joint limitations are increased when physical therapy and orthotic devices are combined in a comprehensive treatment program. References: <ol> <li>Harris, R. and Copp, E.P., "Immobilization of the Knee Joint in Rheumatoid Arthritis," Ann. Rheum. Dis., 21:353, 1962.</li> <li>Partridge, R.E.H. and Duthie, J. Jr., "Controlled Trial of the Effect of Complete Immobilization of the Joints in Rheumatoid Arthritis," Ann. Rheum. Dis., 22:91, 1963.</li> <li>Alexander, J., "Irreversible Contractures: An Impediment to Prosthetic Rehabilitation" Newsletter Prosthetics and Orthotics Clinic, 4:3, 1, 1980.</li> </ol> <div style="width: 400px;">*Justin Alexander, Ph.D. Justin Alexander, Ph.D., is with the Albert Einstein College of Medicine, Yeshiva University, 1300 Morris Park Avenue, Bldg. 'J,' Room 2N4, Bronx, New York 10461. </div> Page Number(s) 2 - 3 Year 1985 Volume 9 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/. 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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_01_030.pdf Text Any textual data included in the document <h2>Two-Stage Cast-taking Procedure for PTS Prosthesis</h2> <h5>Kurt Marschall, CP <a style="text-decoration: none;">*</a></h5> Proper cast-taking and accurate measurements of a patient's remaining extremity, combined with careful evaluation and modification of the positive mold, are the most important steps in the fabrication and fitting of any prosthetic-orthotic device. Success or failure in prosthetic-orthotic fitting is directly related to the cast taken and the modifications incorporated in the positive mold. It is my firm belief that the person taking the cast should also be the one to modify it. Ideally, the modification of any master mold should be accomplished as soon after cast-taking as possible. The reasons are obvious. It makes it possible to recall the characteristics of the patient's extremity and to pay special attention to particular landmarks and problem spots that have been identified. Long delays will only serve to wipe out the memory of these characteristics. Granted, the caseload in some facilities does not permit this ideal situation of an immediate cast-modification procedure. Therefore, it should be the aim that the cast-taker produce a cast that can be easily understood and interpreted by the person modifying it. In the case of the PTS cast, landmarks should be well identified, circumference and length measurements should be accurate and special consideration or conditions should be carefully recorded. These are preconditions for proper cast modification and subsequent fabrication of a superior fitting socket, and form the foundation of any successful below knee fitting procedure. It is now well over twenty years since I first introduced, together with my colleague and partner, Robert Nitschke, CP, the American concept of the PTS prosthesis in Palm Springs, California. It now enjoys a widespread acceptance in the field of prosthetics and has become an integral part of the prosthetic armamentarium. Since then, deviations from the original PTS concept, dictated by physiological reasons, geographic location or climactic conditions have been introduced. The Fillauer removable medial wedge,<a></a> as well as the removable medial brim version,<a></a> are such a case in point. The supracondylar fitting with the anterior portion of the socket cut distal to the midpatella level, which thus sacrifices intimate contact with the quadriceps, should also be mentioned. All of these different techniques have their place. They work well, if, as a prerequisite to socket fabrication, a cast of superior quality and accurate cast modification can be supplied. Twenty years ago, we advocated a one step cast-taking technique, necessitating the use of a cast cutter in the posterior portion of the medial and lateral hamstrings for cast removal. The noise of the cast cutter, accompanied by some heat development when the blade oscillates through the cast, proved to be quite troublesome and sometimes frightening, especially to children and geriatrics. For these reasons we have employed for many years now a two-stage casting procedure in our facilities that produces a cast of superior quality with built-in characteristics that are easily identifiable in our positive molds prior to modification. <h3>MEASURING AND CASTING PROCEDURE</h3> <ol> <li> Materials and tools necessary for cast-taking procedure (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg">Fig. 1</a>): <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg">Figure 1. Materials and tools necessary for PTS prosthesis cast-taking procedure.</a> <blockquote> 2 light cast socks 1" elastic belt and 2 holding clamps PTS caliper A-P tension clamp Bandage scissor Goniometer Modified Ritz stick Orthoflex plaster bandage, 4" Regular plaster of Paris bandages, 4", extra fast setting Revere rubber bands, size 33 or equivalent Otto Bock separation gel (Gipsisoliercreme) or vaseline </blockquote> </li> <li> After positioning patient properly and comfortably on table, examine and palpate extremity carefully. Record findings on measurement sheet. Apply two light cast socks over patient's extremity and identify with indelible pencil all pertinent landmarks and bony protuberances (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg">Figure 2. Identify all landmarks and bony protuberances.</a> <ol> <li> Record circumference at three levels: mid-patellar tendon, mid-portion and around distal end of extremity. </li> <li> Record length of amputated extremity with modified Ritz stick (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg">Figure 3. Record length of extremity with modified Rita stick.</a> </li> <li> Record M-L dimension with PTS caliper at widest margin of knee (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg">Figure 4. M-L dimension at the widest margin</a></li> <li> Record M-L dimension above the medial and lateral femoral condyles (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg">Figure 5. M-L dimension above medial and lateral femoral condyles.</a> </li> <li> Record A-P dimension with knee relaxed and slightly flexed. The amount of flexion depends on the length of the remaining extremity. Seven-10 degrees is usually sufficient for medium sized amputations. Shorter ones may require more flextion (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg">Figure 6. A-P dimension with knee relaxed and slightly flexed.</a> </li> </ol> </li> <li> Wrap the amputated extremity with Ortho-flex bandage starting at distal end and terminating at the mid-patella level. Reinforce with regular, extra fast setting plaster of Paris bandage, and identify with thuimbs the patellar-tendon bridge (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-07.jpg">Fig. 7 </a>and <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-08.jpg">Fig. 8</a>). </li> <li> With plaster of Paris cast still soft and moldable, apply A-P tension clamp (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg">Fig. 9</a>). This makes it possible to shape the cast with both hands while it hardens, thus keeping later cast modifications to a minimum (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-10.jpg">Fig. 10</a>). Please note clamp and hand-induced characteristics of hardened first stage of mold (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-11.jpg">Fig. 11</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg">Figure 9. Apply A-P tension clamp.</a> </li> <li> Use Otto Bock separating gel or vaseline and apply a thin layer to the proximal 1 1/2" of the superior portion of the cast (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-12.jpg">Fig. 12</a>). Measure out six layers of 4" regular, extra fast setting plaster of Paris bandage or splints, sufficient in length to reach slightly past medial and lateral hamstrings (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-13.jpg">Fig. 13</a>). Apply to patient's extremity, overlapping first stage cast by at least one inch and extending over the patella and covering quadriceps tendon by one inch. Use six inch wide splints if necessary. Apply two thin rubber bands to superior edge of wings (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg">Figure 14. Apply two rubberbands to superior edge of wings. </a></li> <li> Place thumbs in the indentations of the mid-patellar tendon bridge and use the index and middle fingers of both hands to apply sufficient pressure to reach the depth of the recorded narrow M-L dimension just superior to the femoral condyles. The fingers should always straddle the ilio-tibial band on the lateral side (Fig. 15). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-15.jpg">Figure 15. Apply sufficient pressure to reach the depth of the recorded narrow M-L dimension. </a></li> <li> After the second stage of the cast has set enough to hold finger impressions in place, remove the rubber bands and mark juncture between first and second stage with indelible pencil (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg">Fig. 16</a>). Remove second stage by carefully lossening and lifting medial and lateral wings free (Fig. 17). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg">Figure 16. Mark juncture between first and second stage.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-17.jpg">Figure 17. Carefully loosen and lift medial and lateral wings free</a> </li> <li> Reflect the top cast sock distally. Let patient's musculature relax completely. While pulling the bottom cast sock proximal, slowly remove first stage (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg">Fig. 18</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg">Figure 18. Slowly remove first stage while pulling the bottom cast sock proximal.</a> Cut off excess cast sock adhering to first stage (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg">Fig. 19</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg">Figure 19. Cut off excess cast sock adhering to first stage.</a></li> <li> Join both stages together again by matching the separation marks exactly (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg">Fig. 20</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg">Figure 20. Join both stages together, matching the separate marks exactly.</a> While holding both stages securely together with the left hand, place plaster of Paris bandage about the juncture and wrap all the way to the top of cast. </li> <li> The negative wrap should display all landmarks clearly (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg">Fig. 21</a>). Check for correct flexion angle. Negative cast can now be filled. <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg">Figure 21. The negative wrap should display all landmarks clearly</a></li> </ol> During the cast-taking procedure, I make it a point to involve the patient by explaining each and every step. I use proper nomenclature and anatomical description of the remaining extremity. We should remember that each patient has gone through a very traumatic, cosmetically and functionally destructive surgical procedure. His or her spirits need to be lifted and encouraged. Most patients appreciate an intimate involvement in their prosthetic rehabilitation. Some of them even retain the knowledge gained during their cast and fitting procedures and answer subsequent questions on a sophisticated level. Treatment of your patient as a human being, rather than as a number among many makes being in this profession such an outstanding experience. <h3>Conclusion</h3> The importance of a good cast-taking technique has been stressed. Ideally, the positive mold should be modified by the cast-taker. In the absence of such a luxury, the cast modifier, with the aid of the measurements and the recording of special considerations, should be able to readily understand the characteristics that have been built into the cast. Proper cast modification will contribute immeasurably to good socket fit and superior function and performance by the amputee. Where the above guidelines have not been followed, an inferior socket fit will result. In such a case, the cast-taking procedure should be repeated and a new socket should be fabricated. Successfully fitting 10 to 20 patients in a row does not make any of us an infallible super-prosthetist. Every once in a while we all have to admit defeat due to oversight of basic principles or failure to adhere to prescribed guidelines and procedures. These infrequent failures will keep us on our toes and make us humble again. But, admitting defeat or failure and correcting it without a moment's hesitation, will make you, in the eyes of your peers, in the eyes of your physician, but foremost, in the eyes of your patient, the better practitioner. References: <ol> <li>Marschael, K. and Nitschke, R., "Principles of the Patellar Tendon Supracondylar Prostheses," Orthopedic Appliance Journal, Vol. 21, No. 1, March, 1967, pp. 33-38.</li> <li>Fillauer, C., "Supracondylar Wedge Suspension of the PTB Prostheses," Orthotics and Prosthetics, Vol. 22, No. 2, June, 1968, pp. 39-44.</li> <li>Fillauer, C., "A Patellar-Tendon-Bearing Socket with a Detachable Medial Brim," Orthotics and Prosthetics, Vol. 25, No. 4, December, 1971, pp. 26-34.</li> </ol> <div style="width: 400px;">*Kurt Marschall, CP Kurt Marschall, CPO is President of Empire Orthopedic Laboratories, a division of Rochester Orthopedic Laboratories, Inc., 249 East Adams Street, Syracuse, New York 13202. </div> Page Number(s) 30 - 34 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg Figure 19 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg Figure 20 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg Figure 21 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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Title A name given to the resource Two-Stage Cast-taking Procedure for PTS Prosthesis Creator An entity primarily responsible for making the resource Kurt Marschall, CP * https://staging.drfop.org/files/original/ab7543cd7a89fbb0411d1f34a0263db8.pdf c5354e4247d698b974287ba4eb8c3224 https://staging.drfop.org/files/original/9425bc5ffbf07ebf9c14b731a150ced2.jpg 35a7c0b562014d4fb50dec04e1a2648b https://staging.drfop.org/files/original/9f1ee7129f74d4da85370f348fdb1836.jpg ff2b1aea5b56e7f14acf06a7b8d20da9 https://staging.drfop.org/files/original/4d370fefd91e735d6fb3ee03340951f3.jpg 9f95d03a610ddbb83b1ad23e3450dfd0 https://staging.drfop.org/files/original/963256fd362491bd682b123274398c06.jpg 6418500d7da7c502d4faec1731934241 https://staging.drfop.org/files/original/011d4c628e420168bd0745099f67527b.jpg f292217f59299efecabdeccec457d0ab https://staging.drfop.org/files/original/0d2ed862497f922a0790d0b16cef7986.jpg 2ab9a719c52fc5660d4b56961d2e5209 https://staging.drfop.org/files/original/354d1f58233229ce31c57886ff84b30f.jpg b44e5eff696f208e7c962ed258e16579 https://staging.drfop.org/files/original/cb80d5a12a017e33e08e597ffb4c58af.jpg e1c1fb775ede1e64579fb7405aa8a5d9 https://staging.drfop.org/files/original/06bfecf29692e230dbfd93c908ce83fa.jpg b482408d3255d9e24ad276d2e4ba913a https://staging.drfop.org/files/original/0265d09264022def5d0709d4d7100463.jpg 769232d27df084123462e0300b6af339 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_01_026.pdf Text Any textual data included in the document <h2>Conventional Fitting of an Unconventional Orthosis</h2> <h5>Donald L. Fornuff, C.P. <a style="text-decoration: none;">*</a></h5> Amyoplasia Congenita (Arthrogryposis Multiplex Congenita) is a congenital abnormality of muscle development which is characterized by marked stiffness and severe deformity in many joints of the limbs—hence, the term arthrogryposis, which means "bent joints." (<a href="/files/original/9425bc5ffbf07ebf9c14b731a150ced2.jpg">Fig. 1</a> and <a href="/files/original/9f1ee7129f74d4da85370f348fdb1836.jpg">Fig. 2</a>). <a href="/files/original/4d370fefd91e735d6fb3ee03340951f3.jpg">Fig. 3</a> shows one of our recent patients, a young woman from South America with arthrogryposis, who was seeking greater range of motion with her present left exoskeletal arm orthosis, combined with easier operation and better cosmesis. Her previous orthosis consisted of a left modified laminated shoulder cap with a large cut out for both the left arm and left breast. The shoulder cap extended from the left clavicle over the shoulder to the soft tissue area between the rib cage and the crest of the ilium on the left side. Set on the superior border of the shoulder cap was a nudge control unit which was used to lock and unlock the elbow and was operated by her chin (<a href="/files/original/963256fd362491bd682b123274398c06.jpg">Fig. 4</a>). A flexion-abduction joint was used at the shoulder. The elbow joint was an outside locking type. A custom made wrist unit served to receive a terminal device. Quarter inch (1/4")—7 cm diameter adjustable rods were the connecting members from the acromion to the elbow and from the elbow to the wrist unit. Operation of the terminal device was accomplished by means of a perineal strap on the left side. A chest strap was used as a means of suspension. Some major considerations for change were: type of socket, improved harness and a more efficient cable system. <h3>Socket</h3> We felt a more comfortable, cosmetically acceptable, and efficient working, above-elbow type socket would be a large improvement over the heavy, bulky, and ill-fitting shoulder socket she was now wearing. Consequently, the patient was casted as if for an above-elbow type prosthesis, with anterior and posterior wings at the proximal end of the socket and an open end distally (<a href="/files/original/011d4c628e420168bd0745099f67527b.jpg">Fig. 5</a>). <h3>Harness</h3> Without a doubt, the two most uncomfortable and least cosmetic harnesses a woman could wear would be a perineal strap and a chest strap. This patient was unfortunately burdened with both. Our solution was to use a conventional A/E harness in conjunction with the A/E type socket with modification of the control attachment strap, which ran from the harness ring through a 1 inch hanger of the control cable, across the back and attaching to the axilla (<a href="/files/original/0d2ed862497f922a0790d0b16cef7986.jpg">Fig. 6</a>). This modification serves two purposes: (1) it prevents the harness from rising on the back, which would be uncomfortable, and (2) it promotes cable operation efficiency by maintaining the cable flow through the lower third of the scapula, where maximum excursion occurs as a result of scapular abduction (which is the motion being used for the function of this orthosis). <h3>Cable Control System</h3> A conventional A/E dual control system was used (<a href="/files/original/354d1f58233229ce31c57886ff84b30f.jpg">Fig. 7</a> and <a href="/files/original/cb80d5a12a017e33e08e597ffb4c58af.jpg">Fig. 8</a>). <h3>Elbow Lock Control</h3> Operation of the elbow lock (E-500 outside locking joints) was facilitated by slight modification of the locking mechanism. Instead of using an elbow lock strap, the cable from the elbow lock was attached proximally to a nudge control unit similar to what was used on her previous orthosis (<a href="/files/original/06bfecf29692e230dbfd93c908ce83fa.jpg">Fig. 9</a>). <h3>Forearm</h3> The forearm consisted of a threaded aluminum rod held onto the lower locking strap of an outside locking joint by means of an adjustable bracket which allows for shortening or lengthening of the forearm as necessary. At the distal end of the forearm, an adapter was placed to receive a wrist flexion unit, into which a hook was placed (<a href="/files/original/0265d09264022def5d0709d4d7100463.jpg">Fig. 10</a>). The forearm set-up was not an original idea, but was modified slightly to provide more range of motion. <h3>Summary</h3> Again, the overall idea was not an original one, but we feel the modifications which were improved upon and a good idea are worth sharing. With this device, combining both the working knowledge and components of prosthetics and orthotics, we made the life of this patient easier and more functional. We felt we met our original goals, which were to improve her range of motion, give her easier operation, improve cosmesis, and provide a more comfortable fitting orthosis. <h3>Acknowledgment</h3> Thanks to Mr. G. Robinson of Robins Aid, who had the original ideas for this orthosis. *Donald L. Fornuff, C.P. Donald L. Fornuff, CP. is with the Prosthetics and Orthotics Department at the Institute of Rehabilitation Medicine of the New York University Medical Center, 400 East 34th Street, New York, New York 10016. Page Number(s) 26 - 29 Year 1985 Volume 9 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Conventional Fitting of an Unconventional Orthosis Creator An entity primarily responsible for making the resource Donald L. Fornuff, C.P. * https://staging.drfop.org/files/original/3eac73a4c08366301177654204d8badb.pdf 6c0ab74d419d52358a0371839fc85799 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_01_023.pdf Text Any textual data included in the document <h2>Upper Limb Prosthetic Management Hybrid Design Approaches</h2> <h5>John N. Billock, C.P.O. <a style="text-decoration: none;">*</a></h5> With the advent of electric powered components and control systems in the past 20 to 25 years, there has been considerable transition in the prosthetic management and rehabilitation of individuals with traumatic and congenital upper limb deficiencies. Furthermore, it has only been within the past 5 years that electrically powered upper limb prostheses have gained clinical acceptance in the U.S. There now exists a complex variety of approaches from which the prosthetics practitioner must choose, in order to provide appropriate prosthetic restoration services. Along with the traditional variety of bowden cable control systems for actuating mechanical components, there now exists a number of myoelectric and switch control systems for use with electrically powered hands, wrists, and elbows. The introduction of these new components and control techniques has greatly increased the complexity of designing an appropriate upper limb prosthesis. As a result, some researchers and manufacturers have worked to develop total systems for the various levels of upper limb deficiencies. These systems generally are designed around a modular concept, where the batteries, electronics, electrodes, etc., are packaged as individual modules for easier handling and assembly. They also utilize a common electrical connection system, which may or may not be compatible with other components and control systems. The modular systems approach reduces the overall complexity in designing prostheses. However, it does not always provide the patient with the most appropriate prosthesis when his individual physiological and psychological needs are considered. It is in such a situation that thought must be given to the possibility of developing a hybrid prosthesis. A hybrid designed prosthesis utilizing components and control methods from various "systems" can, in many cases, enable the prosthetist to design and develop a prosthesis which is more functional and acceptable. The hybrid design approach becomes even more important when managing individuals with upper limb deficiencies above the elbow and higher. Many cases require a combination of electrically powered components that are switch and/or myoelectrically controlled and mechanical body powered bowden cable controlled components. A classical example of this situation occurs in the design of an above elbow prosthesis for an individual with a distal humeral deficiency. A limb deficiency at this level generally does not require the use of an electrically powered elbow since the individual should have sufficient range of motion at the shoulder joint and adequate muscle strength to control a mechanical elbow. A myoelectrically controlled hand introduced into the design of the prosthesis, for this level, can significantly improve it's functional capabilities and aesthetics. This particular hybrid design allows the individual to simultaneously control the elbow and hand rather than sequentially. It has been the author's experience that individuals with this particular design infrequently utilize the mechanical elbow lock to maintain the hand and forearm in a fixed locked position for functional activities. Rather, the elbow is allowed to flex freely and is held momentarily stable with cable tension. The overall control of the prosthesis is more natural since use of the elbow lock is not necessary the majority of the time. Unfortunately, many of the electric powered components and control systems are not designed for hybrid use even though they may have application. In many cases, they are not compatible and require electronic and/or mechanical changes before they can be incorporated into an appropriately designed prosthesis which best meets an individual's needs. Prosthetists of today must expand their technical expertise and knowledge in the areas of electronics and engineering to meet this challenge. With all the complexities surrounding the design and development to today's upper limb prostheses, this additional technical expertise and knowledge becomes even more essential when assessing and evaluating the particular needs of a patient. The clinical assessment and evaluation of individuals with upper limb deficiencies should involve a careful study of their psychological, as well as their psychological needs. All too often, this is an area of overall prosthetics management that receives too little attention. In the author's opinion, it is an essential foundation for successful prosthetic management and rehabilitation. The psychological aspects of an upper limb amputation and its resulting disabilities are too often considered secondarily when determining what will be the most appropriate prosthesis for an individual patient. As professionals, we tend to stress function over aesthetics, when in fact, a primary concern of the majority of patients is the appearance of the prosthesis. These psychological aspects are the greatest barriers an individual patient must overcome if successful prosthetic management and rehabilitation is to be achieved. Their personal acceptance of their disability and motivation to return to society is essential for successful rehabilitation. Their reaction to the prosthesis plays a major role in this acceptance and motivation. The reaction of their immediate family and friends also plays an important role in their acceptance of the prosthesis. Many patients have rejected a prosthesis not because of their own personal feelings, but because of the reaction of others. This is most apparent in the management of children with congenital upper limb deficiencies, since in most situations when the child is under the age of 5, you are managing the parent's desires and not the child's. If the parents have difficulty accepting the child's disability or the prosthesis, they will not encourage normal development and use of the prosthesis. Unfortunately, because many profesisonals are not responding to the psychological needs of the parents, many children are going with a prosthesis today. With adequate information gathered in the initial prosthetic evaluation, further clinical assessment and evaluation procedures should be carried out to determine the most appropriate interface design, control source, and components to be used in the fabrication of the prosthesis. These procedures initially involve the development of a test interface (check socket) for determining the best fitting and suspension techniques to be utilized in the prosthesis. A variety of interface designs and suspension techniques exists for both adults and juveniles at all levels of upper limb deficiencies. All require the development of an appropriate test interface. The development of a test interface is also necessary for use in establishing definitive E.M.G. potential sites when myoelectric control is being considered. When the E.M.G. potential are not adequate or when the patient requires further E.M.G. training, the test interface becomes essential for maintaining consistent placement of the electrodes relative to muscle stress. Further, the test interface allows the practitioner to evaluate a variety of optional control sources and components by developing a test prosthesis around it. This allows pre-prosthetic training and evaluation of the prosthesis in a variety of configurations before the development of a definitive prosthesis. The use of a test prosthesis is essential in evaluating "hybrid" and "system" design approaches for the definitive prosthesis. Myoelectric control systems vary considerably depending on the desired function and availability of adequate muscle sites. In some cases, it is necessary to utilize more than one type of myoelectric control system to achieve the desired functions in a prosthesis. Some systems utilize a single E.M.G. potential from a single site to control a single function, such as in the traditional Otto Bock or Veterans Administration/Northwestern University (VANU) myoelectric control systems. This type of control system would, therefore, require two E.M.G. potential sites to control two functions, such as, hand opening and hand closing. It is suggested that this type of system should commonly be referred to as a "2-site/2-function myoelecric control system." Another system may utilize a single E.M.G. potential from a single site to control two functions, such as in the University of New Brunswick system. This system utilizes one E.M.G. potential site to control two functions. In this type of system a light or low level contraction produces one function and a strong or high level contraction produces another function. It is suggested that this type of system be referred to as a "l-site/ 2-function myoelectric control system." Yet another system may utilize two E.M.G. potentials from two sites to control multiple functions, such as in the Utah Artificial Arm elbow-hand system. This system utilizes two E.M.G. potential sites to control five functions. In this system a single E.M.G. potential from each site (biceps and triceps) controls one function in each electric powered component (hand and elbow), while a co-contraction of both muscles together unlocks the elbow, switching from hand control mode to elbow control mode. It is suggested that this myoelectric control technique be referred to as a "2-site/5-function myoelectric control system." Switch control systems also vary depending upon the desired function and availability of body motions to actuate them. In many cases, in order to provide the desired functions in a switch controlled prosthesis, various types of switch control systems must be incorporated, achieving a hybrid design approach. The most commonly used switch control systems utilize a pull type switch which is actuated by a single body motion to actuate two functions, such as hand opening and hand closing. It is suggested that this switch control technique be referred to as a "1-motion/2-function pull switch control system." Another type of system utilizes a push button type switch, to operate the opposing function. It is suggested that this switch control technique be referred to as a " 1 -motion/1-function push button switch control system." Yet another type of system utilizes a rocker type switch which is actuated by two body motions to actuate two functions in the prosthesis, which in most cases oppose each other. It is suggested that this control technique be referred to as a "2-motion/2-function rocker switch control system." When body motion is being used to actuate a bowden cable control system in a hybrid manner along with switch and/or myoelectric control, it should always be remembered to activate the mechanical component with the primary body motion available. The theory behind this approach is that a bowden cable control system requires significant muscle activity and body motion to produce the force and excursion necessary to actuate a mechanical component. Myoelectric and switch control systems require less muscle activity to produce the force and excursion necessary for actuation of an electric component. The choice of controls utilized in the design and development of an upper limb prosthesis should involve a careful study of an individual's particular needs. Since the terminal device is the most important component of the prosthesis, it is necessary to choose a control technique which will provide the most appropriate actuation of that device. It is felt that myoelectric control provides the most physiological and natural source of control and that whenever possible, it should be given primary consideration. Furthermore, the majority of individuals with upper limb deficiencies generally prefer a hand as a terminal device. In many cases, this desire may be purely psychological, and as professionals we should respect that need. The majority of individuals with upper limb deficiencies are unilateral with the prosthesis obviously becoming the nondominant side. Therefore, it is important that the prosthesis first meet the individual's psychological needs, and secondarily, that it be easily controlled and provide adequate prehension for stabilizing objects, which is the primary function of the non-dominant side during bilateral hand activities. This would obviously seem to indicate that myoelectric control, which best utilizes the residual neuro-muscular system, and an electric powered hand, which provides forceful prehension, should be the first choices in developing a functional prosthesis. Electric powered components have been felt by many not to be sufficiently reliable and durable. This, however, has not proven to be the case when they are appropriately incorporated into a prosthesis and the patient is properly orientated to their care and use. There are those individuals and situations who are abusive to an electric powered prosthesis as well as a mechanical prosthesis. However, they are not the majority and require appropriate consideration prior to design and development of a prosthesis. Hybrid design concepts can also be utilized to enhance the reliability and durability of a prosthesis by allowing the encapsulation of components within the prosthesis that would otherwise be external. This is a concept known as self-containment. Hybrid prostheses can significantly improve the functional restoration and rehabilitation of an individual with an upper limb deficiency. They are an important consideration in the prosthetic management of such individuals and can be the difference between total rejection or functional use of a prosthesis. Unfortunately, upper limb prostheses of this type will most likely continue to be provided in specialized centers and not find their place in common practice unless developers and manufacturers work towards making their components more compatible and interchangeable with those of other systems. *John N. Billock, C.P.O. John N. Billock, C.P.O. is with the Orthotic and Prosthetic Centre of Warren, 145 Shaffer Drive, N.E., Warren, Ohio 44484. Page Number(s) 23 - 25 Year 1985 Volume 9 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 Upper Limb Prosthetic Management Hybrid Design Approaches Creator An entity primarily responsible for making the resource John N. Billock, C.P.O. * https://staging.drfop.org/files/original/aafea6cea49faeadc6dba48217d2ee06.pdf 1144c6f189f7e6d76ebed402cfb5d44c 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_01_017.pdf Text Any textual data included in the document <h2>Externally Powered Prostheses for Children: 1984</h2> <h5>Charles H. Epps, Jr., M.D. <a style="text-decoration: none;">*</a></h5> Not so many years ago children with upper limb deficiencies who appeared in our clinic with body powered prostheses asked for an arm like the one used by the six million dollar man. The television character routinely performed miraculous feats of strength and prehension that made the body powered prostheses look primitive by comparison. I was unable to satisfy such requests at that time. Now, at least for some patients, the long sought externally powered fitting is possible. The available arms do not approach that of the six million dollar man, but we have the means of fitting the below-elbow patient with a myoelectric prosthesis that is gratifying to patient and parents. In our own setting, two factors have converged to make this possible. First, the most important development in our clinic has been the affiliation of the local Variety Club, which established a Limb Bank. The concept is simple, the Variety Tent raises funds for myoelectric limbs, component parts and services. In some cases, the cost of the entire prosthesis is underwritten; in other situations Variety pays the balance not covered by insurance depending upon family finances. There are also components and spare parts available for repairs, courtesy of Variety. Such components keep the down time to a minimum and eliminate the need for two myoelectric prostheses. This arrangement developed between the Juvenile Amputee Clinic (Maternal and Child Health and Crippled Children's Services) at D.C. General Hospital and Washington, D.C.'s Variety Tent Number 11 is an example of how a public-private relationship can benefit the patient. Variety Tents are operational in Grand Rapids, Michigan; Memphis, Tennessee; Detroit, Michigan; Los Angeles, California; Toronto, Canada and other cities. Secondly, the technology has been available for a number of years, but we delayed because of the cost of myoelectric fittings and because the policies of many insurance carriers did not include such devices. It seemed undesirable to fit a child if one could not reasonably expect to continue with subsequent fittings and provide timely repairs. Sörbye in 1971 was among the first to apply myoelectrics to the young preschool amputee. His group operating in the government support health system in Sweden overcame these same problems by providing each patient with two prostheses. The second remained on the shelf as a back-up limb when the first needed repairs. In this manner, down time was eliminated and the child was not without the prosthesis. In the United States there has been a recent change in the policies of many third-party insurance carriers. Today, most will provide funds not only for the initial prosthesis but for replacements and necessary repairs, a not inconsequential cost. Some insurance companies pay total cost while others pay a fixed percentage. <h3>External Power</h3> Over the years, a number of battery powered switch operated devices have become available. The Michigan Feeding Arm was specifically designed to assistance in eating activities and was the first externally powered device developed in the United States for the pediatric age patient. In the early 1970's the Ontario Crippled Children's Center developed the OCCC Coordinated Arm. This was followed by the OCCC Elbow. Both were operated by switches and were designed for the 4-10 year age group. The Michigan Electric Hook (10x size) appeared in 1973 and was appropriate for the child approximately 2-10 years. Its successor, the Michigan Area Child Amputee Clinic Hook (MACAC) (10x size) was an improved version of the earlier hook designed for the same age group. In 1977 we saw the advent of a second elbow, the NYU Motor Lock Elbow, sized for a child six to a small teenager. This item remains experimental. To overcome the objectionable operational noise of the previous powered elbows, the NYU "Hush" Electric Elbow was developed in 1982. A versatile unit, it can be operated by push button or harness pull. Complimenting this armamentarium is the switch operated NYU Prehension Actuator (1982) which is applicable to any cable voluntary opening terminal device. More recently, the Utah Elbow was developed for the adult population but may be used with a child about age 12 years; it can be used with any terminal device and utilizes a dual site myoelectric system. <h3>Myoelectric</h3> The available myoelectric devices also offer a spectrum of choices. There is the University of New Brunswick System which is appropriate for ages 12 and up. This unit uses a surface electrode over one muscle. A small contraction is for closing and a strong contraction for opening. Relaxation of muscle contraction stops the hand at the current position. Sweden contributed the Systemteknik hand in two sizes; 2-6 years for the small child and 5-9 years for the larger child. The unit utilizes a single or double myoelectric electrode. The Steeper hand produced in England has the same size and age indication and similar choice of myoelectric controls. The German contribution is the Otto Bock System covering ages nine to adult with a dual myoelectric site system. These units are expensive but commercially available. The absence of a myoelectric unit developed in the United States is conspicuous. This array of devices presents a challenge to the physician prescribing external power for his patient. There are wide differences in the weight which may be crucial in the young patient with a short stump. However, all are heavy when compared to the body powered prostheses. The battery systems vary from 5 volt to 12 volt with varying useful life after charging. The prescription, therefore, is best written as a collaborative effort by the physician, the prosthetist, and the occupational therapist who has evaluated the patient and will provide the training. <h3>Patient Benefit</h3> After witnessing the satisfaction of the patient and parents after a successful fitting has been accomplished, there is no doubt that external power is preferred over body power in most instances. Function seems more natural when hand opening and closing are controlled by forearm extensor and flexor muscle activity. It is obvious that the psychological benefit of the cosmetic effect is profound on patient and parents alike. The dramatic change can be seen even with the initial application of the arm. External power and myoelectric applications are now state-of-the-art in below elbow cases and should be made available to all who have the interest and proper indications. <h3>The Challenge</h3> There is still much to be done for the amelia and the high above elbow amputee. Efforts must continue to bring the maximum degree of function to patients who are less well served at present. The numbers of patients in this category are small and there are not the normal incentives to manufacturers to expend funds for research and development in this area. The Federal Government may have to support the requisite research to accomplish the necessary break-through. It is ironic that the below elbow patient who enjoys reasonably good function with conventional prostheses would benefit most from the new technology. This is explicable when we realize that this level of limb deficiency makes the task easier. Although the numbers of high level deficiency patients by contrast is small, the need is great. We must continue to work for solutions for these patients who remain underserved at this time. *Charles H. Epps, Jr., M.D. Charles H. Epp, Jr., M.D. is Professor and Chief at the Division of Orthopedic Surgery at Howard University Hospital, 2041 Georgia Avenue, N.W., Washington, D.C. 20060. Page Number(s) 17 - 18 Year 1985 Volume 9 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 Externally Powered Prostheses for Children: 1984 Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/694c8659897265452c14e9ca3192624d.pdf 58cc45863e2c275da7497de4ff593ec2 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_01_013.pdf Text Any textual data included in the document <h2>Innovation and Improivement of Body-Powered Arm Prostheses: A First Step</h2> <h5>Maurice A. LeBlanc, M.S.M.E., CP. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Standard body-powered upper-limb prostheses have not changed significantly since developments in the 1950's which were spurred by World War II. They still employ aircraft technology using shoulder harnesses and steel cables for operation. If one looks at the Manual of Upper Extremity Prosthetics first edition (1952)<a></a> and the Orthopaedic Appliance Atlas—Artificial Limbs first edition (1960)<a></a> compared with 1985 state of the art, one will not find a great deal of change. It is the consensus of several leading prosthetists in the U.S. that many arm amputees are being led into purchasing externally powered arm prostheses because they look more modern and "hi-tech." Present body-powered arm prostheses simply do not offer a good alternative. They look more archaic, and the shoulder harnesses are uncomfortable and restrictive. Body-powered systems have more sensory feedback and generally are more functional (for unilaterals) than externally powered systems.<a></a> However, little or no research is being conducted to improve body-powered arms. More and more amputees are opting for externally powered prostheses,<a></a> and the gap is getting larger between the two types. Estimates of population in the U.S. place the number of upper-limb amputees at about 100,000.<a></a> Of the 50,000 arm amputees estimated to be wearing prostheses, surveys of prosthetic facilities suggest the following levels of amputation: 58% below-elbow, 27% above-elbow, and 15% at the hand/wrist and shoulder.<a></a> Of prostheses being worn, educated guesses suggest that the percentage of externally powered prostheses has increased from five to 10% in the past five years.<a></a> It is the desire of the author to undertake work to effect innovation in body-powered arm prostheses toward the ultimate goal of increasing the acceptance and use of "conventional" upper-limb prostheses for arm amputees in the U.S. Other people have stated this need.<a></a> The author has received support to conduct a one-year study of feasibility for accomplishing the above goal. As a first step, the author has conducted a survey to verify needs and priorities of arm amputees in order to give guidelines for future work. <h3>Conduct Of Survey</h3> Arm amputees and professionals were contacted to assess what wearers like most and like least about their prostheses. Also, ideas for change were solicited. A questionnaire was prepared to provide a standard format, and 30 people were contacted in person or by phone to complete the questionnaire. The people were: <blockquote> 17 amputees 8 prosthetists 3 occupational therapists 2 VA prosthetic reps (also arm amputees) 30 total </blockquote> Of the 17 arm amputees, there were: <blockquote>10 adults and 7 children 13 males and 4 females 14 unilaterals and 3 bilaterals</blockquote> <h3>Results Of Survey</h3> The survey included 11 questions. Results are reported below with the numbers of responses shown. (Some totals exceed 30 because respondents gave two or three answers per question.) <ol> <li> What do you like most about your prosthesis? Most frequent answers: <ul> <li> Function: 17 </li> <li> Reliability: 9 </li> <li> Symmetry/body image: 6 </li> </ul> </li> <li> What do you like least about your prosthesis? Most frequent answers: <ul> <li> Axilla/harness uncomfortable: 10 </li> <li> Appearance poor: 9 </li> <li> Socket hot: 5 </li> </ul> </li> <li> <ol> <li> Is the harness/cable control system satisfactory? 13—Yes, 16—No </li> <li> Does this type of control system need improvement? 25—Yes, 4—No </li> </ol> </li> <li> <ol> <li> Are the harness and socket comfortable? 12—Yes, 17—No </li> <li> Does the general comfort need improvement? 25—Yes, 4—No </li> </ol> </li> <li> <ol> <li> Do the motions and terminal device give you enough function? 11—Yes, 18—No </li> <li> Does the function of the prosthesis need improvement? 29—Yes, 0—No </li> </ol> </li> <li> <ol> <li> Are you pleased with the appearance? 11—Yes, 19—No </li> <li> Does the general appearance need improvement? 25—Yes, 5—No </li> </ol> </li> <li> Rate the following four aspects of your prosthesis in importance to you (1 = most important and 4 = least important) <blockquote> Average Scores: Function: 1.53 Comfort: 1.85 Appearance: 2.79 Control system: 3.53 </blockquote> </li> <li> Any other general complaints of this type of prosthesis?—Text answers to these questions were combined with text answers to questions 3-6 and will be discussed later. </li> <li> Any other ideas for improvement you would like to see worked on?—Text answers to these questions were combined with text answers to questions 3-6 and will be discussed later. </li> <li> If you could dream and create your own perfect prosthesis, what would it look like? Most frequent answers: <blockquote> Natural/normal: 12 Soft/smooth endoskeletal: 11 More function in fingers and wrist: 9 </blockquote> </li> <li> Do you want your prosthesis to look as normal as possible or would you prefer to have some fun with the appearance in colors and designs? Most frequent answers: <blockquote> Want it to look normal: 21 Want to have some fun with it: 4 </blockquote> </li> </ol> <h3>Miscellaneous Considerations</h3> In talking with each of the 30 people surveyed, a number of interesting comments were made which deserve consideration. <ul> <li> The prosthesis is not a second best arm but something different to itself and should have form and beauty for its own sake. </li> <li> While most people stated the goal of having a prosthesis which looks natural, they asked for one which is smooth, inconspicuous, natural in motion, fast, quiet, and streamline rather than asking for a prosthesis which looks human. </li> <li> Several people visualized having an arm transplant or regeneration. </li> <li> A couple of people talked about "functional appearance" or having a prosthesis which is dynamically alive and not dead looking. </li> <li> Many people expressed a desire for a prosthesis which is soft inside, adjusts to the body, feels like part of the body, and feels flexible. </li> <li> Cleanliness is a big issue with a harness, sockets, and prosthesis exterior. Some expressed the desire for throw-away parts and coverings. Also, it is difficult for bilaterals to clean their prostheses when doffed. </li> <li> Bilateral amputees stressed the importance of using their feet as well as the prostheses. There is more dexterity and sensory feedback for function and a preference for using feet except where social situations dictate using the prostheses. </li> <li> Several amputees stressed the importance of the sensory feedback/proprioception inherent in body-powered arm prosthesis. A few voiced the opinion that increased sensory feedback would provide increased function even with present components. </li> <li> A few parents confirmed the desire for very early fitting of infants for various reasons: body image, balance, symmetry, acceptance and function. One parent felt strongly that an infant should have an arm prosthesis because "the brain is looking for a hand" and it affects the growth/development of the child. </li> <li> While the author was conducting interviews with amputees, many of them asked the author for current information about arm prostheses and components. It was clear that some prosthetists are not fully informing amputees of their options and including them in the decision-making process. </li> <li> A few prominent professionals stated very strongly the importance of the prosthetist conducting a very thorough evaluation with the amputee prior to any prosthetic prescription and fitting. It provides the opportunity for the prosthetist to use his/her ingenuity to truly meet the needs of the amputee. </li> <li> Clinic teams sometimes make decisions on prosthetic fitting in five minutes, which is insufficient time to conduct a thorough evaluation. </li> <li> Central fabrication also can be a detriment to successful prosthetic fitting because standard components are applied by a third party without direct amputee contact, thereby reducing the incentive and likelihood for creative and individual solutions to amputees' needs. </li> <li> Education of prosthetists focuses mainly on the mechanics of fabricating prostheses with available components rather than looking comprehensively at the amputee as an individual with special needs. They "follow the book" too much and are "too rigid in prescribing." </li> <li> The success of upper-limb prostheses depends heavily on the skills of the prosthetist. It is too dependent on individuals. It would be beneficial if systems were more modular whereby they would be easier to fit, and performance could be predicted better. </li> <li> Two trends which seem to be gathering professional concurrence are (1) to fit an arm amputee within the "Golden Period" of 30 days after amputation and (2) to fit all arm amputees with a conventional, body-powered prosthesis first.<a></a> </li> </ul> <h3>Conclusions</h3> Function is clearly the most important feature which amputees want and expect from upper-limb prostheses. While the results may be biased because the survey was of body-powered wearers versus myoelectric wearers with hands, the numbers and opinions overwhelmingly emphasize function first. Uncomfortable harness and poor appearance were a close first and second for the most negative feature of arm prostheses. Body-powered arm prostheses need improvement across the board. When making changes, the upper-limb prosthesis should be viewed as a whole system rather than just looking at components. Amputees want a natural moving, pleasant appearing, inconspicuous prosthesis which does not necessarily have to look human. The questionnaire demonstrated a good cross check in validating what amputees and professionals said with how they rated the various aspects of upper-limb prostheses. There has been a great deal of encouragement from amputees and professionals to work on the improvement of body-powered systems. All are anxious to see some innovation and positive change. <h3>Acknowledgment</h3> This work is being supported by Research Fellowship #133FH40021 from the National Institute of Handicapped Research, US Department of Education. References: <ol> <li><a href="poi/1981_02_092.asp">Agnew, P.J., "Functional Effectiveness of a Myoelectric Prosthesis Compared with a Functional Split-Hook Prosthesis: A Single Subject Experiment," Prosthetics Orthotics International, Vol. 5, No. 2, August 1981.</a></li> <li>Aylesworth, R. Deane, Editor, Manual of Upper Extremity Prosthetics, Artificial Limbs Project, University of California at Los Angeles, 1952.</li> <li>Childress, Dudley S., Ph.D., Director, Rehabilitation Engineering Center, Northwestern University, Chicago, Illinois, personal communication, April 1984.</li> <li>Cottenden, A.M.; B. Stocking; N.B. Jones; S.L. Morrison and R. Rothwell, "Biomedical Engineering-Priorities for Research in External Aids," Journal of Biomedical Engineering, Vol. 3, October 1981.</li> <li>Epps, Charles H., Jr., M.D., "Prosthetic-Orthotic Research-A New Thrust Is Needed: A Clinician's Perspective," Clinical Prosthetics and Orthotics, Vol. 8, No. 1, Winter, 1984.</li> <li>LeBlanc, Maurice A., M.S., CP, Patient Population and Other Estimates of Prosthetics and Orthotics in the USA," Orthotics and Prosthetics, Vol. 27, No. 3, September, 1973.</li> <li>Malone, J.M., M.D.; L.L. Fleming, M.D.; J. Rober-son, M.D.; T.E. Whitesides, Jr., M.D.; J.M. Leal, CP; J.V. Poole, O.T.R. and R. Sternstein Grodin, O.T.R., "Immediate, Early, and Late Postsurgical Management of Upper-Limb Amputation," Journal of Rehabilitation Research and Development, Veterans Administration, May, 1984.</li> <li>National Center for Health Statistics, US Department of Health and Human Services, "Prevalence of Selected Impairments-United States-1977," Series 10, No. 134, February, 1981.</li> <li>Orthopaedic Appliance Atlas-Volume 2-Artificial Limbs, American Academy of Orthopaedic Surgeons, J.W. Edwards-Publisher, 1960.</li> <li>Stein, R.B. and M. Walley, "Functional Comparison of Upper Extremity Amputees Using Myoelectric and Conventional Prostheses," Archives of Physical Medicine, Vol. 64, No. 6, June, 1983.</li> <li><a href="http://www.acpoc.org/library/1983_04_009.asp">Trost, Francis J., M.D., "A Comparison of Conventional and Myoelectric Below-Elbow Prosthetic Use," Inter-Clinic Information Bulletin, Vol. 18, No. 4, Fall, 1983.</a></li> <li>Veterans Administration, Rehabilitation Research and Development Service, National Workshop on Prosthetics and Orthotics, Washington, D.C, April 27-28, 1983.</li> </ol> <div style="width: 400px;">*Maurice A. LeBlanc, M.S.M.E., CP. Maurice A. LeBlanc, M.S.M.E., CP. is with the Rehabilitation Engineering Center at Children's Hospital at Stanford, Palo Alto, California 94304. </div> Page Number(s) 13 - 16 Year 1985 Volume 9 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 Innovation and Improvement of Body-Powered Arm Prostheses: A First Step Creator An entity primarily responsible for making the resource Maurice A. LeBlanc, M.S.M.E., CP. * https://staging.drfop.org/files/original/d634f72b53fee3270263d6b02eee78a9.pdf 081468a627be053883d0d2c0f57e0d81 https://staging.drfop.org/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg c6870a13ba528d9a08b712870f181aef https://staging.drfop.org/files/original/021188ebcef7da90fd31f98828fa6492.jpg 219db07046fc7f9d39d4657d7c82b990 https://staging.drfop.org/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg 3883d5d385c53d064fdf6a5ccd89ca18 https://staging.drfop.org/files/original/603316446d9d314a4586a444cf9f0a22.jpg 4ba8c8779644110430c42c63360db0e7 https://staging.drfop.org/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg bd974c771438f676134eb68427186558 https://staging.drfop.org/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg 2f4c92856ae0e6562aebe32d5d1bf29c https://staging.drfop.org/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg a5d2d0752fc526c58c0bc3a2c08f9417 https://staging.drfop.org/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg 07a87e00f96d255cf1334360f01727ca https://staging.drfop.org/files/original/a8cce387b55b45e6a667c49df89ae308.jpg 5bb5287ac69b8ef9966416fdcca3aab3 https://staging.drfop.org/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg 69f9c2b5942f12823da5914a0873a1b3 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_01_002.pdf Text Any textual data included in the document <h2>Historical Aspects of Powered Limb Prostheses</h2> <h5>Dudley S. Childress, Ph.D. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> People involved in work on powered limb prostheses may wonder if the history of this field is important. My answer is that one can learn a lot from history. Nevertheless, Hegel has said, "What history teaches us is that men never learned anything from it." Unfortunately, it sometimes does seem true in prosthetics that we have not always profited from past experiences. Too many aspects of the work are never published, and the multidisciplinary nature of the field produces papers in a broad spectrum of journals that are difficult to track. Books on the field are, unfortunately, not numerous. The brief history that follows is by no means complete, and since some of it involves years that are within readers' memories, I apologize in advance for omissions that anyone may consider significant. The history is intended to entice readers to look more deeply into historical issues. It is also intended to give some perspective on the field and to dispel notions that powered prostheses are only recent developments of "bionic man" research. Wilson<a></a> has written a brief history on external power of limb prostheses and the handbook by Spaeth<a></a> contains an introductory chapter on this subject. Brief surveys are included in papers (e.g. Childress<a></a> or Bottomley et al.<a></a>) Powered limbs have existed for some seventy years. This roughly corresponds with the history of powered hand tools and other powered technical devices used so widely in modern society (e.g. airplanes, automobiles, etc.). This is not surprising since technology in most fields tends to mirror the state of technology generally. The history of powered limbs is also comparable in length with the history of an identifiable field known as "limb prosthetics." I have chosen to consider the history of powered prostheses from a hardware viewpoint and from the viewpoint of important meetings and events. Control approaches, another viewpoint, are considered but not emphasized. Also, the perspective is from America. <h3>Prologue (1915-1945)</h3> The first powered prosthesis, of which I am aware, was a pneumatic hand patented in Germany in 1915.<a></a> A drawing of an early pneumatic hand is shown in <a href="/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg">Fig. 1</a>. <a href="/files/original/021188ebcef7da90fd31f98828fa6492.jpg">Fig. 2</a> shows a drawing of what I believe to be the first electric powered hand. These drawings were published in 1919 in Ersatzglieder und Arbeitshilfen (Substitute Limbs and Work Aids).<a></a> This German publication illustrates the importance of history in prosthetics, containing ideas that are still being discovered today. Although the book Treatise on Artificial Limbs by A.A. Marks, published in 1901, does not contain anything about powered limbs, it too illustrates the importance of history in the field because many ideas put forward in it are also quite modern. <a href="/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg">Figure 1</a>. Early compressed-gas powered hand (Perhaps the first powered prosthesis component). From Ersatzglieder under Arbeitshilfen (Limb Substitutes and Work Aids) 1919. <a href="/files/original/021188ebcef7da90fd31f98828fa6492.jpg">Figure 2.</a> Early electric hand component (Perhaps the first electric hand mechanism). From Ersatzglieder und Arbeitshilfen (Limb Substitutes and Work Aids) 1919. Powered limbs were probably not used to any significant extent between the World Wars, but CO2 powered limbs were used by Weil as early as 1948.<a></a> Development work continued at Heidelberg during the 1950's under Marquardt,<a></a> and the Otto Bock Company became involved with the work about 1962. Laboratories at Munster and Hannover were also involved in this early work that led to clinical applications of gas powered prostheses. Part of Germany's prominent position in the prosthetics field can be traced to their early commitment to development work in the entire field of prosthetics. Kiessling<a></a> was the major U.S. investigator involved with CO2 powered limbs. Of course, the McKibben muscle<a></a> was developed in the U.S., but has been used mainly in orthotics. The first, as far as we know, myoelectric prosthesis was developed during the early 40's by Reinhold Reiter, a physicist working with the Bavarian Red Cross. He published his work in 1948<a></a> but it was not widely known and myoelectric control was destined to be "rediscovered" in England, in the Soviet Union, and perhaps other places during the 1950's. Economic conditions in Germany after World War II prevented the work on myoelectric control from being continued there. <a href="/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg">Fig. 3</a> shows a picture of the first myoelectric hand prosthesis which was probably used around 1943. The system was controlled by a vacuum tube amplifier and was not portable. The hand was a modified Hüfner Hand that continued a control electro-magnet. The system was heavy, large, and not battery operated; the idea was to use it as a special prosthesis at a work station. Reiter hoped that further development could make it portable. <a href="/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg">Figure 3.</a> Electric powered hand used by Reiter in development of first myoelectric prosthesis (Circa 1943). It consists of a Hüfner Hand in which a control magnet has been built. From Grenzgebiete der Medizin (Frontiers of Medicine) 1948. It is an interesting coincidence that the results of the first experiments with myoelectric control were published in 1948, the same year in which the development of the transistor was announced. Practical myoelectrically controlled prostheses required the transistor and its subsequent refinements. Although Reiter conceived and developed the idea of myoelectric control in the early 1940's, others had the same idea later and apparently independently. The late Professor Norbert Weiner of Massachusetts Institute of Technology is reported to have suggested the concept around 1947. Berger & Huppert<a></a> presented the idea in 1952. Battye, Nightingale, and Whillis<a></a> at Guy's Hospital in London developed a myoelectric control system for a powered prosthesis in 1955 in what was for many years thought to be the first demonstration of this principle. That they were not first in no way detracts from their accomplishment. Soviet scientists were apparently the first to use transistors in a myoelectrically controlled prosthesis. The so-called Russian Hand<a></a> was the first semi-practical myo-electrical limb to be used clinically and was sold (although not widely used) on a license basis for application in Great Britain and in Canada. <h3>The Early Years (1945-1967)</h3> As far as the United States is concerned, the year 1945 was a turning point in prosthetics. In January 1945, military personnel, surgeons, prosthetists, and engineers met in Chicago (Thorne Hall, Northwestern University) to consider what should be done about limb prosthetics. This meeting is recognized as the beginning of the prosthetics research and development program by the U.S. government. This program ultimately resulted in the establishment of the Committee on Prosthetics Research and Development (CPRD) of the National Research Council which guided work in the field for over twenty-five years. The post-war years saw tremendous advances in limb prosthetics in general, although powered prosthesis development was slow. During the period 1946-1952, Alder-son, with the support of IBM and the Veterans Administration, developed several electric-powered limbs.<a></a> These IBM arms were impressive engineering achievements for the time, but they were somewhat difficult for amputees to use. The Vaduz hand, developed during the early post-war period, appears to have been a prosthesis ahead of its time and one that contained antecedents of today's electric hands. A German team headed by Dr. Edmund Wilms settled in Vaduz, Lichtenstein after World War II to continue their prosthetic hand development work. They wanted to create a hand controlled by the muscles of prehension, which would operate on a portable power source. The hand they created is shown in <a href="/files/original/603316446d9d314a4586a444cf9f0a22.jpg">Fig. 4</a>. It has been described by Wilms.<a></a> This hand had a gear shifting mechanism to enable it to obtain high gripping force from an electric motor while also having reasonable finger velocity. This is a principle used in current Otto Bock hands. The hand used a unique controller in which a pneumatic bag inside the socket detected muscle bulge through pneumatic pressure, which in turn operated a switch-activated position servomechanism to close the voluntary-closing electric hand. This principle foreshadows the concept of extended physiological proprioception (EPP) introduced by Simpson<a></a> (<a href="/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg">Fig. 5</a>). The complete system is shown in <a href="/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg">Fig. 6</a>. <a href="/files/original/603316446d9d314a4586a444cf9f0a22.jpg">Figures 4a and 4b.</a> Two views of the mechanics of the Vaduz Hand. Note position and force feedback links that connect to the inner transducer. This connects to an outer transducer (a bladder) adjacent to the residual limb in the socket. This voluntary-closing hand was activated by muscle bulge. It operated as a position servomechanism. It contained a gear shifting mechanism and a current cut-off mechanism. From Bulletin of Prosthetics Research, BPR 10-6, 1966. <a href="/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg">Figure 5.</a> Diagram of control circuit for Vaduz Hand. Muscle bulge compresses the outer transducer, which causes expansion of the inner transducer, moving the spindle upward. This activates the switches that close the hand. A link with the output moves the switch assembly along so that the hand stops when the link movement corresponds with spindle movement. Force feedback opens the closing limit switch at some force level when the hand meets an object. This conserves battery power. From Bulletin of Prosthetics Research, BPR 10-6, 1966. <a href="/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg">Figure 6.</a> View of complete Vaduz system. Note similarity of myoelectric systems. From Bulletin of Prosthetics Research, BPR 10-6, 1966. Lucaccini, Kaiser & Lyman<a></a> evaluated the Vaduz Hand. The center at the University of California at Los Angeles, under Lyman's direction, also evaluated the Alderson-IBM arm, the Heidelburg Pneumatic Prosthesis, and other externally powered systems, as well as conducting many control studies of their own. After 1953, the Vaduz Hand was marketed from Paris and consequently was sometimes called the French Hand. It apparently was difficult to keep in optimal mechanical adjustment, but it must be considered as one of the most important ancestors of today's electric hands, and a hand that contained many novel and intriguing concepts. It was available through the mid-sixties. The Russian Hand and Vaduz Hand were followed by an English Hand developed around 1965 by Bottomley.<a></a> This was the first myo-electrically controlled hand that exhibited proportional control (<a href="/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg">Fig. 7</a>). This prosthesis also contained several novel features for that period of time, such as internal force and velocity feedback and a unique myoelectric signal smoothing principle called "autogenic backlash," which produced a more or less consistent direct current (DC) output from the fluctuating myoelectric signal while not sacrificing time response. <a href="/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg">Figure 7.</a> View of myoelectric hand developed by Bottom-ley in England. Note the two external packages on the table, battery on left and electronics on right. This was the first myoelectrically controlled hand that had proportional control. From Science Journal article by R.N. Scott, March 1966. The Russian Hand (<a href="/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg">Fig. 8</a>), Vaduz Hand, and Bottomley Hand were single-function devices and non-adaptive. During the early 1960's Tomovic suggested an adaptive, multi-articulated hand with rudimentary sensory qualities. This resulted in the Belgrade Hand.<a></a> Although this hand was not used clinically to any great extent, it was used extensively in research laboratories and has had influence on robotic hand developments. In 1965, a Swedish research group began work on an electric hand which was adaptive and which had multiple functions (two types of grasp, wrist flexion-extension, and supination-pronation). This became known as the SVEN-Hand<a></a> (<a href="/files/original/a8cce387b55b45e6a667c49df89ae308.jpg">Fig. 9</a>). It also has been used extensively in research, particularly regarding multi-function control<a></a> and concepts employed in it are utilized today in Swedish developments. <a href="/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg">Figure 8.</a> Photograph of Russian Hand. This was the first myoelectric hand that was transistorized and portable (Circa 1959). The external battery pack is shown in the center of the photograph. The electronic package is beneath the battery. The battery charger is at left. Note the long electrode wires and the prosthesis suspension straps. From Science Journal article by R.N. Scott, March 1966. <a href="/files/original/a8cce387b55b45e6a667c49df89ae308.jpg">Figure 9.</a> Photograph of the SVEN-Hand. This was one of the first multifunctional, adaptive, myoelectrically controlled hand prostheses. Congenital amputations caused by the drug Thalidomide resulted in expanded interest in powered prostheses in the 1960's. Pneumatic systems by Otto Bock (hand, hooks, wrist rotators, and elbows) were fitted successfully, particularly in Germany by Marquardt,<a></a> to many children born without limbs. However, pneumatic systems never caught on well in the U.S. probably because of difficulties with the compressed gas. Cannisters of gas were expensive and difficult to maintain and distribute in the U.S. American laws also required steel cannisters, which added to weight. Pneumatic systems have low energy storage densities and this meant that multiple cannisters were required, particularly to supply the energy needs of adult prostheses. On the other hand, these systems have actuators that are light in weight, which are easily controlled, and which have natural compliance properties that keep them from being rigid. Electric power can be stored more cheaply, more safely, and with greater density than gas power. Also, the control possibilities made possible by electronic circuits have given electrical systems an advantage. Unfortunately, the actuators (electric motors and gear mechanisms) tend to be heavy and may result in prostheses that are noisy and naturally non-compliant. They also have zero efficiency when activated in the stalled condition. Some of the negative aspects of electrical actuators have been overcome electronically in today's powered prostheses. Electro-Hydraulic systems may be used in the future because they have the potential advantage of developing high torque in small actuators. However, cost factors for the special hydraulic mechanisms needed, along with technical problems, have restricted development work in this area thus far. Early work was conducted in Canada.<a></a> The Edinburgh arm has been converted to hydraulic power at a couple of centers in the U.K. Research work on multifunctional limb prostheses flourished in the United Kingdom during the 1960's and early 1970's. Most notable among the developments were the Hendon Arm<a></a> and the Edinburgh Arm.<a></a> Both were pneumatic, multi-functional limbs. Simpson used a position servomechanism control principle that he called extended physiological proprioception (EPP), a principle which enables control of multiple functions without excessive mental load on the user. This control technique has been shown to be a better information link between the body and prosthesis than "velocity" controllers.<a></a> The Edinburgh Arm, which was pneumatic, worked in spherical coordinates from the shoulder and was controlled by protraction-retraction and elevation-depression of the two shoulders. If the arm was fitted on the right side, then elevation of the right shoulder elevated the hand about the shoulder joint. Protraction of the right shoulder moved the hand more distant from the shoulder (in a radial direction). Protraction of the left shoulder moved the hand medially, and elevation of the left shoulder supinated the hand. The wrist was linked to the shoulder and elbow so as to maintain attitude of the hand during shoulder or elbow motion. This made it possible to hold a glass of water without worrying too much about spilling the contents during arm movements. Carlson<a></a> has called this kind of joint coupling, "kinematic coupling." Opening and closing the hand or terminal device of the arm was controlled by a switch through some other motion of the body. The arm was complex and difficult to keep functional on active children but the control was remarkable. Children operated its multiple functions naturally, without much training, and seemingly without too much mental load. <a href="/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg">Fig. 10</a> shows the mechanism. Less complex (and less functional) all-electric EPP-type controllers are now under study in the U.S. and Scotland. <a href="/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg">Figure 10.</a> Photograph of the mechanism of the Edinburgh Arm, developed by D.C. Simpson. This CO2-powered limb had four degrees of freedom (five if the terminal device was included) and kinematic coupling of the wrist to the elbow and the shoulder. It used spherical coordinates and was controlled by position servos that mechanically linked shoulder girdle position with prosthesis position. It is one of the most complete powered arms ever developed. Proceedings of meetings form an excellent historical record of powered prostheses. The first meeting of consequence in the U.S. concerning powered prostheses was held at Lake Arrowhead, California in 1960,<a></a> and was sponsored by the National Research Council. The second major meeting of this kind in the U.S. was held in Warrenton, Virginia in 1965<a></a> with considerable international input. Subsequently, the Committee on Prosthetics Research & Development (CPRD) held regular meetings related to applications of external power in limb prosthetics, and the reports of these meetings form a good record of U.S. activity in this field. Myoelectric control received a major boost in America through a 1966 symposium in Cleveland, Ohio (Case Western Reserve University) entitled "Myoelectric Control Systems and Electromyographic Kinesiology." Bottomley demonstrated his elegant myoelectric system at that meeting. The meeting was also attended by Professor Robert N. Scott of the University of New Brunswick. Scott headed a group that developed the first myoelectric control mechanism in North America.<a></a> A Yugoslavia-based conference, around 1963, called "External Control of Human Extremities" was followed by a similar conference in Dubrovnik, Yugoslavia and this international conference has been held there every third year since 1966. The Proceedings of the "Dubrovnik Conference," as it is often called, are a singular record of international developments in powered limb research and development since the early sixties. Three other symposia produced significant early publications. The symposium on "Basic Problems of Prehension, Movement and Control of Artificial Limbs"<a></a> organized in London in 1968 by the Institution of Mechanical Engineers contains a wealth of information on powered limbs. The "Dundee Conference" held in Dundee, Scotland in 1969 resulted in the book Prosthetic and Orthotic Practice.<a></a> It covers prosthetics generally but has a fair amount of material on powered prostheses. Finally, the Swedish conference of 1974<a></a> produced a book that concerned early research and development work on powered prostheses and orthoses. <h3>Growing Up (1967-1977)</h3> I have selected the decade of 1967-1977 as one of "growing up" because 1967 is about the time it became possible to purchase a powered prosthesis commercially in the United States, and it was approximately 1977 before powered upper-limb prostheses began to take on some real clinical significance (i.e. larger numbers of clients fitted). The Viennatone Hand was the first commercial system available in the U.S. This hand came about as a result of Otto Bock Orthopedic Industries, a German prosthetics company, and Viennatone, an Austrian hearing aid company with expertise in electronics. Shortly thereafter, Otto Bock developed their own myoelectric system and a new hand mechanism. The Viennatone and Otto Bock Hand mechanisms (both designed by Otto Bock) have been altered somewhat through the years, but their basic appearance and design principles remain essentially unchanged. In the early days of myoelectric control (e.g. 1968), the battery or battery and electronics had to be worn outside the prosthesis, usually in a chest pouch, on a clip at the waist, or on a band around the humeral section of the arm. The wires and connections required by this kind of configuration led to failures due to wire breakage. There was also electrical interference on occasion. In addition, the components outside the prosthesis were a nuisance to fit and to wear. In 1968, I was involved in fitting a college student with one of the first self-contained and self-suspended below-elbow prostheses.<a></a> The Viennatone Hand mechanism was used in conjunction with a myoelectric controller developed at Northwestern University. Self-containment and self-suspension are standard procedures for below-elbow prostheses today. The Veterans Administration Prosthetics Center (VAPC) modified the Viennatone Hand mechanism and packaged it with a modified version of the electronic system developed at Northwestern. The VAPC contracted for this system to be manufactured by Fidelity Electronics, Ltd. and this system was marketed for a period of time. An interesting electric powered hand of this period was the hand developed at the Army Medical and Biomechanical Research Laboratory.<a></a> This hand contained a "slip detector" in the thumb. The hand would grip to about 2 Lff at the finger tips. If the object to be held started to slip, the hand would automatically increase gripping force until slippage stopped. Schmidl<a></a> was actively fitting many upper-limb amputees with myoelectrically controlled, powered limbs during this period and he achieved clinical significance with powered limbs well before this happened in the U.S. His center in Italy was also involved early in fittings of multifunctional limbs. Three-state controllers are used to control electric elbow, electric wrist rotator and electric hand from three muscle electrode sites. The Italian group has been at the forefront of progress in the fitting of powered limbs. Engineers at Temple University-Moss Rehabilitation Hospital<a></a> were probably first to attempt multi-functional control of elbow, humeral rotation, and wrist using pattern recognition techniques on myoelectric signals from multiple muscle sites of the upper arm and shoulder. They had some laboratory success. Swedish scientists<a></a> did similar work to control multiple functions of the hand (rotation, flexion-extension, and prehension). The New Brunswick laboratory has played an active role in developing control methods for powered limbs in North America and is well known for three-state control design and development. They have also been active in research on sensory feedback<a></a> and the University of New Brunswick sensory feedback system is the only one available today, of which I am aware. Sensory feedback was examined by many research groups during the 1970's. I reviewed some of this work in an article appearing in the Annals of Biomedical Engineering.<a></a> In the late 1960's and 1970's much experimentation and development were engendered in the field of external electric power. The Japanese developed a myoelectric powered hand.<a></a> MIT scientists designed the Boston Arm,<a></a> the first myoelectrically controlled elbow. The Ontario Crippled Children's Centre (OCCC) Elbow, a switch-controlled electric elbow was also developed in the late sixties, and is still in use. A number of electric elbows, the Rancho Electric Elbow (from Rancho Los Amigos Hospital) the AMBRL Elbow (from the Army Medical and Biomechanical Research Laboratory), and the VAPC Elbow (from the VA Prosthetics Center) also made their appearance in this time period. The Boston Elbow, AMBRL Elbow, and Rancho Elbow were evaluated by the Committee on Prosthetics Research and Development (CPRD).<a></a> Subsequently, the Applied Physics Laboratory in association with Johns Hopkins University developed a powered unit<a></a> capable of pulling the cable of conventional cable-operated, body-powered prostheses. It could be controlled by other inputs, such as from skin motion sensors, which were used with several fittings for high-level arm amputees. The Boston Elbow was redesigned extensively to become the Liberty Mutual Powered Elbow,<a></a> available through Liberty Mutual Insurance Company. The Boston Elbow was also undoubtedly a stimulus to Jacobsen who did his graduate studies at MIT and who later developed the finely-crafted Utah Arm,<a></a> available through Motion Control, Inc. in Salt Lake City. Likewise this research at MIT influenced Hogan,<a></a> who today is developing an elbow in which elbow compliance is controlled by myoelectric signals. The VAPC elbow was manufactured by Fidelity Electronics and used to some extent by VA clients. It was controlled by the VAPC pull switch. The OCCC elbow (available through Electro-Limb in Toronto) has been a workhorse for many years. It, along with other elbows of its period, influenced Lembeck<a></a> in development of the NYU Elbow at New York University. This elbow is presently manufactured by the Hosmer Dorrance Corporation. The OCCC has been a leader in the fitting and development of powered limbs. It is interesting how influential children's prosthetics programs in Germany, Sweden, Britain, and Canada have been on the field of powered prostheses. This is partially the result of government sponsored research programs directed toward amputations caused by the drug Thalidomide. Besides the electric elbow, the Ontario group have made small electric hands available through Electro-Limb for many years and their new electric hand is the latest evolutionary result of their continuing development work in this area. Sorbye<a></a> in Sweden, pioneered the fitting of child amputees with myoelectric hands during the early 70's. His work stimulated the development of the Systemteknik Hand. His work also stimulated interest in the U.K. and an evaluation program there found myoelectric hand systems valuable for child amputees. This undoubtedly had an influence on the development of the Steeper child-sized hand. When Colin McLaurin was at Northwestern University in the early 1960's he developed a "feeder arm" for the Michigan Area Amputee Center (MAAC) in Grand Rapids, Michigan. It was a kinematically coupled limb, designed to enable children with bilateral amelia to eat. A single electric drive mechanism at the elbow moved the terminal device from plate to mouth in a mechanically predetermined fashion. Subsequently, McLaurin moved to OCCC and was responsible for many developments there. Later, Dr. Aitken of MAAC requested the Prosthetics Research Laboratory at Northwestern to re-design the "feeder arm." The Michigan Arm resulted, which was a simple arm with electric hook and electric elbow similar in shape and function to one of Simpson's early CO2 powered limbs. The electric terminal device for the Michigan Arm became commercially available through Hosmer Dorrance as the Michigan Hook. This was one of the first electric hooks to become commercially available. Of course CO2 powered hooks had been used for many years. Also, it should be noted that Bottomley<a></a> designed a unique CO2 powered hook in the 1960's that had many merits which were never exploited. The Michigan Hook was a stimulus for Lembeck at New York University to develop the Prosthesis Assist Device. Like the Michigan Hook and the earlier systems at Johns Hopkins, it pulls on a cable to open a voluntary-opening hook or hand against a resisting spring (e.g. rubber band). This form of electric power utilization in prostheses lacks control sophistication but has simplicity of design and operation. Electric-powered prosthetic hooks have generally been thought to be desirable, particularly by Americans in the prosthetics field. During the mid-seventies, the VAPC developed an electric hook.<a></a> A few years earlier, Northwestern had introduced the synergetic prehension concept and the Synergetic Hook.<a></a> The VA purchased 12 synergetic hooks and evaluated them on VA clients. However, only recently has there been interest in commercial development of this prehension device for interchangeable use with electric hands. Otto Bock developed the Greifer during the late 1970's. It is a novel prehension device that is interchangeable with the Otto Bock Hand. This device is valuable for persons engaged in heavy-duty activities. The commitment of Otto Bock Orthopaedic Industries, Inc. to the powered limb field cannot be overlooked in any historical review. Without availability of Otto Bock hands, wrist rotators, and electronic control systems, much research work in this field would have been stymied for lack of components. Of course, without available commercial components that were backed strongly by educational programs and literature, and by repair and maintenance, it would have been impossible for practicing prosthetists to serve their clients well. Needless to say, Otto Bock, through research, production, education, and product support has made an unparalleled contribution to development for almost a quarter century. <h3>The Present (1977-1984)</h3> The last seven years has been a period marked not by experimental powered fittings in a small number of research centers or elite institutions, but rather by the clinical use of powered limbs by prosthetists practicing all over the country. This "coming of age" was vividly evident at the education seminar entitled, "Current Clinical Concepts of Electrically Powered Upper-Limb Prostheses" in Chicago in September, 1984 and sponsored by the American Academy of Orthotists and Prosthetists. This seminar, convened within a few hundred yards of where prosthetics research was born in the U.S., was not a seminar of researchers or a seminar directed toward particular products or particular methods; it was a seminar of clinicians involved with powered-limb fittings. Undoubtedly, this meeting was a milestone in the history of powered prostheses in this country. An interesting aspect about this period has been the upsurge of clinical fittings of powered prostheses and the increase of commercially available powered components. At the same time, there seems to have been some reduction of research efforts in this area. It is an area that has received considerable attention over the last twenty-five years, and perhaps research is just gathering its breath for the next important push. Whatever the situation, the clinical results show that progress has been made. That this progress has been difficult and hard won with many setbacks, is an indication of the difficulty of the problem being addressed. Indeed, adequate replacement of the human hand and arm is one of the most difficult problems facing medical technology. <h3>Future Trends</h3> From a technical viewpoint there will probably be movement to smaller electronic systems that have extremely low quiescent power. This will enable small power sources to be used when they are coupled with highly efficient prehension devices. Consequently, it may be possible to fit myoelectrically controlled, electrically driven prehension devices to partial hand amputees. Availability of wrist function should make this kind of fitting very effective. This new possibility with technology, coupled with the new surgical reconstruction techniques for the hand, should open up many new possibilities for rehabilitation of partial hand amputees. There should be an increase in reliability and serviceability of powered limb systems. They will become more modular, as well as smaller and lighter. Electro-mechanical components will become more efficient and will have improved dynamic performance. That is, they will be faster and more responsive to the desires of the amputee. New prehension devices, interchangeable with hands and hooks, will be developed. Computer-based controllers will be used in artificial arms, particularly those for multifunctional control. The Utah Arm will probably be the first commercially available arm to contain a computer-based controller. Prosthetists will develop better suspension techniques that minimize or eliminate harnessing in powered limb fittings. They will also, through case studies, develop fitting principles that will enable the various components to be fitted components to be fitted effectively, used appropriately in combinations, and used creatively with body-power. I hope that new control strategies will become available which will enable arm amputees to use multifunctional prostheses without excessive mental load. When this may happen is difficult to predict. <h3>Summary</h3> I have attempted to put powered limb components available today into perspective from an historical viewpoint. None of the devices used today appeared "de novo." All have been influenced by historical events and concepts, the state of technology, and prosthetics practice. References: <ol> <li>Alderson, S.W., "The Electric Arm," Human Limbs and Their Substitutes, Eds. Klopsteg, P. and William, P., McGraw-Hill, 1954 (Reprinted by Hafner Press, 1969), Chapter 13.</li> <li>Almström, C, Herberts, P., and Caine, K., "Clinical Application Study of Multifunctional Prosthetic Hands," Report 2:77, Research Laboratory of Medical Electronics, Chalmers University of Technology, Göteborg, Sweden.</li> <li>Battye, C.K., Nightingale, A., and Whillis, J., "The Use of Myo-Electric Currents in the Operation of Prostheses," J. Bone & Joint Surg., 37B, pp. 506-510, 1955.</li> <li>Berger, N. and Huppert, C.V., "The Use of Electrical and Mechanical Muscular Forces for the Control of an Electrical Prosthesis," Amer. J. Occup. Ther., 6:110-14, 1952.</li> <li>Bottomley, A., "Myo-Electric Control of Powered Prostheses," J. Bone & Joint Surg., 47-B(3):411, 1965.</li> <li>Bottomley, A., "Design Considerations for a Prosthetic Prehension Device," Proc. of Intl. Symp. on External Control of Human Extremities, Dubrovnik 1966 (Published 1967), pp. 82-84.</li> <li>Bottomley, A., Kinnier Wilson, A.B., and Nightingale, A., "Muscle Substitutes and Myo-Electric Control," J. Brit. I.R.E., 26, pp. 439-448, 1963.</li> <li>Carlson, L.E., and Radcliffe, C.W., "A Multi-Mode Approach to Coordinated Prosthesis Control," Proc. of 4th Intl. Symp. on External Control of Human Extremities, pp. 185-186, Dubrovnik, 1972, (published 1973).</li> <li>Childress, D.S., "Closed-Loop Control in Prosthetic Systems: Historical Perspective," Annals of Biomed. Engr., Vol. 9, pp. 293-303, 1980.</li> <li>Childress, D.S., "Powered Limb Prostheses: Their Clinical Significance," IEEE Trans. Biomed. Engr., BME-20, No. 3, pp. 200-207, 1973.</li> <li>Childress, D.S., "An Approach to Powered Grasp," Proc. 4th Intl. Symp. on External Control of Human Extremities," pp. 159-167, Dubrovnik, 1972 (published 1973).</li> <li>Childress, D.S., and Billock, J.N., "Self-Containment and Self-Suspension of Externally Powered Prosthesis for the Forearm," Bull. Prosthetics Research, BPR 10-14, pp. 4-21, 1970.</li> <li>Dahlheim, W., Pressluft hand fur kreigsbeschädigte Industriearbeiter Z. komprimierte und flüssige Gase, German Patent (1915).</li> <li>Dorcas, D.S., and Scott, R.N., "A Three-State Myoelectric Control System," Med. Biol. Engr., Vol. 4, pp. 367-370, 1966.</li> <li>Doubler, J.A., and Childress, D.S., "Design and Evaluation of a Prosthesis Control System Based on the Concept of Extended Physiological Proprioception," J. of Rehab. Research and Development, 21:1, BPR 10-39, pp. 19-31, 1984.</li> <li>"Externally Powered Prosthetic Elbows-A Clinical Evaluation," Comm. on Prosthetics Research and Development (CPRD), Report E-4, National Academy of Sciences-National Research Council, 1970.</li> <li>Geddes, L.A., Moore, A.C., Spencer, W.A., and Hoff, H.E., "Electropneumatic Control of the McKibben Synthetic Muscle," Orthopaedic & Prosthetic Appliance J., 13, pp. 33-36, 1959.</li> <li>Herberts, P., Almström, C, Kadefors, R., and Lawrence, P., "Hand Prosthesis Control Via Myoelectric Patterns," Acta Orthopaedica Scandinavica, Vol. 44, pp. 389-409, 1973.</li> <li>Herberts, P., and Petersen, I., "Possibilities for Control of Powered Devices by Myoelectric Signals," Scand. J. Rehab. Med., 2:164-170, 1970.</li> <li>Hogan, N., Mechanical Impedance Control in Assistive Devices and Manipulators," Proc. of the Joint Automatic Controls Conf., San Francisco, Vol. 1, August, 1980.</li> <li>Jacobsen, S.C., Knutti, D.F., Johnson, R.T., and Sears, H.H., "Development of the Utah Arm," IEEE Trans. Biomed. Engr., BME-29, No. 4, pp. 249-269, 1982.</li> <li>Kato, I., et al., "Multifunctional Myoelectric Hand Prosthesis with Pressure Sensory Feedback System-WASEDA Hand-4P," Proc. 3rd Intl. Symp. on External Control of Human Extremities, pp. 155-170, Dubrovnik, 1969 (published 1970).</li> <li>Kessler, H.H., and Kiessling, E.A., "Pneumatic Arm Prosthesis," Am. J. Nursing, 65:6, 1965.</li> <li>Kobrinskii, A.E., Bolkhoivin, S.V., Voskoboini-kova, L.M., Joffe, D.M., Polyan, E.P., Slavictskü, Ya. L., Sysin, A. Ya., and Yakobsen, Ya, S., "Problems of Bioelectric Control," Proc. Intl. Fed. on Automatic Control Conf., pp. 1119-22, Moscow, 1960, (Butterworth, London, 1961).</li> <li>Lembeck, W., Personal Communication, 1984.</li> <li>Lucaccini, L.F., Kaiser, P.K., and Lyman, J., "The French Electric Hand: Some Observations and Conclusions," Bull. of Prosth. Research, BPR 10-6, pp. 30-51, 1966.</li> <li>Mann, R.W., "Cybernetic Limb Prosthesis," Annals of Biomed. Engr., Vol. 9, pp. 1-43, 1981.</li> <li>Marguardt, E., "The Heidelberg Pneumatic Arm Prosthesis," J. Bone & Joint Surg., 47-B:3, pp. 425-434, 1965.</li> <li>McWilliam, R., "Design of an Experimental Arm Prosthesis: Biological Aspects," The Basic Problems of Prehension, Movement and Control of Artificial Limbs, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 74-81, 1969.</li> <li>Montgomery, S.R., "Design of an Experimental Arm Prosthesis: Engineering Aspects," in The Basic Problems of Prehension, Movement and Control of Artificial Limbs, The Institution of Mechanical Engineer, Proc. 1968-69, Vol. 183, Part 3J, pp. 68-73, 1969.</li> <li>Prosthetic and Orthotic Practice, based on Dundee Conference of 1969, Ed. G. Murdoch, Edward Arnold Ltd., London, 1970.</li> <li>Rakic, M., "The Belgrade Hand Prosthesis," in The Basic Problems of Prehension, Movement and Control Artificial Limbs, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 60-67, 1969.</li> <li>Reiter, R., "Eine neue Electrokunsthand," Grenzgebiete der Medizin, 4:133, 1948.</li> <li>Salisbury, L.L., and Colman, A.B., "A Mechanical Hand with Automatic Proportional Control of Prehension," Med. Biol. Eng., Vol. 5, pp. 505-511, 1967.</li> <li>Schlesinger, G., "Der Mechanische aufbau der kunstlichen glieder," in Ersatzglieder und Arbeitshilfen, Borchardt, M., et al., Eds., J. Springer, Berlin, 1919.</li> <li>Schmidl, H., "The I.N.A.I.L. Experience Fitting Upper-Limb Dysmelia Patients with Myoelectric Control," Bull. of Prosthetics Research, BPR 10-27, pp. 17-42, 1977.</li> <li>Scott, R.N., Brittain, R.H., Caldwell, R.R., Cameron, A.B., and Dunfield, V.A., "Sensory Feedback System Compatible with Myoelectric Control," Med. & Biol. Eng. & Comp., Vol. 18, No. 1, pp. 65-69, 1980.</li> <li>Seamone, W., "Development and Evaluation of Externally Powered Upper-Limb Prosthesis," Bull. of Prosthetics Research, BPR 10-13, pp. 57-63, 1970.</li> <li>Simpson, D.C., "An Externally Powered Prosthesis for the Complete Arm," in The Basic Problems of Prehension, Movement and Control of Artificial Limbs, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 11-17, 1969.</li> <li>Sorbye, R., "Myoelectric Controlled Hand Prostheses in Children," Int. J. of Rehab. Research, Vol. 1, pp. 15-25, 1977.</li> <li>Spaeth, J. P., Handbook of Externally Powered Prostheses for the Upper Extremity Amputation, Charles C. Thomas, Springfield, 111., 1981.</li> <li>Stevenson, D.A., and Lippay, A.L., "Hydraulic Powered Arm Systems," in The Basic Problems of Prehension, Movement and Control of Artificial Limbs, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 37-44, 1969.</li> <li>"The Application of External Power in Prosthetics and Orthotics," Report of Conference at Lake Arrowhead, California, Publication 874, National Academy of Sciences, National Research Council, September, 1960.</li> <li>"The Basic Problems of Prehension, Movement and Control of Artificial Limbs," The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, 1969.</li> <li>"The Control of External Power in Upper-Extremity Rehabilitation," Report of Conference held at Warrenton, Virginia, April, 1965, Publication 1352, National Academy of Sciences-National Research Council, 1966.</li> <li>"The Control of Upper-Extremity Prostheses and Orthoses," based on a conference held in Göteborg, Sweden, 1971, Charles C. Thomas, Springfield, Illinois, 1974.</li> <li>VAPC Research Report, Development (Components), Powered Hook developed by C. Mason, Bull. of Prosthetics Research, BPR 10-16, pp. 217-219, 1971.</li> <li>Williams, T.W., "Clinical Applications of the improved Boston Arm," Proc. Conf. on Energy Devices in Rehab., Boston (Tufts), 1976.</li> <li>Wilms, E., "Die Technik der Vaduzer Hand," Orthopädie Technik, 3, 7, 1951.</li> <li>Wilson, A.B., Jr., "Externally Powered Upper Prostheses," Newsletter . . . Prosthetics and Orthotics Clinic, Vol. 2, No. 1, pp. -4, 1978.</li> <li>Wirta, R.W., Taylor, D.R., and Finley, F.R., "Pattern-Recognition Arm Prosthesis: A Historical Perspective-A Final Report," Bull, of Prosthetics Research, BPR 10-31, pp. 8-35, 1978.</li> </ol> <div style="width: 400px;">*Dudley S. Childress, Ph.D. Dudley S. Childress, Ph.D. is Director of the Prosthetics Research Laboratory and Director of the Rehabilitation Engineering Program at Northwestern University, Room 1441, 345 East Superior Street, Chicago, Illinois 60611. </div> Page Number(s) 2 - 13 Year 1985 Volume 9 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Historical Aspects of Powered Limb Prostheses Creator An entity primarily responsible for making the resource Dudley S. Childress, Ph.D. * https://staging.drfop.org/files/original/00aef4cd6df4fe2afbe93e23bb1aa9a0.pdf 27266064d8bfe3c96f4086c7204d1b26 https://staging.drfop.org/files/original/08880a20a3c0f8fd3794a62b5e39233d.jpg 79a06756e4f898cff5eebb111185d355 https://staging.drfop.org/files/original/f314fd85de1bb9acb2edfc3629026582.jpg 38d5c67d49c718680e501e2c20e483ff https://staging.drfop.org/files/original/56dbb5a30ba120dc374233660a6d08f2.jpg 66064d3a55ad5117af2b25623bc9cc92 https://staging.drfop.org/files/original/2d2151c41c8d769207ce1150be49de3c.jpg a9ad2494375193603f1088dc4f80b52f https://staging.drfop.org/files/original/35ce4605762acb542ff3e5cfb0953f88.jpg 338a3e36c40cb57d3a465aa7b51a0fed https://staging.drfop.org/files/original/1a6880facfd5db40696e5d6d3e54f5c7.jpg 9f7281a6ee94e4e07aa0cb3a096b65a9 https://staging.drfop.org/files/original/0cb44f1af50f82e37a10bcf6655eef8f.jpg d39462496db66313910dd49940ae4454 https://staging.drfop.org/files/original/1568f3bda968608839fa654316c6fcdf.jpg 751c90e73f3344c1b5bd104bcd06bcde Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_235.pdf Text Any textual data included in the document <h2>Mechanical Comparison of Terminal Devices</h2> <h5>James D. Corin, M.S. <a style="text-decoration: none;">*</a> Teresa M. Holley, CP. <a style="text-decoration: none;">*</a> Rodney A. Hasler, M.E. <a style="text-decoration: none;">*</a> Richard B. Ashman, Ph.D. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Considerable controversy has developed over the appropriateness of fitting "functional hand" prostheses to juvenile and adolescent amputees. This controversy is further enhanced by the cosmetic advantages of functional hands over the more traditional hook terminal devices. Conversely, experience has shown the hook terminal devices to offer greater functional control. Prosthetists often feel obliged to fit the amputee with a more functional terminal device, while the amputee often wishes to relinquish some function for cosmesis. Because the functional hands available today do not approach the necessary control, and because hooks are so uncosmetic, a significant percentage of upper limb amputees tend not to wear their prosthesis. The fundamental question presented to the prosthetist in fitting an amputee is how much function can be gained with a particular device. If function is defined simply as prehension grip force and grip width, the next question is whether an amputee can fully operate the particular device completely and comfortably. To date, very little objective data has been available on the comparison of terminal devices. Hence, prescription principles on the part of most prosthetists have been somewhat subjective. Quantitative force and excursion are not usually critical in fitting low level amputees; but the strength adolescents, juveniles, and higher level adult amputees can induce, becomes quite variable. The study presented here is an objective comparison of several terminal devices for mechanical function. The measured parameters were prehension grip force, grip width at full open, excursion range, and the excursion force required to fully open the terminal devices. <h3>Methods</h3> Test Protocol All test data presented here was accomplished on a MTS-858 universal materials testing machine. With this hydraulically powered machine, a piston-like cross-head can be positioned accurately, while loads created on the test specimens are monitored. The degree of sophistication of this machine is not critical to the test protocol. Any testing apparatus can be used as long as displacement and created force can be measured accurately. Two different tests were performed on each terminal device at each of the different tension settings available. The first test will be referred to as the excursion test. Here, the cross head and load cell of the test machine were attached to the cable actuator of the terminal device (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-01.jpg">Fig. 1</a>). The terminal device itself was mounted rigidly to the machine base. The result of this test was a plot of excursion of the cable actuator against the tensile force generated in pulling the cable (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-02.jpg">Fig. 2</a>). The rate of pull was constant at 4" per minute and, because of this slow rate, loading was considered to be static. The plots of excursion force verses excursion of the cable actuator were all of the same general form. <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">Fig. 3</a> shows generalized force versus excursion plot. To present the actual loading curves for each device tested would have taken considerable space, therefore, for each device the only parameters that were tabulated are "A," "B," "C," "D," and "E." The portion of the curve up to "A," "C," represents the pre-loading of the terminal device. Excursion of the cable up to this point does not significantly move the appendages of the terminal device and is primarily due to slack in the system. The pre-load force "C," is the force necessary to overcome preloading of the spring or bands. The force constant "D," of a particular terminal device is the slope of the loading curve between the end of preloading and full open excursion of the cable. The full open excursion of the cable actuator is the distance "B," while the force required to fully open the device is labeled "E." It should be noted that with the five parameters, an estimation of the excursion-load curve of a particular device can be reconstructed. It should also be noted that the tabulated excursion parameters were measured by pulling the terminal devices open. If one was to continue to plot force versus excursion while the device was allowed to close, one would find much lower forces for a given excursion. This hysterisis in the loading curve is due primarily to friction. The loading curves are presented, rather than the unloading curves, because this is the manner in which the devices are operated. <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-01.jpg">Figure 1. A 2.5" U.N.B. STEEPER set up for excursion testing on the MTS-858 universal machine.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-02.jpg">Figure 2. Experimental plot of excursion force vs. excursion travel on a 2.5" U.N.B. STEEPER terminal device. Notice that at 0.45" the characteristics of the curve changes. This is the point (A,C) at which the hand just begins to open.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">Figure 3. Generalized version of excursion force vs. excursion with parameters indicated.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">A-Pre-load excursion (inches)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">B-Full opening excursion (inches)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">C-Pre-loading force (lb.)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">D-Force constant in loading (lb./in.)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">E-Total excursion force at full open (lb.)</a> The second test performed was to assess the prehension gripping forces that are created with each device. With the hand in a horizontal position, the base of the test machine was attached to the thumb, or one hook half, with a cable. The phalanges, or other hook half, were attached to the cross head and load cell of the test machine via a cable (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-04.jpg">Fig. 4</a>). The prosthesis was started in the full open position. A plot of grip force verses grip width was created by allowing the device to close at a constant rate of 4" per minute (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-05.jpg">Fig. 5</a>). From these plots, the parameters "G," "H," and "I," were calculated for use with the generalized graph (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">Fig. 6</a>). It should be noted that the plotting direction of these curves was opposite to those discussed in Figures 2 and 3. Since the hand was started full open, maximum prehension grip force "I" and the full open grip width "F" are plotted first. The force plotted here represents the force created by the device upon its own closing. The force necessary to pull the appendages open would be greater than this force, due to friction. In <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">Fig. 6</a>, "G" is referred to as the initial prehension force. This is the force created just prior to the grip closing completely. Also, the prehension grip force constant, "H" is the slope of the unloading curve between fully open and closed positions of the terminal device. With the parameters "F," "G," "H," and "I," an approximate reproduction of prehension grip force verses grip width can be created. <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-04.jpg">Figure 4. A 2.5" U.N.B. STEEPER set up for prehension grip testing on the MTS-858 universal machine.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-05.jpg">Figure 5. Experimental plot of prehension grip force vs. grip width for a 2.5" U.N.B. STEEPER. This plot was started with the hand full open, a 2.25" grip width, and 2.5 lb. grip force. The steep slope at approximately 0.4" is where the inner locking mechanism activates. The hand is essentially closed at this time.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">Figure 6. Generalized version of prehension grip force vs. grip width, with parameters listed.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">F-Full opening grip width (inches)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">G-Initial prehension grip force (lb.)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">H-Prehension grip force constant (lb./in.)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">I-Total prehension grip force (lb.)</a> <h3>Results</h3> Table I lists the measured parameters derived from the two tests of 33 terminal devices. Of the 12 parameters listed, the first nine were described previously in the test protocol section. The J-th parameter is the number of different devices tested of each type. When more than one device was tested of a particular type, results were averaged. The criteria for testing most of the devices was based on local availability. The ratio of maximum prehension grip force to excursion force is often called the efficiency of a terminal device. The K-th parameter is the measured efficiency. The last parameter, listed as "L," is that of the work required to open the terminal device by pulling the actuator cable. Work is defined as the excursion force times excursion length and is measured by calculating the area under the force-excursion curve. This parameter can be estimated to reasonable accuracy by considering the area under the generalized force-excursion curve (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">Fig. 3</a>). The work, or area under this curve can be calculated as: work = (1/2)*(A*C) + (B-A)*C + (1/2)*(E-C)*(B-A) <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-08.jpg">Table I. Values measured from hook and hand type terminal devices.</a> <h3>Description of Terminal Devices Tested</h3> The following list of terminal devices corresponds to the device number of Table I. <ol> <li> CAPP regular spring, center pull, nylon cabled </li> <li> CAPP soft spring, center pull, nylon cabled </li> <li> HOSMER SSS-555, 1 band, steel cabled </li> <li> HOSMER SSS-555, 2 bands, steel cabled </li> <li> HOSMER SSS-555, 3 bands, steel cabled </li> <li> HOSMER 10P, 1 band, steel cabled </li> <li> HOSMER 10P, 2 bands, steel cabled </li> <li> HOSMER 10P, 3 bands, steel cabled </li> <li> HOSMER 10X, 1 band, steel cabled </li> <li> HOSMER 10X, 2 bands, steel cabled </li> <li> HOSMER 10X, 3 bands, steel cabled </li> <li> HOSMER 12P, 1 band, steel cabled </li> <li> HOSMER 12P, 2 bands, steel cabled </li> <li> HOSMER 88X, 1 band, steel cabled </li> <li> HOSMER 88X, 2 bands, steel cabled </li> <li> HOSMER 88X, 3 bands, steel cabled </li> <li> HOSMER 99X, 1 band, steel cabled </li> <li> HOSMER 99X, 2 bands, steel cabled </li> <li> HOSMER 99X, 3 bands, steel cabled </li> <li> U.N.B. STEEPER, 2.0" w/glove, nylon pull </li> <li> U.N.B. STEEPER, 2.25" w/glove, tension #1 (softest), nylon pull </li> <li> U.N.B. STEEPER, 2.25" w/glove, tension #2, nylon pull </li> <li> U.N.B. STEEPER, 2.25" w/glove, tension #3, nylon pull </li> <li> U.N.B. STEEPER, 2.50" w/glove, steel cabled </li> <li> U.N.B. STEEPER, 2.75" w/glove, steel cabled </li> <li> HOSMER SIERRA, gloved, steel cabled </li> <li> HOSMER ROBINS-AIDS, soft-mechanical, gloved, steel cabled </li> <li> HOSMER BECKER-IMPERIAL, gloved, steel cabled </li> <li> HOSMER, #201 gloved, steel cabled </li> <li> HOSMER, #301 gloved, steel cabled </li> <li> HOSMER, #401 gloved, steel cabled </li> <li> OTTO-BOCK, 6.75", gloved, steel cabled </li> <li> OTTO-BOCK, 7.75" gloved, steel cabled </li> </ol> <h3>Discussion</h3> General trends in the measured parameters become evident on closer examination of <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-08.jpg">Table I</a>. Organization of these tables is such that devices with numbers less than 20 were hook type terminal devices, while those with numbers 20 and over were functional hands. Preload excursion, parameter "A," can be thought of as the excursion necessary to take up slack in the system. Some functional hand units require as much as 1/2" of excursion before any opening occurs. Full opening excursion, parameter "B," and the total excursion force necessary to open the terminal device, parameter "E," are self explanatory. If an amputee cannot generate either the excursion or the necessary force, a different terminal device should be considered. It should be noted that children usually have trouble operating a device with an excursion force greater than ten pounds. The pre-loading force "C" and the force constant "D" are useful parameters in assessing the function of a terminal device when the amputee can marginally create the forces and excursion necessary for full opening. In marginal cases, large pre-loading forces will limit the function of a device. For example, although the UCLA CAPP, device number one, only takes eight pounds to open fully, a patient must be able to create at least 4.5 pounds to start the device in motion. Without regard for the pre-load, one might incorrectly think that four pounds of excursion force would open the device halfway. A terminal device with a high pre-opening excursion (more prominent in hands) could be used on an amputee with good strength initially, but might have weakness toward the end of the excursion range. This is particularly true for higher levels of amputation which rely more on scapular abduction and less humeral flexion. Another important factor to note is the grip performance of the terminal devices. Here the full open grip width "F" and maximum prehension grip force "I" are the important notable values. The parameter that includes both grip and excursion is "K," the ratio of maximum grip force to excursion force. This term was measured to be greater than 0.40 for all of the hook type devices examined, and less than 0.40 for the functional hands. Some hooks revealed efficiencies as high as 0.70. It should be noted that the ratio of maximum grip force to excursion force can be calculated from the geometry of a particular device and is independent of the spring or rubber band tension. The measured results show this to be the case, in that parameter "K" did not significantly vary when spring tensions or the number of rubber bands were changed. Measured efficiencies for the functional hands were, in general, less than hook terminal devices. This consistent discrepancy is due largely to friction in the mechanics of the internal hinges within the hands in addition to glove attachments. The final parameter "L" which is the total amount of work required to operate the terminal device is also of extreme importance. Hands compare more favorably to hooks because on a general basis hands require less excursion than hooks for full opening. This is an important factor for children as well as higher levels of amputation, because of less available excursion. Plotting maximum prehension grip force against total excursion force, the relative performance between hooks and hands can be compared (Fig. 7). For clarity, the hand device numbers were plotted with a preceding dash. For any particular excursion force, it can be easily seen that grip force is greater for the hook devices. The devices 7, 8, 10, 11, and 19, were particularly good performers, which required excursion forces less than 15 pounds, and created prehension grip forces greater than seven pounds. In light of this comparison, it should be challenging for terminal device designers to come up with functional hand devices that approach the efficiencies of hooks. <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-07.jpg">Figure 7. Graph of prehension grip force vs. excursion force for all terminal devices. Note that all hand terminal devices have a preceding dash.</a> <h3>Conclusions</h3> This comparison of terminal devices is only preliminary in that many more terminal devices have yet to be analyzed. Furthermore, the number of devices tested was very small. In spite of these limitations, the best protocol allowing comparisons between the different terminal devices was felt to be objective and reflect the relative performance of different devices. <h3>Acknowledgments</h3> This research was funded by the King Foundation, Dallas, Texas and the Research Fund of Texas Scottish Rite Hospital for Crippled Children. We wish to also thank Hosmer Dorrance and Liberty Mutual for the donation of their terminal devices. *Richard B. Ashman, Ph.D. Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219. *Rodney A. Hasler, M.E. Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219. *Teresa M. Holley, CP. Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219. *James D. Corin, M.S. Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219. Page Number(s) 235 - 244 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-01.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-05.jpg Figure 7 TABLE I http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-08.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-07.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-02.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Mechanical Comparison of Terminal Devices Creator An entity primarily responsible for making the resource James D. Corin, M.S. * Teresa M. Holley, CP. * Rodney A. Hasler, M.E. * Richard B. Ashman, Ph.D. * https://staging.drfop.org/files/original/d473917f5c93279c86fec167ec3e6f8d.pdf 52522a97179122f2dab8aa3dded039d2 https://staging.drfop.org/files/original/cd42d129793a2e44547062aae35b954c.jpg 7fa5af2ce6f8ad613bc3161879335a63 https://staging.drfop.org/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg b4f8eac8a1df5167a5581f3d8051bb22 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_230.pdf Text Any textual data included in the document <h2>The Relationship Between Orthotics and Gainful Employment of the Disabled</h2> <h5>J.E. Yourist, Ph.D. <a style="text-decoration: none;">*</a> Z.A. Latif, Ph.D. <a style="text-decoration: none;">*</a> S.T. Layton, Ph.D. <a style="text-decoration: none;">*</a> J.H. Bowker, M.D. <a style="text-decoration: none;">* </a></h5> <h3>Statement of Problem</h3> Physical and sensory disabilities restrict individuals from functional access to the environment.<a></a> Since our environment is best suited to the average person, losses such as these represent formidable barriers to fruitful interactions with the environment and society. Of special significance in this regard is the ability to function productively in gainful employment. National statistics reveal that the unemployment rate among the disabled is tenfold that of the general population (70% versus 7%).<a></a> Barring all other variables, this statistic reflects that our environment is especially inaccessible to the disabled. There are several factors which contribute to this serious unemployment problem.<a></a> Notable among these is the fact that the disabled are unable to return to work due to "access" deficiencies caused by the nature of their disability. In this sense "access" means to bridge the barriers to the environment imposed by physical or sensory disability (<a href="/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg">Fig. 2</a>). This paper deals with the probable relationships between adaptive devices and employment/economic opportunities for the disabled. <h3>Probable Solutions to Access Deficiencies</h3> Appropriate solutions to these "access" problems can be complex, but all necessitate the use of orthotic or adaptive devices. Typically, these devices will aid the disabled to achieve a level of performance that, at best, approaches that of the able-bodied person. The primary device for the severely disabled remains the wheelchair which, when appropriately prescribed and adapted, provides mobility throughout the workplace and good sitting posture for proper interface with tools at the workstation. A stand-up chair allows the worker to utilize a standard file cabinet and reach objects on higher shelving. Quadriplegics can manipulate keyboard sticks either with wrist-driven flexor-hinge orthoses if C-6 function is present or with the use of a universal utensil holder for those with C-5 function. The advent of high-technology electronic devices such as computers and robots has greatly expanded the horizons of the severely disabled in the workplace. These devices, which are cost and energy efficient, can transform minimum physical energy into tangible and impressive work events. A simple example is that of a quadriplegic operating a microcomputer by activating a switch by a "sip and puff" device or speech-recognition software and hardware. For the purpose of this discussion, it is necessary to focus on the relevance of these devices to independent living and the achievement of gainful employment for the disabled. A behavioral model for task performance may be considered which allows the definition of the necessary device required to achieve a particular task. <a href="/files/original/cd42d129793a2e44547062aae35b954c.jpg">Fig. 1</a> is a schematic representation of the performance of a common task by an able-bodied individual. In this illustration, an intent or desire to perform a particular task is first identified.<a></a> After assessing the person's inherent capabilities and resources, the activity can then be performed. Consequently, the immediate environment is altered, a purposeful response is made, and the consequences are appreciated. <a href="/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg">Fig. 2</a> depicts the same task presented to a disabled individual. This schematic is altered to demonstrate the physical and/or sensory barriers to completing a similar task.<a></a> A disabled person may have a desire to perform this task, but may not have the same inherent capabilities or the resources as the able-bodied counterpart. At this juncture, "access" deficits to the environment become obvious. An adaptive device is required to facilitate the fulfillment of this task. One might expect the appreciation factor to be much higher compared to the able-bodied person. <h3>Improvement of Function</h3> For many years orthoses have been successfully fitted to restore and sustain the ability to carry out common activities of daily living. These biomechanical devices have improved the ability of the disabled person to perform such physical tasks as sitting, walking reaching, and grasping. Functionally, many of these activities are no different than those found in the current workplace. Those disabled persons previously employed in manual labor or manufacturing jobs would probably be displaced from their previous employment. This is due, in part, to the fact that conventional orthoses have definite limitations in their ability to replace the physical potential of the able-bodied. Therefore, till now, the highly disproportionate number of unemployed disabled persons does not indicate a positive correlation between employment and the use of traditional orthoses or adaptive devices. However, the emergence of microcomputer technology during the last decade has provided new potential for more effective use of these devices. Furthermore, the microcomputer can be regarded as both a biomechanical accessibility device and an employment tool which can be utilized for physical and economic rehabilitation. <h3>The Change in Definition of Work</h3> Our global economy is rapidly evolving from an "industrial" to an "information" age.<a></a> Jobs are becoming more knowledge-based with increasing dependence on computer technology as the sole productivity tool.<a></a> Indeed, the management of information is being realized as a central resource or commodity for jobs. Consequently, demand for manual labor is being steadily replaced by a demand for workers who can effectively manage information. In the coming decade, more than 50 percent of all jobs in this country will be found in high technology based information management. The personal computer is the principal instrument used in these jobs.<a></a> These events are quite beneficial to those who are physically disabled, because the labor market will depend in a large degree on mental rather than physical capabilities. Coinciden-tally, the tool used in these new jobs is the same tool that can be used to access the environment: the microcomputer. Economic Rehabilitation Even in view of recent economic and technological developments, the question of the high ratio of unemployment among the severely disabled remains a serious and complex problem. In most cases, the severely disabled are displaced from their previous careers and require intensive rehabilitation to re-enter the job market. This implies that rehabilitation is certainly not complete until educational/retraining and economic goals are met to achieve financial independence. Therefore, complete rehabilitation is defined here as the process by which a person who is disabled and unemployed, can be physically and, more importantly, functionally and economically rehabilitated. This can only be achieved through a comprehensive program which includes not only conventional strategies of physical and occupational therapy, but vocational diagnostics, vocational counselling and retraining, and lastly, job placement. MEED (Microcomputer Education for the Employment of the Disabled) Appropriate vocational diagnostics and job retraining are key elements in successful economic rehabilitation. In most instances, this training has been inadequate, frequently resulting in supported job placement. Such a disincentive is often compounded by the possible loss of government-subsidized unemployment benefits and health care coverages. Therefore, at the University of Miami, we have developed an economic rehabilitation program based on high-technology called MEED, or Microcomputer Education for Employment of the Disabled. MEED was conceived from the federal Projects With Industry (PWI) model to pilot a high-technology approach to rehabilitative training. It is a microcomputer-based training and placement program for the severely disabled, teaching information management skills which are necessary for competitive employment in business. This training is comprehensive, job-targeted, and cost-effective. <h3>Other Causes of High Unemployment</h3> Although access barriers are keeping many disabled persons from the workplace, their high rates of unemployment certainly reflect a minimal relationship between employment and adaptive devices. These devices may promote job function, but may not significantly increase the chance of that person acquiring a job. Many other factors come into play, especially the social issues facing disabled individuals and the marketability of their job skills. Other factors also contribute, including: first, unavailability of suitable retraining programs; second, chronic health problems; and third, government-established major work disincentives, such as disability payments. <h3>Conclusions</h3> In our judgement, feasible vocational retraining approaches are needed. They must be designed to equip disabled individuals with marketable skills which are necessary for competitive employment. Partnerships among several sectors of the community are essential to make these efforts a success. These include academia, government, business and industry, and the rehabilitation and health-care communities. Conventional orthoses will play a significant role in complementing the function of high technology devices. For example, various splints and universal utensils will improve computer keyboard access and function. However, technology holds the key to the future of economic rehabilitation. We believe that the computer, particularly the microcomputer, is central to achieving this goal. The microcomputer is not only a valuable business productivity tool, but is also a vehicle through which a severely disabled individual can "access" his environment. In a sense, the microcomputer itself can be viewed as an orthotic or adaptive device. It is an extension of not only the body, but also the mind. So, in the "information age," the microcomputer is assuming a pivotal role in improving the quality of life for the able-bodied as well as, and even more importantly, for the physically disabled. References: <ol> <li>DeJong, Gerben, and Lifchez, Raymond, "Physical Disability and Public Policy," Scientific American, June, 1983, vol. 248, no. 6, pp. 40-49.</li> <li>Bowe, Frank, Ph.D., "Making Computers Accessible to Disabled People," Technology Review, January, 1987, pp. 54-59.</li> <li>Jaffee, David, "High Technology and New 'Access Devices'" from lecture and written material at High Technology Education for Employment of Disabled Conference, Miami, Florida, March, 1987.</li> <li>Harris and Associates, Inc., The ICD Survey of Disabled Americans Bringing Disabled Americans into the Mainstream, March, 1986.</li> <li>Spencer, William, M.D., "Technology and Rehabilitation," lecture at Symposium on Computers in Medical Care and Education, Washington, D.C, October, 1986.</li> <li>Cornish, Edward, "The New Industrial Revolution: How Microelectronics May Change the Workplace," Careers Tomorrow, C. Norman, 1983, pp. 26-35.</li> <li>Cornish, Edward, "Careers with a Future: Where the Jobs Will Be in the 1990s," Careers Tomorrow, M. Cetron andT. O'Toole, 1983, pp. 10-19.</li> </ol> *J.H. Bowker, M.D. John H. Bowker, M.D., is a professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami Schools of Medicine. He is also the Medical Director of the University of Miami/ Jackson Memorial Rehabilitation Center in Miami, Florida. *S.T. Layton, Ph.D. S.T. Layton, Ph.D., is Associate Director of the MEED Program at the University of Miami School of Continuing Studies. *Z.A. Latif, Ph.D. Z.A. Latif, Ph.D., is Assistant Professor in the Department of Medicine and Consultant to the MEED Program at the University of Miami School of Medicine. *J.E. Yourist, Ph.D. Jay E. Yourist, Ph.D., is Assistant Professor in the Department of Medicine and the Director of the MEED Program at the University of Miami Schools of Medicine and Continuing Studies, P.O. Box 016960, Miami, Florida 33101. Page Number(s) 230 - 234 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_230/1987_04_230-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_230/1987_04_230-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Relationship Between Orthotics and Gainful Employment of the Disabled Creator An entity primarily responsible for making the resource J.E. Yourist, Ph.D. * Z.A. Latif, Ph.D. * S.T. Layton, Ph.D. * J.H. Bowker, M.D. * https://staging.drfop.org/files/original/d7bbda5fa4a94c9b44ad420c291a651d.pdf 1fbf7ce3189a6a47e65af6fd71c3f8d6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_225.pdf Text Any textual data included in the document <h2>Psychological Aspects of Spinal Cord Injury</h2> <h5>Katharine S. Westie, Ph.D. <a style="text-decoration: none;">*</a></h5> Spinal cord injury (SCI) is a massive assault to the psyche as well as the body. Within moments, a person who had been active and independent becomes immobilized, loses control of bowel, bladder, sexual and other bodily functions, and is dependent on others to meet the most basic needs. The instantaneous effects of the injury result in total disruption of the victim's life, and the beginning of a life-long psychological adjustment process. Optimal emotional adjustment is imperative to the recovery and rehabilitation process, due to the tremendous psychological energy and motivation required for a SCI patient to learn self-care, independence, and psychosocial coping skills. <h3>Theories of Psychological Adjustment</h3> Psychological adjustment to SCI has been conceptualized in terms of three major models. The first is referred to as the "stages" theory, and is derived from the well known work on grieving done by Lindeman and Kubler-Ross.<a></a> This theory proposes that individuals adjusting to losses, such as SCI, experience certain psychological stages in the readjustment process. These include (1) shock and denial, (2) depression, (3) anxiety, (4) anger, (5) "bargaining," and (6) adaptation. In using this model, it is important to understand that not all patients go through all stages, that a patient may go through a stage more than once and that stages are not necessarily experienced in a given order. This model is helpful in recognizing these emotional responses as a normal, healthy, and appropriate part of adjustment to SCI. The second model is referred to as the "developmental" theory. It is derived from Er-ikson's work on psychosocial stages of development, from infancy to adulthood.<a></a> As applied to SCI, the developmental theory assumes that the trauma results in a natural regression, followed by a reworking of some developmental tasks previously mastered in childhood, starting with (1) basic trust, (2) autonomy, and (3) initiative. Physically and emotionally, SCI patients must progress through tasks of infancy and childhood again. Like infants, they initially may be unable to verbally communicate, need to be fed and moved, have no bowel and bladder control, and are totally dependent. As they progress through rehabilitation, they relearn childhood tasks such as rolling, feeding, developing a bowel and bladder routine, mobility, and other basic activities of daily living. They experience the adolescent task of separation from parental figures as they work toward the independence of adulthood. The rehabilitation program can be seen as facilitating attainment of these developmental landmarks. The third model, the "individual differences" theory, proposes that adjustment is primarily related to individual differences in patients' premorbid personalities. These models provide three different approaches to understanding psychological adjustment to SCI. However, they need not be seen as mutually exclusive. In fact, when used together, they provide a more complete picture of SCI patients' complex adjustment process. <h3>Psychological Responses of Staff</h3> Rehabilitation professionals working with SCI may find that certain patients elicit grieving responses in them, similar to those of their patients. When staff members identify with or become emotionally attached to patients, they may find themselves experiencing symptoms of depression, anger, or even denial. Highly motivated staff may also find it difficult to cope with noncompliance of depressed or angry SCI patients. Occasionally, when staff members' goals for resistant patients are not met, they may blame themselves for perceived failures or subconsciously direct anger and frustration toward patients. Although these are normal emotional responses, they may interfere with staff members' well-being and effectiveness. When situations such as these occur, consultation with the rehabilitation psychologist can provide the staff member with behavioral management techniques and enhance personal coping skills and insight. Professionally facilitated groups designed to provide peer support, teach stress management skills, and prevent "burnout" are also recommended. <h3>Head Injury in SCI</h3> Closed head injury (CHI) frequently accompanies traumatic SCI, though it often goes unrecognized. The reported incidence of head injury in SCI ranges from 10% to 58%.<a></a> Recent studies indicate that neuropsychological deficits are common among SCI patients.<a></a> Morris, et al. state that 50% of all SCI patients may be expected to exhibit evidence of CHI and some degree of cognitive impairment.<a></a> Even mild head injuries can significantly affect cognitive and emotional functioning, especially during the first months post-injury. The most prominent areas of cognitive dysfunction following CHI are in learning, memory, and speed of information processing, all important to learning of new skills in rehabilitation settings.<a></a> Thus, patients' ability to acquire new knowledge may be greatly diminished at the precise time that intense demands to learn are placed on them.<a></a> CHI-related behaviors such as poor social judgment, poor frustration tolerance, impulsivity, emotional lability, perseveration, difficulty in initiating behavior, decreased mental stamina, fatigability, and irritability are often misperceived by staff as enduring premorbid personality traits. Neuropsychological testing can enhance patient and staff insight into the effects of CHI and facilitate treatment planning. <h3>Psychological Treatment Approaches in the Rehabilitation Setting</h3> Though the primary responsibility for psychological care of the SCI patient is assigned the psychologist and social worker, other rehabilitation professionals on the interdisciplinary team play an important role. Sensitivity to the patients' emotional status allows for treatment planning and interaction that maximizes physical and psychological rehabilitation. Ideally, psychological rehabilitation begins in the Intensive Care Unit (ICU) soon after injury. At this time, many SCI patients are intubated and unable to verbally communicate. They often experience disorientation, depression and anxiety, sensory and sleep deprivation, and perhaps the temporary delusional and hallucinatory state known as "ICU psychosis." This is a critical time for team members to offer emotional support, establish a communication system and determine what the patient wants to know. Some need extensive information about their injury and care in order to best cope with fears and anxiety. Others clearly want to delay knowing more about their condition. Most welcome reassurance that their emotional responses and concerns are normal and accepted. As the patient progresses through acute care into the rehabilitation setting, regularly scheduled psychotherapy sessions can facilitate the adjustment process. The psychologist can help the team understand the patient's stage of adjustment, and provide consultation on behavioral management approaches. Emotional responses dealt with by psychotherapy include a range of ego defenses, most commonly repression and denial. It is important to recognize that these defenses protect the psyche from material too traumatic to deal with consciously, thereby preventing decompensation. In this regard, denial and repression are adaptive, and indeed may be the reason SCI patients are able to function in the stressful rehabilitation situation so soon post-injury. Typically, as denial decreases over time, depression, anxiety, and anger increase. How these emotions are expressed depends largely on the patient's premorbid personality style. Normal emotional responses to SCI may be manifested in behaviors which impede progress in the rehabilitation setting. For instance, depression may cause psychomotor slowing, decreased motivation, and social withdrawal. Anxiety may create psychogenic somatic symptoms and poor concentration. Anger may result in noncompliant or destructive behavior. Psychotherapy can help via reinforcing adaptive coping skills and teaching new coping strategies. The psychologist may also work with the interdisciplinary team to develop behavioral modification programs, based on learning theory, to decrease these behaviors. Contingency management and behavioral "contracting" are most frequently used in rehabilitation settings. Approaches emphasizing positive reinforcement to "shape" desired behaviors are particularly effective.<a></a> Although such programs may be time-consuming initially, they can rapidly decrease maladaptive behavior and ultimately increase the patient's sense of control and self-esteem. Psychological treatment of SCI often includes group psychotherapy, which is an excellent method to both maximize patient learning and efficiently use therapist time. Patient groups can provide emotional support, peer role models, teach new coping skills, and decrease social discomfort. Likewise, multiple-family group psychotherapy is a powerful and effective tool for facilitating family adjustment to SCI.<a></a> Family members experience similar emotional responses to the patient and similarly benefit from psychological intervention. If not included in the team effort, a well-meaning family member could inadvertently sabotage the independence-oriented rehabilitation approach, or be too psychologically distressed to provide the emotional or physical care the patient needs. Other issues which need to be routinely addressed by the psychologist, in conjunction with the rehabilitation team, are sexual adjustment, vocational rehabilitation and pain management training. Prevention of medical complications, particularly those which have significant behavioral/emotional components, need to be emphasized. An example is pressure sores, which often occur when depression and/ or substance abuse lead to poor self-care. <h3>Psychological Response to Orthotic Devices</h3> SCI patients' ability to emotionally adjust to orthotic devices (sometimes referred to as "gadget tolerance"), is related to type of orthosis, premorbid personality factors, and stage of emotional adjustment. Orthoses used to stabilize the spine after surgery sometimes become the "target" of patients' emotional distress. For instance, it is easier for the patient who is denying the seriousness of his SCI to blame pain and decreased function on the TLSO. Anger expressed toward an inanimate object is "safe," whereas anger directed toward family or staff may have negative repercussions. Insight into these psychody-namics can help the orthotist deal with constant requests for adjustments to orthoses, or anger responses of post-surgical SCI patients. Upper and lower limb orthoses used to increase independence elicit a variety of emotional responses. The potential for increased function often provides a major psychological "lift," enhancing patients' sense of competence and self-esteem. However, inclusion of psychological factors in the selection of candidates for orthoses is critical. Fitting a patient who is not emotionally ready for an orthosis will result in loss of time and a failure experience for all concerned. There are numerous reasons why SCI patients may resist orthotic devices, or are unsuccessful with them, including the following: Body image Many SCI patients value the fact that they look "normal" except for the wheelchair. The magnitude of disability may be "invisible." When orthoses are introduced, patients sometimes report that people stare at them more. Their sense of "being different" and social discomfort increases. For this reason, sensitivity to aesthetics is important in designing orthoses for this population. Independence-Dependence Conflicts In some patients, there are secondary gains in their dependent state, though they may not be consciously aware of this. For example, when an upper limb orthosis significantly increases independence in activities of daily living, the patient may experience withdrawal of valued reinforcers (e.g. time and attention from caregivers). This can lead to rejection of the orthosis. If significant others (family and staff) are willing to provide extra attention and reinforcement for the new independence behaviors, these issues usually resolve well. Self-Concept SCI patients may not integrate disability into their self-concept for some time. In one study, 130 SCI patients were interviewed about their dreams in order to examine subconscious content regarding self-perception. The authors found that 75% of these patients, injured less than one year, had never seen themselves in a wheelchair in dreams.<a></a> This is one illustration of the initial need of SCI patients to maintain an underlying self-image as nondisabled. Orthoses may conflict with this self-image in more recently injured SCI patients. Denial Orthoses may threaten patients' denial systems. Patients not yet ready to acknowledge the extent or permanence of their disabilities frequently reject orthoses. Alternatively, they may accept temporary orthoses, but reject definitive ones. Patients with self-image and denial issues benefit from psychotherapy and being given more time to adjust emotionally to their disability. They should be provided with information on obtaining recommended orthoses for the future. At the other extreme, patients sometimes build denial systems based on unrealistically high hopes for orthoses. For example, a patient using lower limb orthoses for ambulation may find they are not practical for use in valued pre-injury activities. This could lead to breaking down of denial and increased depression or anger, which may temporarily create decreased motivaton or rejection of the orthoses. Clear communication, emphasizing realistic expectations before introducing orthoses, may prevent some of these responses. Premorbid Personality Longstanding personality attributes (such as poor frustration tolerance, risk-taking behavior, and substance abuse) and stage of adjustment (especially depression) can lead to poor self-care resulting in pressure sores or poor follow-through in any activities requiring sustained effort. Attention to psychological factors in selecting candidates for orthoses is the most important factor in preventing these problems. <h3>Summary</h3> Spinal cord injury results in an overwhelming physical and emotional adjustment process. By understanding emotional responses, and applying them in treatment planning and interaction with patients, rehabilitation professionals can greatly enhance the psychological adjustment of SCI patients. References: <ol> <li>Bond, M.R., "Neurobehavioral Sequelae of Closed Head Injury," in I. Grant and K.M. Adams (Eds.), Neuropsychological Assessment of Neuropsychiatric Disorders, New York: Oxford University Press, 1986, pp. 347-371.</li> <li>Davidoff, G., J. Morris, E. Roth, and J. Bleiberg, "Cognitive Dysfunction and Mild Closed Head Injury in Traumatic Spinal Cord Injury," Archives of Physical Medicine and Rehabilitation, 66, 1985, pp. 489-491.</li> <li>Dunse, C, R. Eichberg, and D. Deboskey, "The Incidence of Neuropsychological Deficits in the Spinal Cord Population," paper presented at the Third Annual Houston Conference on Neurotrauma, Houston, Texas, February, 1987.</li> <li>Erikson, E.H., Insight and Responsibility, W.W. Norton, 1964.</li> <li>Hoffman, Loren L., "Auditory-Verbal Memory Abilities Following Traumatic Spinal Cord Injuries: A Comparative Study," doctoral dissertation, Georgia State University, 1987.</li> <li>Kubler-Ross, Elisabeth, On Death and Dying, New York: MacMillan Publishing Company, Inc., 1969.</li> <li>Lindenmann, Erick, "Symptomatology and Management of Acute Grief," American Journal of Psychiatry, 101:143, September, 1944.</li> <li>Morris, J., E. Roth, and G. Davidoff, "Mild Closed Head Injury and Cognitive Deficits in Spinal-Cord-Injured Patients: Incidence and Impact," Journal of Head Trauma Rehabilitation, 1(2), 1986, pp. 31-42.</li> <li>Rohren, K., B. Adelman, J. Puckert, B. Toomey, B. Talbert, and E. Johnson, "Rehabilitation in Spinal Cord Injury: Use of a Patient-Family Group," Archives of Physical Medicine and Rehabilitation, 61, 1980, pp. 225-229.</li> <li>Taylor, G.P., and R.W. Persons, "Behavior Modification Techniques in a Physical Medicine and Rehabilitation Center," The Journal of Psychology, 74, 1970, pp. 117-124.</li> <li>Westie, K.S., and J. Evans, "Self-Perception as Disabled in Dreams of Spinal Cord Injured Persons," paper presented at American Psychological Association Convention, New York, 1987.</li> <li>Westie, K., and W. McKeon, "Multiple-Family Group Psychotherapy in Treatment of Spinal Cord Injury Families," paper presented at American Association of SCI Psychologists and Social Workers Convention, Las Vegas, Nevada, November, 1987.</li> <li>Wilmot, C.B., D.N. Cope, K.M. Hall, and M. Acker, "Occult Head Injury: Its Incidence in Spinal Cord Injury," Archives of Physical Medicine and Rehabilitation, 66, 1985, pp. 227-231.</li> </ol> *Katharine S. Westie, Ph.D. Katharine S. Westie, Ph.D., is Director of Clinical Psychology for the Spinal Cord Injury Service at the University of Miami/Jackson Memorial Rehabilitation Center in Miami, Florida. Page Number(s) 225 - 229 Year 1987 Volume 11 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Psychological Aspects of Spinal Cord Injury Creator An entity primarily responsible for making the resource Katharine S. Westie, Ph.D. * https://staging.drfop.org/files/original/15815c49a6adce1760436c8f5ae00753.pdf ccf779f3680911a29673df7262a2d03a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_215.pdf Text Any textual data included in the document <h2>Mobility and Mobility Devices for the Spinal Cord Injured Person</h2> <h5>Samuel R. McFarland, MSME <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> In the dictionary, the preferred definition of mobility is "the quality of being movable."<a></a> A second definition, more sociological in scope, defines mobility as "the movement of people in a population, from place to place, or job to job, or social position to social position." The second concept captures the significance of mobility as it relates to the life of a spinal cord injured individual. Spinal cord injury is a condition that most commonly affects young, physically active adults who have already established a social pattern in their lives. Certainly, spinal cord injury (SCI) causes impairment of movement, but more importantly, it may constrain a person's capacity for self-di-rected, purposeful movements, which are important to almost all activities. Much of the medical rehabilitation of a SCI patient involves therapeutic interventions aimed at increasing the range, strength, and coordination of body movements that have been impaired by an insult to the central nervous system. To fully appreciate the scope of mobility impairments encountered by SCI patients, we must examine the entire spectrum of activities that can be affected by limitations of movements. Independence, social and personal interactions, career development, and access to public facilities are some of the freedoms that can be adversely affected by mobility impairment.<a></a> A thorough discussion of the methodology for reestablishment of mobility for SCI patients must include topics such as therapeutic interventions, orthotic appliances for stabilizing and enhancing the performance of musculoskeletal components, devices for extending the range or speed of movements, and substitutions for lost or severely limited functions. This article will not dwell on therapy, which is more appropriate for other authors, nor on orthotic appliances, since that subject is covered well in the accompanying articles on spinal stabilization and upper limb orthotics. Rather, it will attempt to represent some of the mobility considerations that are common to SCI and to discuss the application of products and techniques associated with ameliorating movement limitations. For the sake of simplifying the myriad array of details that can be covered under the general heading of mobility, this article will survey a sequence of activities that start with static support of the body and proceed to increasingly more complex movements in terms of range, speed, and energy demand. The author admits to a bias toward devices and technologies, which will be reflected in the discussions that follow, but he wishes to emphasize his belief that the only successful technical solution to a mobility problem is the one that integrates well with other rehabilitation interventions and withstands the test of time and use by the patient. Simplicity, cosmetic design, and reliability are essential to the immediate and long-range acceptance of adaptive technology by the user.<a></a> <h3>Background</h3> Spinal cord injury commonly results in permanent paralysis of some of the large and powerful skeletal muscles of the body. The location of the injury along the spine correlates roughly to the cumulative amount of paralysis that results. The closer the injury site is to the head, the greater the involvement. Trauma incurred at the spinal column can affect the transmission of the nerve signals to all parts of the body served by the injury site and beyond. However, functional deficits incurred by SCI are almost always incomplete, meaning seldom is there complete loss of function or bilateral symmetry of effects below the site of the injury (lesion). For the sake of this paper, however, it will suffice to consider only two general types of functional paralysis: paraplegia and quadriplegia. Impaired voluntary control of skeletal muscles is not the only significant impediment resulting from SCI. Other organ functions can be affected as well. Bowel elimination, bladder voiding, sexual function, sweating, bone strength, and peripheral vascular circulation can all be altered in response to spinal cord insult. A common and troublesome side-effect is involuntary contraction of a muscle, spasm. Not only is the motor function of a nerve network affected, but also the sensory aspect. The combination of loss of sensation and reduced tissue blood circulation resulting from everyday bumps and pressures incur a high risk of undetected soft tissue damage. In insensate tissues, such seemingly minor injuries can easily progress into massive tissue death in the form of a decubitus ulcur. "Decubiti" are immensely threatening to a spinal injured person, not only because of the irreversible tissue damage, but also due to the extensive time loss and expense incurred in the treatment. All of these conditions must be kept in the forefront of planning for mobility and will be mentioned from time to time in the text that follows. <h3>Transfer</h3> The initial and simplest tasks of SCI mobility begin with rising from a reclining position, from which seated tasks, ambulation, or wheeled mobility can proceed. If starting from a bed, the person must first be able to sit up. A paraplegic or quadriplegic with good shoulder strength, may be able to sit up without assistance. Some may prefer to use an overhead handle, often called a trapeze, or a looped strap, to pull up into a sitting position. Sometimes a hospital type bed, with a powered drive to the articulated back section, can raise the person to a sitting position from which he can turn and let his legs off the bed in preparation for standing. A standing transfer, even with an attendant assisting is desirable because the weight is borne on the legs, but not by the attendant or a transfer device. If the legs are capable of supporting body weight, with or without bracing, the person may develop greater independence. When the quadriplegic or high paraplegic is not able to stand without braces, the transfer from a sitting position to another seat is somewhat more complicated because of the physical strength required to lift the body, change levels between sitting surfaces, and traverse the distance. Transfer aids foster independence and supplement the work of an attendant. For wheelchair transfers, it may be helpful to use a sliding board (also called a "transfer board"), a short length of wood or rigid artificial material that bridges the gap between two sitting surfaces, such as the bed and wheelchair. A paraplegic, and some low level quadriplegics, can momentarily life his weight and move in short, sideways increments from one surface to another. A strong and active paraplegic will probably vault by pushing downward with his hands or swing from an overhead handle, in lieu of being burdened with a transfer board. Even a person who cannot transfer himself can be aided by sitting on a piece of sturdy fabric which may be pulled sideways across the sliding board by an attendant. If a sliding transfer is not possible, a person can be lifted while sitting in a fabric hammock by a mechanical patient lift that incorporates an electrical motor or hydraulic jack mechanism to provide the lifting force. The hammock is attached overhead to the lifting device which is usually operated by an attendant. Some can be self-operated if appropriate fail-safe or emergency mechanisms are built in to compensate for equipment failure. Elaborate custom installations of overhead tracks can allow a person to be transported from bedroom to bathroom and beyond. Overhead lifts are also available for transferring from a wheelchair into a car, but with the advent of van adaptations, they are losing acceptance among users. The lifting and sliding principles used in transfer aids are applied in many products used in home and institutional settings, especially in the bedroom and bathroom. A common application of the sliding-lifting principle is the bathtub transfer aid, a device used to help a person transfer safely into the bathtub and lower himself into the tub for bathing. Some products are completely passive, incorporating a sliding pathway for the user to traverse across the tub rim. Some are powered seats, often driven by faucet water pressure, that raise and lower the seated occupant relative to the tub bottom. A more expensive form of lifting aid for the home is the vertical shaft home elevator that is used to give mobility between vertically separated living areas. Installation usually requires alterations to the structure of the building. A somewhat less expensive approach, where applicable, is the stairway elevator, which can be added to an existing staircase. Available as a chair for ambulatory persons and a platform for wheelchair riders, it typically follows the path and incline of the stairs and usurps a portion of the walking path. The least expensive adaptation for moving between levels, especially from outside, is the ramp. Ramps have been well defined in standards produced by the American National Standards Institute.<a></a> Outdoor elevators that are added on, rather than built into a building, usually called porch lifts, are made primarily for wheelchair users where ramp construction is impractical and a landing platform can be placed next to an outer door. Home elevators of all forms are usually sold and custom-installed by specialty vendors that are associated with vendors of other mobility aids. <h3>Standing Aids</h3> Paraplegics and quadriplegics, although unable to stand unassisted, can derive both physiological and psychological benefits from standing.<a></a> Being able to stand allows a wheelchair user to reach work surfaces and interact with standing people at their level. There are static devices, called standing frames, that hold a person in a standing position by binding him to an upright, rigid structure. The user must pull himself up from a seated position into the device and secure the binding straps or close and latch a supporting gate. The manipulations involved may require the assistance of another person. A more complicated device that allows more independent operation by the user is the mobile Stander that uses a power source to raise the person to a standing position and support him there. This principle has been incorporated into two forms of wheeled mobility. In the one form, the person may move slowly around for short distances on smooth surfaces after he rises to the standing position by controlling an electrically powered drive mechanism. In the other form, the assistive force standup mechanism has been added to a wheelchair. When the occupant is standing, the device is immobile. When the occupant is seated, it functions as a regular wheelchair. Another standing device, but one that provides a modicum of mobility is the swivel walker, or "parapodium," that is used by a very few paraplegic adults. <h3>Ambulation</h3> Walking is the most common form of mobility for humans and the mode most desired by people who have limitations that diminish or eliminate their ambulation abilities. Where there is any possibility of a mechanism to regain the ability to walk or move about in a standing posture, even if it is slow and requires great expenditure of energy, a person often prefers to ambulate rather than use wheeled mobility. Even temporary standing, without walking, can be used to enable a person to get through narrow entry ways, such as toilet compartments, bathrooms, and closets. The desire to remain upright has sustained the development and application of torso and leg braces, standing aids, and even artificial stimulation of paralyzed muscles by externally supplied electrical signals. At a lesion level around high thoracic, the instability of the torso suggests that ambulation may be less secure and more demanding of energy than wheeled mobility. <h3>Stability</h3> One of the more important considerations in assuring the fullest functional mobility of the SCI patient is stabilizing the proximal parts of the body in order to facilitate the most controlled movements of the distal portions. The person fitted with the finest of upper limb orthoses or supplied with the most elaborate vehicle control system will be substantially incapable of adequate performance if the body is not appropriately stabilized. Securing the proximal portions of the body is a critical consideration and can easily be both underestimated and overdone. It is quite common that a patient will be trained to substitute certain spared muscle functions for those that have been impaired. If a substitute muscle is occupied with stabilizing the torso, it will be effectively unavailable for its substitute function. Similarly, if the proximal base of distal limb segments has been too severely confined, the distal functions will be limited. In general, the SCI patient will be concerned with use of the upper body for control and work tasks, so the primary concern should be focused on providing a secure base for the torso, while retaining a sufficient range of upper body motion to allow the arms and hands to perform functional tasks. These principles will be restated more specifically in the sections that follow. <h3>Wheeled Mobility</h3> When walking is not an option, or when the upper limits of speed and range of ambulation are too low for the mobility needs of the person or the occasion, the indicated mobility aid is the wheelchair or any one of a variety of wheeled devices. The basic, most familiar form of the wheelchair is a shiny, tubular metal, open-framed structure that has four wheels, two small casters in front and two large drive wheels in the rear. Details of implementation vary slightly, but the design remains essentially the same from brand to brand. They are intended to fit an average sized person, withstand heavy use with minimal maintenance, and be propelled primarily by an attendant. A wheelchair produced for these purposes is known in the industry as a commodity wheelchair and is intended for temporary use by any one person but repeated use by many people. This is the type of wheelchair that insurance companies and government-based reimbursement programs provide for nursing home and convalescent use. Chronic users of wheelchairs should not use a commodity chair, but should be guided toward the use of a prescription wheelchair, which looks similar to the commodity chair, but is available in a variety of dimensions that can be more carefully sized to the user and embodies some optional features that better suit the demands of everyday, independent usage. Prescription wheelchairs tend to be lighter in weight, more durable, and offer less resistance to rolling than the commodity type because of the use of more specifically suitable materials and components and more exacting tolerances in their manufacture. Available options include variations in wheel and tire size and type, variable seating dimensions and configurations, removeable armrests and footrests, and selection of frame and upholstery material and color.<a></a> The diameter of the wheel and type of tire affect the maneuverability, rolling resistance, and riding comfort. Hard rubber or polymeric tires offer less rolling resistance than pneumatic tires, but transmit more of the shock of pathway irregularities to the rider than the softer, pneumatic tires. Similarly, small diameter wheels offer less inertial resistance to rolling than larger diameters, but the greater curvature imparts higher impact forces to the rider and inhibits movement over rough surfaces. For a chronic user, a wheelchair should be very carefully sized and the components and accessories selected to assure efficiency of operation, postural support, and prevention of medical complications of disability. In general, a wheelchair should be as narrow as possible without pressing against the hips, thereby allowing the greatest freedom of access through narrow passageways and the maximum of mechanical advantage for propulsion and control. The back height should provide good postural support, but minimize interference with the arms during a propulsion stroke. Low level, active paraplegics may prefer a very low back to maximize freedom of arm and upper body movements. The height of the seat bottom is governed by three dependent variables; arm access to the pushrims, footplate clearance above the ground, and even distribution of the sitting load along the underside of the thighs and buttocks (taking the compressed thickness of any cushion into consideration).<a></a> The wheelchair seat cushion is a crucially important accessory component for a person who does not have sensation in the lower body and legs.<a></a> A cushion is intended to help distribute the gravitational loading forces of the occupant over the broadest possible area of the sitting surface and minimize the point pressure that occurs near the bony prominences of the pelvis and hips. There are many types of cushions that utilize a broad variety of materials and configurations, such as polyethylene foam, air and fluid-filled pillows, and semirigid and custom contoured devices. Each design has proponents who claim it is the best universal solution to the problem of pressure sores (decubitus ulcers), a major health problem for paralyzed persons with diminished or absent sensation. Since the formation of de-cubiti is related to many factors, such as pressure distribution and duration, temperature, moisture, diet, activity level and seating geometry,<a></a> it follows that no cushion can serve as a universal preventative measure. However, it is generally accepted by clinicians and users that there is a type of cushion best suited to each individual and careful selection for each person is important. It has also become increasingly more common for wheelchair seating experts to recommend that the hammock-style seat be replaced with a rigid member to provide a solid support structure for the type of cushioning material that is chosen. Hammock seats tend to wrap around the buttocks, creating a squeezing and shearing force pattern that tends to restrict tissue circulation. Also, the hammock is inherently unstable as a support for a high center of mass. The prescription wheelchair has recently undergone a rapid evolution in materials and design, resulting in lighter weight, smoother operation, greater durability and a change of image for the user. Wheelchairs are now offered in a mosaic of materials, colors, frame styles, and applications.<a></a> Largely because of the demand and innovations arising from the wheelchair sports movement, a new breed of daily use wheelchair has been developed and the market has accepted it with enthusiasm and buyer support. The new breed of wheelchair, now being labelled the "ultralight," embodies higher performance materials and design innovations including radial, rather than crossed (bicycle style) spoke patterns, aluminum alloy rims and hubs, die cast metal or injection molded polymeric wheels, adjustable position (fore/aft and up/down) and angle of axles, rigid (non-folding) and take-apart frames, and designer colors in anodized and polymeric finishes. The new product is less medical in appearance, more energy efficient to use, and more reliable and durable to the user. Although most of these changes have been directed at the manually propelled wheelchair for active adult paraplegics, some of the same innovations are beginning to be applied to powered chairs as well. The addition of mechanisms that propel the vehicle using electric motor power has provided a means of independent mobility for previously dependent users with quadriplegia. The most commonly used powered wheelchairs are supplied from the manufacturer as an integrated product that combines conventional frame and seating design with motorized propulsion. The power drive wheelchair (also called "electric" and "battery powered") was originally the result of relatively minor design improvements to the basic tubular metal wheelchair. Beginning in the early 1970s, the concept of a wheeled device, especially for severely disabled users, was reexamined by designers in North America and Europe. The result of that scrutiny was a proliferation of design ideas and clinical studies, some of which have resulted in commercially viable products. Out of that innovation revolution, stimulated in part by government supported research programs and workshops,<a></a> have come significant changes in propulsion and control of the electrically powered vehicle, an understanding of the health and performance benefits of carefully seating and positioning the occupant, and two new distinctly different types of powered vehicles. The first thrust of innovation dealt with obtaining new control modes for the user who could not operate the conventional joystick controller. One of the most common modifications of the powered wheelchair, and most important to the independence of the user, is the relocation or other alteration of the operator control device (typically an electromechanical joystick). It is now possible, with the purchase of options from the wheelchair manufacturer, or modifications developed by separate suppliers, for a severely impaired person to drive a powered wheelchair using any available physical movement on the body, including the head, chin, eyes and feet. It is also possible now to control a powered wheelchair with oral modulation of the breath and pneumatically powered electronic switching (the "sip and puff" control). The second most noteworthy trend in the redesign of the basic vehicle has been the separation of the seating function from the vehicular function. Conventional wheelchairs had been designed so that the chassis of the vehicle and the frame supporting the seat were the same. Therefore, changing the seat meant changing the total unit. The current focus on separating the functions has freed the vehicle designers and body positioning designers to pursue independent courses of study, resulting in both improved vehicle performance and enhanced comfort and health for the user. Scientific knowledge of the biomechanics and physiology of the wheelchair occupant is now being more appropriately applied to the development of specialized seating systems that position the body statically, and periodically reposition it, to promote improved vascular circulation and breathing, pressure relief and posture, leading to greater comfort, health, and prolonged periods of functional independence for the user.<a></a> An entirely different form of vehicle, the powered cart, has also been developed during the past decade, primarily for people who are ambulatory, but limited in speed and range of ambulation. The cart does not look like the basic wheelchair, rather a scaled-down, one person version of the familiar golf cart. Intended primarily for public use by less severely disabled people, the cart is available in a variety of three and four-wheel versions with either tiller or joystick control. People who might otherwise use ambulatory aids or manually-propelled wheelchairs may choose a cart to gain greater speed, range, and (in some models) rough terrain travelling capabilities. Use of the cart should be confined, however, to areas where motor vehicles are not likely to travel. On the road travel for wheelchair users should be limited to persons riding in specially adapted automobiles, trucks, and buses. <h3>Adapted Motor Vehicles</h3> As a passenger or as an operator, a spinal cord injured person can greatly extend his range of travel by using a motor vehicle. The motor vehicle, whether a passenger car, a truck, or a mass transit vehicle, presents some significant impediments to use by an SCI person and typically must be modified to accommodate him. The impediments can be roughly grouped into three categories: access, securement, and control. In order to safely and comfortably use a motor vehicle, a person must be able to get into (and out of) the vehicle, be seated comfortably and secured against any hazards that are presented by vehicle motion, and, if feasible, he must be able to exercise guidance or accessory control over the vehicle. Access to the vehicle is the pivotal concern, for if the individual cannot enter the vehicle, securement and control functions are moot. Entry into a vehicle is affected by the size and shape of the doorway, the height and slope of the ground just outside the vehicle, and the amount of time consumed in the boarding process; these parameters can be effectively controlled with an adapted personal vehicle. Mass transit vehicles, which are designed to quickly transport large numbers of people, present a great challenge to people who use ambulation aids and wheelchairs because transit systems typically operate on hurried schedules and boarding occurs in tight spaces. Access to busses, trains, and airplanes is a problem if the person cannot enter the vehicle where it is normally available for boarding without displacing other passengers or delaying the route schedule. Despite these conflicts, many of the modern mass transportation systems have incorporated accommodations for mobility limited people and their mobility devices.<a></a> Older systems are typically not accessible and not feasible for retrofit. Personal vehicles and small busses for groups of mobility impaired people, however, can be selected and effectively adapted with structural modifications and add-on products. Personal vehicles are more adaptable. Many people prefer to use a passenger sedan, rather than a van or bus, simply because it is smaller and less costly to own and operate. Paralyzed people, except for those who ride power drive wheelchairs, can get into a sedan without using special access equipment, but may need a little more time than able-bodied people. They must learn to be selective about the place on the sidewalk, at the curb, or in the garage where they board, because the height and slope of the ground often affect the ease of boarding. Generally desirable features in a car include a tall, wide door opening, a door that swings open to a large angle, and a seat at chair height with firm padding and low friction upholstery. A broad driprail or handle located overhead near the door opening can give a person something to hold or pull against during the transfer process. Large interior leg space is important, especially to someone who wears a long leg brace. Seating is only part of the access problem, since once the person is seated, the mobility aid must be stowed. A crutch or cane can be stowed inside the car, but a walker may be too bulky unless it is the type that folds up for storage. A wheelchair creates a special problem which will be discussed later. The person who can enter a passenger car, even with difficulty, may find entry to a van or bus to be impossible because the height of the seat from the ground is typically too great to enable direct sitting from outside the van. The person must enter the van before sitting. Van seats more nearly resemble a chair in height and attitude, so they are more accommodating to a mobility impaired person than the seats of a passenger car, but the height of the entry step on a van is as much an impediment to an ambulatory SCI person as stairsteps in a building. Even if he can surmount the stepwell and get inside, he cannot stand upright either for sitting or moving about, unless the roof has been extended. On vans that have been modified for a raised roof, the side or rear cargo doorway is also modified to give more head clearance to people entering and leaving the passenger area. To accomplish the transition from ground level to the level of the van floor, both ambulatory people and wheelchair users can be aided by a ramp or a platform lift. The ramp is the least expensive access device and offers the most trouble free service, but another person is needed both to deploy it into operating position and to assist the user while he is traversing the bridge. The lift, though more expensive, is frequently preferred over the ramp. For attendant operation, a lift carries the load, thereby reducing the labor and risk of injury. Unlike a ramp, certain types of lifts can be self-operated by a passenger in a wheelchair. There are two general designs of platform lifts: the folding lift (also called flop-out) and the swinging lift (also called rotary). A lift of the folding type consists of a platform for supporting and carrying the passenger and an electromechanical or electrohydraulic power mechanism that provides the lifting force. Deployed for operation, it unfolds outward to a horizontal attitude ready for moving the passenger between the floor and ground levels. The folding lift is usually offered in semi or fully automatic operating modes. The semi-automatic version raises and lowers under power while an attendant provides the controlling function as well as the stowage operation (opening/closing doors and folding/ unfolding the platform). The more complicated, and more costly, fully automatic version is further equipped with switches and drive mechanisms that allow the user to control the entire process independently. Typically, the installation of a fully-automatic lift is accompanied by the installation of a powered door opener and an external lift access control panel to complete the total system of components that provide the user with a capability for independent access to the vehicle. The swinging lift is almost always provided in a fully-automatic configuration. The platform travels vertically outside the opened cargo door between ground and vehicle floor levels. At the floor level, the platform swings (rotates) about a vertical axis into the vehicle and remains there for its stowed position, thereby limiting the available floor space inside the vehicle. This type of lift is somewhat less expensive to purchase and is lighter in weight than the folding type, but typically will not accommodate a full-sized powered wheelchair or cart. Many users of wheelchairs can transfer to the automobile or van seat without assistance. Often the transfer is aided by the sliding across a transfer board and sometimes by pulling up on an overhead handle or wriststrap. Each person must develop his own transfer technique based on the spatial geometry of the opened doorway, the location of the seat and vehicle interior appointments, and the nature of his physical ability. The transfer process will also vary with the vehicle being used and nature of the trip. Use of a taxicab, rental car, or a friend's car presents a greater challenge because of the variability of vehicle type, many of which are not suitable to the individual wheelchair user. After transferring themselves into the car, passengers (or drivers) of sedan-type vehicles must load the wheelchair into the car or park it at the debarkation point before they can close the door. If an attendant (or cab driver) is present, the chair can be placed in the trunk, in the back seat, or on a special rack attached to the back bumper. The independent wheelchair user must either stow the wheelchair (folded or dismantled) inside the car behind the front seat or on the roof outside. Strong and agile paraplegics can usually fold the chair and pull it inside. Those who are less able sometimes use a rooftop carrier to stow the chair. A passenger who transfers to a seat inside a van (a desirable practice from the standpoint of safety) can usually tether the empty wheelchair next to him inside the van, making it readily accessible for re-transfer and exiting the vehicle. Access to the vehicle seat does not complete the process of safely preparing for travel. The passenger should be secured. With many SCI people, safety securement is more than a crash protection mechanism, because they may have insufficient upper body strength to withstand common vehicle accelerations. A seatbelt or over-the-shoulder harness can be very important for both purposes. When an ambulatory person is seated in a vehicle, he can almost always use the conventional safety restraint belt for passenger security. So can a wheelchair user who is able to transfer from the wheelchair to the vehicle seat. When a wheelchair user cannot transfer, he should use some form of restraining device. As a general rule, both the wheelchair and its occupant should be restrained (separately) by a vehicle structural member. Many designs of restraining devices have been tried and tested by researchers and manufacturers. To date, only two relatively satisfactory approaches have been produced. In one, the wheelchair is permanently fitted with an additional structural subassembly which serves to reinforce the structural integrity of the wheelchair and engage a mating assembly that is securely anchored to the frame of the van. Though demonstrated to be an impact resistant combination,<a></a> this approach has the disadvantage of restricting a passenger to the use of a van that carries the mating structure and of imposing additional weight on the routine mobility of the wheelchair, demanding additional propulsive energy from either the arms of the occupant or the batteries of the power system. A second approach separately tethers the wheelchair and the wheelchair occupant to the vehicle structure, using belts. The tethering operation is virtually impossible for a wheelchair user to perform independently and is time-consuming even for an attendant. Some of the restraint devices that are provided for wheelchairs, however adequate to the task for wheelchairs of the basic design, will not engage certain forms of wheeled mobility aids at all. Passengers using such non-standard aids must often travel unrestrained. Many SCI people can be adapted to driving.<a></a> Although they may lack the leg and arm function required to operate the pedals and steering wheel, they may employ specialized products called automotive adaptive controls (also called hand controls and foot controls). Such devices transfer the locus of driving control from its conventional position in the vehicle to a location and configuration that can be operated effectively by parts of the body that are functionally able to handle the task. If the feet are not able to operate the throttle or brake pedals, a mechanical linkage can be added to transfer the input to a hand-operated lever. For most products, the throttle and brake are combined into a single lever. Since the hand-control completely occupies one hand with starting and stopping, the other hand must do all the steering. If that hand is limited in strength, common to quadriplegics, a steering wheel spinner may be needed to assure constant hand contact with the wheel throughout its rotational circuit. Spinners are available in a variety of configurations, depending on the nature of the hand disability. Other adaptive devices take the form of extensions of vehicle control levers, shafts, and pedals (such as turn signal, gear selector, steering column, throttle, brake, and emergency brake) that improve the mechanical advantage, extend the locus of activation, or transfer the operation to the opposite side. Hand controls typically do not prevent another person, who is not disabled in driving function, to drive the car since the conventional controls remain intact, having been added-to rather than replaced. Just extending and relocating the application of forces is sometimes inadequate to enable a quadriplegic to drive. Where conventional power assisted steering and braking requires more force than the driver can exert, it is possible to further reduce the force or range of movement required to operate the controls by performing a more extensive modification of the vehicle control components. Reduced effort steering, throttle, and brake conversions diminish the force the driver must supply. Since the driver who needs force amplification is unable to operate the vehicle without the modification, the complete reduced-effort system should be supplied with backup power that will sustain hydraulic and vacuum reserves, even if the engine (the primary source) fails. With the use of a reduced-effort system, the mechanical advantage of a large diameter steering wheel and extended lever arms is no longer needed, so the range of movement of the input controls can be reduced to accommodate limitations in upper extremity movement. A small diameter steering wheel, even one that is repositioned through universal joints and angular drives (so-called "horizontal steering"), extends the possibility of driving to people with even greater limitations of limb movement. As with all mobility aids, professional help with selection and training is very important to the ultimate successful application of automotive adaptive aids. Specialized assessment and training facilities have been established in conjunction with major rehabilitation centers worldwide. The staff of these centers typically includes a therapist, a driver trainer, and an equipment specialist who combine their expertise to provide the disabled driver candidate with comprehensive assessment, equipment selection, vehicle modification, and driver training.<a></a> In some areas, the vendor of vehicle adaptive equipment and modifications is responsible for the recommendation of products and services, but the more comprehensive clinical team approach seems to be more objective. <h3>Conclusion</h3> Helping to attain mobility for the spinal cord injured individual is a multiparameter equation. Mobility is key and essential to almost all aspects of the process of rehabilitation and return to active life postinjury. Many products and technologies are available to help extend the residual capabilities of the patient. A team approach to mobility assessment, prescription, and training will greatly encourage the development of a system approach that can lead to a well integrated plan for the user. References: <ol> <li>Axelson, Peter W., Dennis Gurski, and Ann Lasko-Harvill, "Standing and Its Importance in Spinal Cord Injury Management," Proceedings of the Tenth Annual Conference on Rehabilitation Technology, San Jose, California, June, 1987, pp. 477-479.</li> <li>Bolton, Michael, "The Ann Arbor Transportation Authority's Experience," Proceedings of the National Workshop on Bus-Wheelchair Accessibility, Seattle, Washington, May 7-9, 1986, U.S. Urban Mass Transportation Administration, DOT-1-87-11, pp. 2-16-2-21.</li> <li>Brubaker, Clifford, Ph.D., "Fitting a Person with a Chair," Clinical Supplement No. 2, "Choosing a Wheelchair System," Journal of Rehabilitation Research and Development, Veterans Administration Rehabilitation Research and Development Service, Baltimore, Maryland (in press).</li> <li>Crase, Nancy (editor), "Fourth Annual Survey of the Lightweights," Sports 'N Spokes, 11:6, March/April, 1986, pp. 19-30.</li> <li>Hobson, Douglas A. and Elaine B. Treffler, "Towards Matching Needs with Technical Approaches in Specialized Seating," Proceedings of the Seventh Annual Conference of the Rehabilitation Engineering Society of North America, June, 1984, Ottawa, Canada, pp. 486-488.</li> <li>Luce, Thomas P., The Handicapped Driver's Mobility Guide, American Automobile Association, Traffic Safety Department, Falls Church, Virginia, 1984.</li> <li>McFarland, Samuel R., "Personal Licensed Vehicles for Disabled Persons," Paraplegia News, 36(6), June, 1982, pp. 33-38.</li> <li>McFarland, Samuel R. and Lawrence A. Scadden, "Marketing Rehabilitation Engineering," SOMA, Engineering for the Human Body, 1:2, American Society of Mechanical Engineers, New York, July, 1986, pp. 19-23.</li> <li>Phillips, Lynn, Peter Axelson, Mark Ozer, M.D., and Howard Chizeck, Spinal Cord Injury, A Guide for the Patient and Family, Raven Press, New York, New York, 1987.</li> <li>Proceedings of the National Symposium on "Care, Treatment and Prevention of Decubitis Ulcers," Sponsored by the Paralyzed Veterans of America, Washington, D.C, November, 1984.</li> <li>Schneider, Lawrence W., Ph.D., "Sled Impact Tests of Wheelchair Tie-Down Systems for Handicapped Drivers," Project Report, University of Michigan Transportation Research Institute, Ann Arbor, 1985.</li> <li>"Specifications for Making Buildings and Facilities Accessible to and Usable by Handicapped People," ANSI Standard No. A117.1-1980, American National Standards Institute, New York, New York.</li> <li>The American College Dictionary, Random House, New York, New York, 1967, p. 780.</li> <li>Wheelchair III, Report of a Workshop on "Specially Adapted Wheelchairs and Sports Wheelchairs," Sponsored by the Veterans Administration Rehabilitation Research and Development Service and the Rehabilitation Engineering Society of North America, LaJolla, California, September, 1982.</li> <li>Wilson, A. Bennett, Jr., Wheelchairs, A Prescription Guide, Rehabilitation Press, Charlottesville, Virginia, 1986.</li> <li>Zacharkov, Dennis, Wheelchair Posture and Pressure Sores, Charles C. Thomas, 1984.</li> </ol> *Samuel R. McFarland, MSME Samuel R. McFarland, MSME, is Director of Rehabilitation Engineering at the National Rehabilitation Hospital, 102 Irving Street, N.W., Washington, D.C. 20010. Page Number(s) 215 - 224 Year 1987 Volume 11 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Mobility and Mobility Devices for the Spinal Cord Injured Person Creator An entity primarily responsible for making the resource Samuel R. McFarland, MSME * https://staging.drfop.org/files/original/1191469674a4152e921228b656aa1dfe.pdf d08f2c16efeb47cb114ce1f919ffdaed Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_210.pdf Text Any textual data included in the document <h2>Orthotic Management of the Surgically Stabilized Spine in Quadriplegic and Paraplegic Patients</h2> <h5>Michael MacMillan, M.D. <a style="text-decoration: none;">*</a> E. Shannon Stauffer, M.D. <a style="text-decoration: none;">*</a> Daryl G. Barth, C.P.O. <a style="text-decoration: none;">*</a></h5> Recent developments in the diagnosis and understanding of spinal dysfunction have affected both surgical and orthotic management of post-traumatic spine instability. The diagnosis of spinal instability has been clarified by clinical study of its natural history and by application of advanced imaging techniques.<a></a> Biomechanical studies have defined the role of each vertebral component in maintaining structural stability.<a></a> Surgical techniques and instrumentation for treating this problem have also evolved rapidly. These advances have resulted in an improved approach toward operative management of spinal instability. First, because the outcome of spinal injury can be more accurately predicted, surgery can be elected earlier for disorders that certainly would fail with nonoperative management. Surgery systems are available which maximize their effect in both obtaining and maintaining optimal spine positions. These reliable instruments have allowed surgeons to apply operative stabilization to a wider range of spine problems. Therefore, the orthotist is presented with an increasing number of patients who have undergone surgical stabilization and require postoperative immobilization. The purpose of this paper is to review the rationale for surgical treatment of traumatic spine disorders. This review will identify both the neurological and mechanical factors which must be addressed. Some of the instrumentation systems available and a few of their advantages and disadvantages will be examined. Finally, five separate areas of the spine will be identified and the special orthotic considerations in each region reviewed. The primary concern in all injuries to the spine is the neurologic status of the patient. There are three general categories of neurologic injury for which reduction and stabilization of the spine improves recovery.<a></a> The first group includes the Brown-Sequard, anterior cord, and posterior cord syndromes. These are collectively known as incomplete cord syndromes. Stabilization of the spine in the presence of these lesions can significantly improve neurologic recovery in a majority of cases. The second class of neurologic injury which is benefited by stabilization is nerve root compression at the cervical level. The recovery of a single nerve root at the cervical level dramatically improves the function of the patient for the rest of his life. This recovery can be facilitated by stabilization. The final lesion helped by internal fixation is the progressive neurological deficit. Often motion at a site of neurologic damage aggravates the injury. Surgical stabilization can reduce irritation and promote recovery. Thus, irrespective of the integrity of the spine, surgery can be indicated for neurologic conditions alone. However, loss of structural integrity can itself be an indication of operative treatment. If an area of bony disruption has resulted in significant deformity or has compromised the spine's ability to resist further deformity, surgical stabilization may be indicated. Authors have established guidelines for angulations and displacements to define this instability, but in all cases the final diagnosis of instability is largely clinical.<a></a> Pain at an area of compromised stability may also be an indication to reduce and stabilize a lesion. However, again the final determination is made on clinical grounds. If internal fixation of the spine is indicated, the subsequent step is the selection of an instrumentation system and postoperative immobilization method for that patient. In dealing with quadriplegic and paraplegic patients, a major concern is skin insensitivity. Although postoperative cast immobilization provides the most rigid support and protection, it also presents the highest risk for skin and wound complications. It is generally agreed that orthoses which can be removed once or twice a day for skin inspection are best suited for neurologically impaired individuals.<a></a> The dilemma the surgeon faces is how to mobilize the patient as soon as possible after surgery, yet not use the rigid protection of casts. The solution to this problem has been the development of more rigid internal fixation systems for the spine. Ultimately, the characteristics of the spinal column disruption determines the choice of instrumentation. Flexion, compression, and distraction are the three major mechanisms of spinal injury. Rarely does one force occur totally independent of the others. Usually one force is predominant with variable effect of the other two. The instability resulting from each of these forces, the instrument techniques used to counteract each of the deforming forces, and finally how the postoperative orthosis is also used to counter the mechanism of injury will be discussed. Fractures which result primarily from flexion often involve crushing of the vertebral body anteriorly and distraction of the posterior elements. Generally speaking, instrumentation systems to correct this problem rely on three-point bending to reduce the fracture and maintain position. The Harrington system uses a single hook at either end of a rod to effect leverage against the kyphus and create an extension force. A long rod is required for this, so that excessive force is not generated under the single hook. In order to shorten the length of the rod and improve fixation, other systems have developed methods for attaching the rod to every segment over which it passes. The Luque, Wisconsin, and Cotrel-Dubosset instruments are examples of this segmental type fixation. These systems have three advantages over Harrington rods. By fixing the rod to each segment over which it passes, the large leverage force necessary to reduce the deformity is evenly distributed over several segments. This reduces pull-out failure. Because this force is distributed evenly, it is possible to reduce the total number of segments stabilized by the rod, thus preserving spinal motion segments. And finally, these segmental fixation systems are significantly more stable, which helps promote bony fusion of the injured segment. Another method of obtaining three-point reduction while improving instrument fixation is the use of transpedicular screws for placement of the hardware. This system uses a short plate placed over the vertex of the kyphus, and then screws placed through the plate are firmly anchored to the uninjured vertebra above-and-below the fracture. As the screws are tightened, the kyphus is slowly reduced. These devices involve the least number of normal vertebral segments to achieve reduction. They are exemplified by Steffee and Roy-Camille plates. The segmentally fixed rods and transpedicu-larly anchored plates described above have excellent immediate stability. The major requirement of the postoperative orthosis is to reduce the stress on the implant by preventing repetitive forward bending of the patient. Orthotic requirements for Harrington rods systems are more demanding. With only single hook attachment, Harrington rods require an orthosis which generates a supplementary three-point bending force to reduce the possibility of hook pull-out. Because there are multiple unfixed segments where fusion is expected to occur, postoperative mobilization should be rigid enough to prevent non-unions from rotation and side-bending movements. In fractures where axial compression is the major deformity, the vertebral body can burst both anteriorly and posteriorly. To reduce the fracture, an instrumentation system capable of distracting vertebral segments is chosen. Again, Harrington rods can be used in this situation. They have a hook in one end that can be ratcheted against the rod to distract and pull apart the segments above and below the crushed vertebra. Segmental wiring alone is ineffective in reducing vertebral body burst fractures. However, many surgeons first use Harrington rods to counteract the compressive force, then use wires attached to the rod at every level to get the advantages of segmental wiring. This combination is lightly referred to as "Harri Luque." Plates anchored to the spine with transpedicular screws are incapable of generating a distracting force. An experimental Swiss system attaches a threaded distractor to the spine with screws and can be used to distract burst-type fractures. Orthoses cannot effectively counteract an axial load, or the results of the compressive mechanism of injury. Therefore, the orthosis is used exclusively to protect the implants from stress while the bone graft is consolidating. Again, the orthosis is most clearly indicated when Harrington rods are the only instruments maintaining the reduction. These single hook rods are subject to dislodgement if excessive bending or torsional forces are encountered. The loss of structural integrity resulting from distraction injuries has different implications in the diagnosis and treatment of this instability. While flexion and compression forces generally cause anterior bony collapse, distraction injuries tend to cause posterior ligament disruption. Since the injury is a traumatic tearing of ligaments and discs, the instrumentation is used to compress or pull the separated segments together. In the thoracolumbar spine, hooks enclose the vertebrae above and below the site of injury and are connected by a threaded rod. Turning of the rod slowly approximates the hooks and reduces the deformity. However, this type of injury predominantly occurs in the cervical spine. In this location, wires are usually used to draw the separated segments together. Because of the ineffectiveness of ligamentous healing, bone graft fusion is used in conjunction with internal fixation. Postoperative orthotic management in this situation is more complementary than supplementary. Whereas the internal fixation stabilizes in flexion, it offers little resistance to extension. Therefore, the orthosis should emphasize stability in extension. For the sake of completeness, orthotic management after anterior spinal decompression and fusion should also be mentioned. When this procedure is performed, most of the affected vertebra is removed and replaced with a block of iliac bone graft. Present anterior spine instrumentation uses a threaded rod attached to the spine with screws to afford stability. Control of motion in all planes by the orthosis is required in this clinical situation. The previous section dealt with the indications and techniques of spinal internal fixation, with emphasis on the role of postoperative orthotic management. Next, five regions in the spine and some specific orthotic requirements for each will be identified. Particular emphasis will be placed on whether a specific injury requires an orthosis to restrict or only to reduce intervertebral motion. When an orthosis restricts intervertebral motion, less than ten percent of normal motion is possible at that segment with the orthosis in place. An orthosis which restricts motion is used when either no or minimal internal fixation is used to provide stability. When up to 30% of motion at an intervertebral segment is possible while wearing an orthosis, the orthosis is said to only reduce intervertebral motion and not restrict it. A reduction orthosis is indicated to protect inherently stable fractures or spines internally stabilized secondary to surgery. The first anatomic area to be discussed is the upper cervical spine. In this area, instability can result from fractures of the atlas, from fractures of the odontoid process, and from disease processes such as rheumatoid arthritis and tumors. Orthoses generally are inadequate in restricting intervertebral motion between the occipito-atlanto-axial segments. Therefore, for virtually any upper cervical disorder requiring restriction of intervertebral motion, application of a halo and vest is indicated.<a></a> One possible exception is the SOMI brace, which can be used to effectively restrict instability from ruptures and attrition of the transverse ligament of the atlas.<a></a> The second anatomical area is the lower cervical spine. This extends from C3 through T1. Restriction of motion in this region is required in at least three situations. One is a flexion injury which compresses the vertebral body anteriorly and disrupts ligaments posteriorly. A second need for restriction is for extension injuries which avulse both the anterior longitudinal ligament and the intervertebral disc. A final situation is postoperative management of lower cervical fusions in which no internal fixation is used. In these situations, a cervicothoracic four-poster device should be used. If only reduction of intervertebral motion is required, then application of a Philadelphia collar is all that is necessary. The usual clinical situation needing reduction of intervertebral motion is immobilization after posterior cervical stabilization with wires. The third anatomical region lies between T3 and T10. The thoracic region possesses the most inherent stability of the entire spine. For this reason, the bracing requirements are minimal. If no internal fixation is performed, the stabilization afforded by the thoracic cage need only be supplemented by a thoracolumbosacral orthosis (TLSO) to ensure maintenance of position. Segmental type operative fixation is especially suited for the thoracic spine. When this is performed, often no postoperative orthosis is required. Postoperative immobilization is still required in the thoracic spine when Harrington instrumentation is employed. In the fourth region, the thoracolumbar junction, the use of orthotic management is dependent on whether or not surgical stabilization is performed and if so, which instruments are used. In this area, from T11 through L3, the typical fracture occurs from a combination of flexion and compression forces and is termed a "burst" fracture. Nonoperative management of this lesion relies on bracing to create an extension moment to reduce the amount of collapse during healing. Operative treatment has a combined goal: to reduce and hold the fractured segments while leaving mobile as many normal lumbar segments as possible. For this reason either segmentally attached rods or transpedic-ularly applied plates are used in this area. Since these systems possess significant inherent stability, the TLSO provides effective postoperative immobilization. This orthosis has been demonstrated to be effective for the upper lumbar spine.<a></a> The final anatomical area, the lumbosacral spine including L4, is least subject to traumatic fractures. It does, however, present some interesting challenges to obtaining effective immobilization. Operative treatment in this area should also preserve as many mobile lumbar segments as possible. With L4 fractures, the lumbosacral articulation can often be maintained. However, the more rare L5 fractures usually require fusion to the sacrum. Because of the need for short but extremely rigid spinal instrumentation, systems using transpedicular fixation are favored for lumbosacral fusions. Although this fixation method is rigid, the high stresses at the lumbosacral junction dictate that external immobilization be used, especially if two level fusions are attempted. The TLSO has almost no ability to immobilize the lumbosacral motion segment. Therefore, the use of a one-half spica cast is recommended for use after lumbosacral surgery.<a></a> In summary, the role of orthotics in the postoperative management of spinal instability is critical. Because the lack of normal sensation precludes the use of casts in quadriplegics and paraplegics, the proper fabrication and application of an orthosis is essential. Knowledge of the original fractures forces, as well as an understanding of the principles of operative stabilization, can assist the orthotist in managing the postoperative immobilization of the injured spine. References: <ol> <li>Denis, F., "Spinal Stability as Defined by the Three-column Spine Concept in Acute Spinal Trauma," Clin Ortho, 189, 1984, pp. 65-76.</li> <li>Sances, A., J.B. Myklebust, D.J. Mainman, S.J. Larsen, J.F. Cusick, R.W. Jodat, The Biomechanics of Spinal Injuries. CRC Critical Reviews in Biomedical Engineering 11(1), 1984, pp. 1-65.</li> <li>Stauffer, E.S., "Neurologic Recovery Following Injuries to the Cervical Spinal Cord and Nerve Roots," Spine, 9(5), 1987, pp. 532-3.</li> <li>White, A.A., M.D. Panjabi, I. Posner, W.T. Edward, W.C. Hayes, "Spinal Stability: Evaluation and Treatment," AAOS Instructional Course Lectures Volume XXXIV. The Spine. Chapter 23. CV Mosby, St. Louis-Toronto-Princeton, 1985.</li> <li>Dickson, J.H., D.R. Harrington, W.D. Erwin, "Results of Reduction and Stabilization of the Severely Fractured Thoracic and Lumbar Spine, "J Bone and Joint Surg, 60A(6), 1978, pp. 799-805.</li> <li>Bradford, D.S., B.A. Akbarnia, R.B. Winter, E.L. Seljeskog, "Surgical Stabilization of Fracture and Fracture Dislocations of the Thoracic," Spine, 2(3), 1977, pp. 185-196.</li> <li>Johnson, R.M., D.L. Hart, E.F. Simmons, G.R. Ransby, W.O. Southwich, "Cervical Orthoses," J Bone and Joint Surg, 59A(3), pp. 332-339.</li> <li>Fidler, M.W., "The effect of four types of support on the segmental mobility of the lumbosacral spine," J Bone and Joint Surg, 65A(7), 1983, pp. 963-7.</li> </ol> *Daryl G. Barth, C.P.O. Daryl G. Barth, C.P.O., is Assistant Director of Orthotic and Prosthetic Services for the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine. *E. Shannon Stauffer, M.D. E. Shannon Stauffer, M.D., is Professor of Chairman of the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine. *Michael MacMillan, M.D. Michael MacMillan, M.D., has a Spinal Fellow with the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine in Springfield, Illinois. Page Number(s) 210 - 214 Year 1987 Volume 11 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthotic Management of the Surgically Stabilized Spine in Quadriplegic and Paraplegic Patients Creator An entity primarily responsible for making the resource Michael MacMillan, M.D. * E. Shannon Stauffer, M.D. * Daryl G. Barth, C.P.O. * https://staging.drfop.org/files/original/593a03bd32e0a38628a533eb480e570b.pdf 7b1c18e73ced8fe84e9ce8c8c1551759 https://staging.drfop.org/files/original/7abfc3f82f27d4cae4864fbc83eaa7ca.jpg 51ff09f2f28f7f856979e6a6880eb923 https://staging.drfop.org/files/original/38ff763dad0b8d9e9954644067509495.jpg bd3bf6528c0085cc6aec3c8e955cb979 https://staging.drfop.org/files/original/f8e2a31c0bd3f95b729300ee8c9879cc.jpg 28b176e97650c170308ba1a969fc1571 https://staging.drfop.org/files/original/f562a9fa3c3f94727515c29bd75cc559.jpg ef14a7b5fad4b0c30065f491fcc01227 https://staging.drfop.org/files/original/6952f83ebe300a2539999786a8831c6a.jpg 3a2eea97c038487eeb84b84f6f4c61c8 https://staging.drfop.org/files/original/a314d14c2a1d04870c0d8d62a4925f3e.jpg fa6737f21ac8c44366271c5a592814ec https://staging.drfop.org/files/original/32544d213596bd32eea634e714494839.jpg 41c5aef37e93e2a99658b953ffde267b https://staging.drfop.org/files/original/95627bf9ee488969ba0a0130899f6d6b.jpg 5ca5658e1c297471c234c6713c8746de https://staging.drfop.org/files/original/e48666013dc08eecebb3d1cb7fe5473f.jpg 3d05ef9c7dd1ba2645c171d070eb7714 https://staging.drfop.org/files/original/45a501b0f715878b320272e655015f75.jpg 93ea84bf6b4d4429ef22f77912316288 https://staging.drfop.org/files/original/5ee12f7068fd98808db19c82e6b00c57.jpg 930d382e602d78a03a66fab3ed2e7f66 https://staging.drfop.org/files/original/313f5c71cdce0cf79795463dcc4a01e4.jpg b50b7f4e4974f517055a27ac650ed7d3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_201.pdf Text Any textual data included in the document <h2>The Team Approach to Orthotic Management in Quadriplegia</h2> <h5>Wayne R. Rosen, CO. <a style="text-decoration: none;">*</a> Janie J. McColey, O.T.R. <a style="text-decoration: none;">*</a> John H. Bowker, M.D. <a style="text-decoration: none;">*</a></h5> This article presents the approach to orthotic intervention in quadriplegia taken at the University of Miami/Jackson Memorial Rehabilitation Center. To begin, it must be emphasized that quadriplegia implies not only loss of walking, but also loss of normal use of the hands. Since our hands are the tools with which we sustain life, a major goal of rehabilitation must be to restore the ability to independently carry out common activities of daily living such as feeding, grooming, and manipulation of devices which may allow resumption of educational and vocational goals.<a></a> As health care professionals in the rehabilitation field, we must be aware of advances in technique and equipment which can enhance the ever-increasing life span of this young population whose educational, economic, and social progress has been so severely curtailed.<a></a> The role of the orthotist and occupational therapist as members of the rehabilitation team is to address this very underemphasized problem of upper limb management. When the spinal cord team is first asked to evaluate and treat a newly injured quadriplegic patient, they must take into consideration all aspects of care, not just those in their individual areas of specialization. During the acute medical phase, the emphasis is on preserving life and preventing further neurological damage. At this stage, there is little concern for joint positioning or splinting. After life-threatening problems have been addressed, however, prompt management of the upper limbs is of primary importance if we are to avoid joint stiffness and/or deformity which would interfere with the progression of rehabilitation.<a></a> This approach to the upper limbs involves a number of basic methods: frequent joint range of motion, limb positioning with and without positioning devices (temporary and permanent), dynamic orthoses (temporary and permanent), and externally powered orthoses. In our facility, spinal cord injured patients are initially placed on Roto-Rest beds. These beds, with their continuously alternating side-to-side motion, have proven to have a positive effect on the respiratory, renal and circulatory systems, as well as providing skin protection for the S.C.I. patient.<a></a> There is, however, potential for loss of glenohumeral and scapular mobility with its use for extended periods. We have currently adapted the bed so as to allow positioning of the shoulders in abduction and external rotation, alternating with the usual adduction and internal rotation. This change of shoulder position has been included in our regular routine of joint range of motion and should reduce the pain and stiffness that often interferes with arm placement and coordination.<a></a> Elbow flexion-forearm supination deformity is another potential problem, especially in C5 quadriplegics.<a></a> This may be managed by positioning the elbow in extension and pronation between range of motion sessions. The use of thermoplastic elbow-extension splints (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg">Fig. 1</a>), bivalved casts (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg">Fig. 2</a>), or serial casting (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg">Fig. 3</a>), will assist the therapist in maintaining proper position. Functional hand position should be maintained with the use of a resting hand splint (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg">Fig. 4</a>) or a functional long opponens splint with C-bar and lumbrical bar (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg">Fig. 5</a>), to avoid the development of a flat "simian" hand. <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg">Figure 1. Elbow Control Orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg">Figure 2. Bivalved plaster cast.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg">Figure 3. Serial casting (Plaster of Paris).</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg">Figure 4. Thermoplastic resting splint.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg">Figure 5. Long opponens with MCP extension stop.</a> Once the patient is medically stable, he is able to begin a more active phase of rehabilitation, including the use of functional orthoses, if appropriate. His response to this whole process depends largely on the success of the first few days, which in turn depends on how the treatment team constructs the patient's first experiences of sitting, trunk balancing, and functional arm placement. Only when control of these factors is satisfactory will it be appropriate to introduce orthoses for function. This becomes a critical point in time for the patient and therapist, because two possible approaches to future functional activities exist. The first approach is based on the use of adaptive devices which will allow some patients to perform specific functions such as self-feeding and oral-facial hygiene. However, it is our feeling that even at this early stage, multipurpose temporary functional orthoses must be introduced if definitive orthoses are to play a useful part in the patient's life. Therapists should be prepared to fabricate and properly fit a training orthosis, which will allow the patient reasonable options in developing his functional goals.<a></a> The following chart provides guidelines for management techniques according to the level of remaining neurologic function. Many of the orthotic options listed in the "Recommended Management" column are from the N.Y.U. Upper Extremity Orthotics Manual.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-07.jpg">Chart, Chart (cont'd)</a> The guidelines listed above have been generally accepted throughout the world as the rational basis for orthotic intervention. The following variables, however, must receive equal consideration before an orthosis can be successfully fit to a patient. Locality The patient should reside not only reasonably close to a facility capable of adjusting his orthosis, but should have accessible transportation available if a problem arises. Cost Sufficient funds must be allocated to cover not only the initial cost of the orthosis prescribed but also maintenance and replacement as necessary.<a></a> Gadget Tolerance The patient must have the patience to don and doff the orthosis or he will discard it because it "takes too long to apply." He may then actually prefer to sacrifice his independent performance of intricate manual tasks by either choosing a less effective piece of adaptive equipment or relying on another person for assistance. We, as practitioners, must monitor the attitude of a candidate to be sure that the function of the orthosis will be greater than the perceived inconvenience of wearing it.<a></a> Dominance The hand preferred prior to injury for writing and activities of daily living will usually be maintained as the dominant hand. This hand should be fit initially and the patient's progress monitored with specific activities before fitting the nondominant hand. Specific activity usage will determine whether or not the second orthosis is indicated.<a></a> Vocation/Avocation The patient's ability to perform fundamental activities of daily living is basic to maximum restoration, but it is equally important to determine additional intended uses of the orthosis, both vocationally and avocationally (i.e., manual work, desk work, telephone answering services). These data will help determine the type of materials suitable for fabrication or even the type of orthosis that would best suit the individual's needs.<a></a> Psychological/Familial Roles Assessment of the patient's psychological status is vital in establishing a treatment plan. Psychological make-up of the individual can play a very large role as to whether or not the patient will accept an orthosis. In this regard, cosmesis may play as important a role as function when dealing with a person's already altered body image. Psychological intervention is necessary to assist the patient through the stages of denial, anger, and depression to final adaptation. Indeed, the team members may need help in dealing with their own value systems regarding quality of life in relation to long term disability. The personalities of the patient and family members, as well as those of the orthotist and occupational therapist, play important roles in rehabilitation after a spinal cord injury. An air of confidence emanates from professionals who are comfortable and confident with the task at hand. This confidence can be passed on to the patient, who will in turn become comfortable and confident with the orthosis being fitted. Too often, however, therapists and orthotists are not comfortable with the intricacies of fabricating upper limb orthoses, leaving the patient at a disadvantage as he begins his rehabilitation process, in that he may not be made aware of all the options available, but rather only those preferred by the professionals. Therefore, it is necessary to assemble a team of practitioners who are well versed in all aspects of their respective specialties so as to not hinder the patient in an already stressful situation. Family support is also extremely important as a reinforcement of professional recommendations. Clear, concise instructions should be given to the patient and family members in order to increase the effective use of the orthosis.<a></a> Economics Since most orthotists in private practice cannot afford the luxury of skill maintenance for the small part of orthotic practice represented by upper limb orthotics, the majority of these devices are being made in an institutional setting, where an orthotist and occupational therapist on staff service the needs of quadriplegics. More time and energy can then be devoted, with less concern for monetary return, to fabrication and fitting of a complex device such as a wrist-driven prehension orthosis. Being on-site means quicker response time to the patient with no travel time for the practitioner, which also means that more time can be spent actually working with the patient as the need for adjustment arises. The expertise afforded by a qualified and skilled team of practitioners to the patient can only help an already trying and difficult situation.<a></a> Through a team approach to orthotic evaluation of the spinal cord injured patient, the best orthosis for that individual should be provided. That does not necessarily mean the most complex or expensive orthosis. It means that, given a specific clinical picture, an orthosis is chosen based on all the factors previously discussed. The purpose of setting standards and guidelines is to increase the success rate of our patients, in allowing them every opportunity to return to a meaningful lifestyle. When this occurs, we as practitioners have done our job and can consider the input of our specialty a success. Conversely, our failures have a negative effect on both the patient and the practitioner. For the patient, it becomes a setback in that his hospital stay may be extended or, more importantly, the potential for independence may be lost because of rejection of the orthosis. For the practitioner, it may be not only a time of second-guessing, but a learning experience at the patient's expense. Our approach to fitting of functional orthoses is as follows. All candidates for wrist driven prehension orthoses are initially fitted by the occupational therapist with a temporary training orthosis, namely the Rehabilitation Institute of Chicago (R.I.C.) tenodesis splint (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg">Fig. 6</a>). The patient then trains for a period of time determined by the therapist. Once he has mastered this device, he can be fit by the orthotist with a definitive orthosis. The choice at our facility is the Engen wrist-driven prehension orthosis (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg">Figure 7</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg">Fig. 8</a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg">Fig. 9</a>). We feel this device best suits our needs because of ease of fit, adjustability, and cosmesis.<a></a> The occupational therapist trains the patient to use his orthosis for activities of daily living, including the important function of self-catheterization of the bladder.<a></a> By virtue of thorough training, we feel the acceptance rate of orthoses is increased. <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg">Figure 6. R.I.C., Tenodesis (temporary) splint with wrist extended and fingers apposed.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg">Figure 7. Wrist-driven prehension orthosis with wrist in neutral position and fingers open-Ranchos Los Amigos type.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg">Figure 8. Wrist-driven prehension orthosis with wrist extended and fingers apposed-Engen type.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg">Figure 9. Wrist-driven prehension orthosis (Modified N.Y.U.-I.R.M. system).</a> Unfortunately, our success rate with the Externally Powered Prehension Orthosis (EPPO) has not been as favorable as that of the wrist driven type (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg">Fig. 10</a>). Two-thirds of all EPPOs that have been fit at our institution have not been used long-term. The feedback from our patients is that they were trained throughout the long rehabilitation process to adapt with the aid of special equipment and then, just prior to discharge, given a brace to replace the adaptive equipment. The patient who spent four to six months in the rehabilitation facility would have perhaps a week to learn to function with his new orthosis. It is hardly surprising that, in most cases, the orthosis was discarded in favor of the adapted equipment with which they were familiar. The problem has been, that for high cervical injuries, a training version of an externally powered prehension orthosis does not exist. This problem could be solved by development of a training EPPO in which the components could be reused on different patients. The only parts of the orthosis that would need to be custom-made would be the hand shells. The cost to the patient for these would be minimal and in the long run we could save the patient the cost of a very expensive "closet trophy" if he proved to be a poor candidate. We have initiated this project as a joint effort of the Occupational Therapy Department and the Department of Orthotics. <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg">Figure 10. Externally powered prehension orthosis.</a> <h3>Summary</h3> The fabrication and fitting of functional upper limb orthoses in quadriplegia requires close team work, especially between the orthotist and occupational therapist if the ultimate goal of acceptance of the orthosis as a useful aid to activities of daily living is to be achieved. We feel strongly that quadriplegics with wrist extensors should be fitted early with a functional training orthosis rather than supplied with activity-specific adaptive equipment. A confident, caring attitude on the part of the occupational therapist and orthotist can also do much toward achieving this goal. For quadriplegics with shoulder and elbow motion but no wrist extension, a training version of an externally powered prehension orthosis is badly needed for evaluation prior to ordering a definitive device. Success in the fitting of complex orthoses such as these requires almost unlimited "gadget-tolerance" on the part of the practitioner, if not the patient. The ultimate professional responsibility is to be equipped with both the manual skills and the objectivity to introduce all available options to our patients for their acceptance or rejection. References: <ol> <li>Abrahams, D., R.D. Shrosbree, and A.G. Key, "A Functional Splint for the C5 Tetraplegic Arm," Paraplegia, 17:2, July, 1979, pp. 198-203.</li> <li>Allen, V.R., "Follow-up Study of Wrist-Driven Flexor-Hinge-Splint Use," The American Journal of Occupational Therapy, 25:8, 1971, pp. 420-422.</li> <li>Becker, D., M. Gonzalez, G. Amilcare, F. Eismont, and B. Green, "Prevention of Deep Venous Thrombosis in Patients with Acute Spinal Cord Injuries: Use of Rotating Treatment Tables," Neurosurgery, 20:5, 1987, pp. 675-677.</li> <li>Berard, E., J. Depassio, N. Pangaud, and J. Landi, "Self Catheterization: Urinary Complications and the Social Resettlement of Spinal Cord Injured Patients," Paraplegia, 23, 1985, p. 386.</li> <li>DeVivo, M.J., P.R. Fine, H.M. Maetz, and S.L. Stover, "Prevalence of Spinal Cord Injury: A Re-estimation Employing Life Table Techniques," Archives of Neurology, 37, 1980, pp. 707-708.</li> <li>Eisenberg, M.G. and D.O. Tierney, "Changing Demographic Profile of the Spinal Cord Injury Population: Implications for Health Care Support Systems," Paraplegia, 23, 1985, pp. 335-343.</li> <li>Fishman, S., et al., The Upper Extremity Orthotics Manual, New York University Post-graduate Medical School.</li> <li>Lamb, Jr., C.R., A.J. Booth, and M.E. Godfrey, "Flexor Hinge Splint: Modification to Allow Radial Deviation," Archives of Physical Medicine and Rehabilitation, 55, July, 1974, pp. 322-323.</li> <li>Meyer, C.M.H., R.D. Shrosbree, and D.L. Abrahams, "A Method of Rehabilitating the C6 Tetraplegic Hand," Paraplegia, 17, 1979-80, pp. 170-175.</li> <li>Nichols, P.J.R., S.L. Peach, R.J. Haworth, and J. Ennis, "The Value of Flexor Hand Splints," Prosthetics and Orthotics International, 2, 1978, pp. 86-94.</li> <li>Patterson, R.P., D. Halpern, and W.G. Kubicek, "A Proportionally Controlled Externally Powered Hand Splint," Archives of Physical Medicine and Rehabilitation, 52:9, September, 1971, pp. 434-438.</li> <li>Spieker, J.L. and B.J. Lethcoe, "Upper Extremity Functional Bracing: A Follow-Up Study," The American Journal of Occupational Therapy, 25:8, 1971, pp. 398-401.</li> <li>Stauffer, E.S. and V.L. Nickel, "Control Systems for Upper Extremity Function in Traumatic Quadriplegia," Paraplegia, 10, 1972, pp. 3-10.</li> <li>Yarkony, G.M., L.M. Bass, V. Keenan, III, and P.R. Meyer, Jr., "Contractures Complicating Spinal Cord Injury: Incidence and Comparison Between Spinal Cord Centre and General Hospital Acute Care," Paraplegia, 23, 1985, pp. 265-271.</li> <li>Zrubecky, G. and M. Stoger, "The Orthosis for Restoration of Prehensile Function in Tetraplegics," Paraplegia, 11, 1973, pp. 228-237.</li> </ol> *John H. Bowker, M.D. John H. Bowker, M.D., is Professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami School of Medicine and Medical Director of the University of Miami/Jackson Memorial Rehabilitation Center in Miami, Florida. *Janie J. McColey, O.T.R., is the Supervisor of Occupational Therapy, Spinal Cord Unit at the University of Miami/Jackson Memorial Rehabilitation Center in Miami. *Wayne R. Rosen, CO. Wayne R. Rosen, CO., C.P.E.D., is Chief Orthotist, Department of Prosthetics and Orthotics at the University of Miami/Jackson Memorial Rehabilitation Center, 1611 N.W. 12th Avenue, Miami, Florida 33136. <div style="width: 400px;"></div> Page Number(s) 201 - 209 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg Figure 6 CHART http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-07.jpg CHART CONT. http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-08.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg Figure 9 FIGURE 8 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg Figure 10 FIGURE 9 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg Figure 11 FIGURE 10 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Team Approach to Orthotic Management in Quadriplegia Creator An entity primarily responsible for making the resource Wayne R. Rosen, CO. * Janie J. McColey, O.T.R. * John H. Bowker, M.D. * https://staging.drfop.org/files/original/02e028e3e75d48a51464d262823def1c.pdf d29d6d36d9bfa48369439bb49c9a0cc0 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_199.pdf Text Any textual data included in the document <h2>The Basis of Orthotic Management in Quadriplegia</h2> <h5>John H. Bowker, M.D. </h5> Statistics indicate that there are 150,000-200,000 spinal cord injured persons in the United States.<a></a> Each year, approximately 10,000 newly injured are added to this figure. About 80% are males under the age of 40 years, while slightly more than half (53%) are quadriplegics, with low cervical injuries being most common.<a></a> In recent years, improved medical management has led to an increase in post-injury life expectancy in spinal cord injury to a probable 30 to 40 years.<a></a> This ever-increasing national prevalence of spinal cord injury poses major problems in rehabilitation, several of which will be addressed in this issue of Clinical Prosthetics and Orthotics. When the spinal cord team first confronts a person with a cervical spine injury, the first two priorities are preservation of life itself and prevention of further damage to the spinal cord and spinal nerve roots. Immobilization of the neck, followed by traction-reduction of vertebral malalignment, is carried out concomitantly with physiologic stabilization. Special studies, including magnetic resonance imaging, are then done to determine the need for immediate surgical relief of extrinsic pressure on the cord due to residual vertebral malalignment and/or fragments of bone or intervertebral disc. Intraoperative imaging with ultrasound further aids in the identification and removal of fragments causing extrinsic pressure. The preservation or restoration of function of just one nerve root by precise surgery of this sort can make the crucial difference between a modicum of independence and total dependence in self-care. Depending on the specific injury and the surgeon's preference, stabilization of the spine may be accomplished by means of a halo external fixation system alone or by internal fixation with wires and bone grafts, supplemented by an orthosis. In either case, stabilization will expedite the rapid mobilization of the patient. At this point, a decision can be made regarding the appropriateness of orthotic fitting. A brief mention has been made of the functional significance of each residual cervical nerve root in the quadriplegic. This may be further elaborated upon as follows: <ul> <li>Fourth cervical root (C-4): innervates the diaphragm, allowing independent breathing.</li> <li>Fifth cervical root (C-5): innervates the deltoid and biceps/brachialis, providing shoulder abduction/flexion and elbow flexion, respectively.</li> <li>Sixth cervical root (C-6): innervates the radial wrist extensors, permitting wrist dorsiflexion and a passive opposition of thumb and fingers by "tenodesis effect" of the finger flexors.</li> <li>Seventh cervical root (C-7): innervates the triceps, wrist flexors and finger extensors, allowing elbow extension, wrist volar flexion, and finger extension, respectively.</li> <li>Eighth cervical root (C-8): innervates the finger flexors, allowing a gross grasp.</li> <li>First thoracic root (T-1): innervates the intrinsic muscles of the hand, resulting in complete hand function, including grip and a precise thumb to finger pinch.</li> </ul> It is important to note three features of this progressive classification to develop a clearer understanding of its relative limitations. Firstly, many muscles are supplied by two roots. The root associated with a given muscle in the list above is that which primarily innervates that muscle. The preservation of the next lower root provides not only an additional distal function, but also greater strength in the muscle just above, due to the activation of additional motor units by this secondary nerve root. Again, this argues for preservation of every possible root. Secondly, preservation of root function is often asymmetrical. For example, a quadriplegic may have a functional level of C-5 on one side and C-6 on the other. In this case, an orthotic prescription for one side will be totally inappropriate for the other. Thirdly, with nerve fiber (axon) regrowth, improvement in strength of a given muscle may occur over time. Occasionally, even the next higher root may recover as well. Monitoring by repeated muscle testing can thus lead to a progressive change in orthotic prescription. The occupational therapist, by virtue of her close daily contact during the rehabilitation process, is often the first team member to note these changes. To aid in the prognosis of muscle return, it is now possible, by advanced biofeedback techniques, to find functioning motor units in muscles considered "paralyzed" by conventional muscle testing techniques. Following identification of working motor units, it may be possible to strengthen them with bio-feedback-directed exercise. This often results in the addition of another useful upper limb function with or without the help of an orthosis. Before an upper limb orthosis can be used, the quadriplegic must be positioned so that visual feedback allows contact between a partially insensate hand and the object to be manipulated. A properly designed and carefully fitted wheelchair can, therefore, be considered the basic orthosis for the quadriplegic. Lateral trunk supports or a corset may also be essential for functional sitting posture, freeing the upper limbs from supporting the trunk. Throughout the process of rehabilitation, the orthotist should work closely with all members of the team, but especially the occupational therapist, physical therapist, psychologist, and physician if acceptance and use of orthotic devices is to be achieved. Successfully fitted orthoses are useful not only for self-care, but can also play a major role in achieving the ultimate goal of rehabilitation, the return to gainful employment. Many types of electronic devices, including computers, are manipulated more easily with an orthosis. In conclusion, it is hoped that this issue will be helpful in not only delineating the unique role of the orthotist in the care of the quadriplegic, but equally importantly, in demonstrating the need for communication and cooperation among all team members, if we are to offer optimum care to our patients. References: <ol> <li>DiVivo, M.J., Fine, P.R., Maetz, H.M., and Stover, S.L., "Prevalence of Spinal Cord Injury: A Re-estimation Employing Life Table Techniques," Archives of Neurology, 37:1980, pp. 707-8.</li> <li>Eisenberg, M.G. and Tierney, D.O., "Changing Demographic Profile of the Spinal Cord Injury Population: Implications for Health Care Support Systems," Paraplegia, 23:1985, pp. 335-343.</li> <li>Green, B.A., Callahan, R.A., Klose, K.J., and DeLa-Torre, J., "Acute Spinal Cord Injury: Current Concepts," Clinical Orthopaedics and Related Research, 154:January-February, 1981, pp. 125-135.</li> <li>Young, J.S., Burns, P.E., Bowen, A.M., and McCut-chen, R., Spinal Cord Injury Statistics: Experience of the Regional Spinal Cord Systems, 1982, pp. 13-14.</li> </ol> Page Number(s) 199 - 200 Year 1987 Volume 11 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Basis of Orthotic Management in Quadriplegia Creator An entity primarily responsible for making the resource John H. Bowker, M.D. https://staging.drfop.org/files/original/bd8676bd2ae282b639f2399c6de321e3.pdf ffb53e28db8f2fc150a90906e09d5a19 https://staging.drfop.org/files/original/b5b98ec26d73edf01c22777a6f4f5372.jpg 2970dc2423a7e01f1bb92f8ceb1a1354 https://staging.drfop.org/files/original/bb57324218f589f3d313b6eacad77646.jpg 39967dc29d987500fb2008de8d00e469 https://staging.drfop.org/files/original/9f4e8fe4f15db8a5f8ba4d01ee1a70be.jpg 27a0ccb1ddc4f295ced948da5496ca58 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_173.pdf Text Any textual data included in the document <h2>Below-Knee Waterproof Sports Prosthesis with Joints and Corset</h2> <h5>Alfred W. Lehneis, CP. <a style="text-decoration: none;">*</a></h5> This article is concerned with the development of a waterproof below-knee prosthesis with knee joints and corset, utilizing the supracondylar/suprapatellar (SC/SP) suspension socket. A case report is described below. The patient had a below-knee amputation due to traumatic injury with a resultant amputation length of the tibia of approximately 1" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-1.jpg">Fig. 1</a>). This patient currently wears a PTB type socket with leather thigh corset, polycen-tric joints and an SC/SP suspension socket, thus, no auxilliary suspension was necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-2.jpg">Fig. 2</a>). He was doing well with this design in all activities of daily living, but desired a waterproof prosthesis for boating. <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-1.jpg">Figure 1. Length of tibia is approximately 1".</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-2.jpg">Figure 2. Patient currently wears a PTB type socket with a leather thigh corset.</a> In developing the waterproof design, the following components were utilized: Kingsley beachcomber foot, Otto Bock polycentric stainless steel knee joints, and a corset fabricated from 4mm Subortholen thermoplastic. Closures were 1" dacron straps with virgin nylon buckle closures used on scoliosis type body jackets. The fitting and fabrication of the prosthesis was as follows: the patient was casted (including the thigh) and the cast modified, using standard procedures for SC/SP suspension, an insert was fabricated from Pelite™, and the socket was fabricated with acrylic resin and carbon/glass reinforcements, especially at the side bar attachment sites. After fabrication of the socket, the socket was foamed up and set-up on a Staros-Gardner coupling and aligned atop the beachcomber foot. The bars were then attached directly to the socket (not over the foam build-up), and the area over the bars filled with fiberglass/resin putty. The thigh bars were contoured to the modified cast, over which the Subortholen thermoplastic had been molded and attached to the corset. The patient was then fitted and aligned in the usual manner, but while wearing topsider type boating shoes. After optimum alignment was achieved, the Staros/Gardener coupling was transferred out. This can be accomplished on a horizontal transfer device. The prosthesis was then shaped to the patient's tracing and measurements and reduced to accommodate the lamination thickness. The sole of the foot is then removed and a woman's nylon is pulled over the entire prosthesis, followed by the PVA sleeve. A lamination of one carbon-glass and two nylons without pigment is performed. After the lamination is set, the laminated shell is split longitudinally on the posterior aspect (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3</a>), taken off the prosthesis, and taped back together to retain its shape. <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Figure 3. The laminated shell is split longitudinally on the posterior aspect.</a> The shaped portion of the prosthesis is cut to allow for a 3" ankle block and the socket is cut at the base. The foam between the ankle and socket is now eliminated (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3</a>). The foam ankle block and the foam at the base of the socket can be sealed with a resin-silica mix to prevent water penetration. The laminated shell should be sealed with tape on the outside, and the seam should be sealed on the inside with Siegelharz. The socket and ankle block can then be bonded to the laminated shell. Once this is set, the outer shell should be sanded for a second lamination, and approximately 1" of the proximal socket and distal ankle block perimeter should be exposed (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3</a>). The prosthesis is then filled with sand through the hole at the bottom of the ankle block. The hole is then sealed with play dough. Lay-up of the prosthesis consists of six alternating layers of nylon and nyglass. Two pieces of polypropylene with 120° arcs (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3</a>) should be placed between the joints and the socket after the first two layers to allow attachment of the joint clevis after lamination. These pieces are removed after lamination. The foot drain hole is then reopened to release the sand. A second 1/2" hole should be drilled posterior and distal to the socket end to allow air to enter and escape the inner hollow of the leg. This allows water to enter and escape the foot drain hole and prevent bouyancy of the prosthesis. The thermoplastic corset is finished with a polyethylene tongue and dacron strap closures as described earlier. When assembling the prosthesis, bonding of the foot should be as recommended by Kingsley, Mfg. or using Devcon two-part epoxy. <h3>Acknowledgments</h3> The author gratefully acknowledges the technical contribution of Roger Losee, CO., and Robert Wilson, M.S., for the illustration in <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3.</a> *Alfred W. Lehneis, CP. Alfred W. Lehneis, CP., is with Lehneis Orthotics and Prosthetics Associates in Roslyn, New York. Page Number(s) 173 - 175 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.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 Below-Knee Waterproof Sports Prosthesis with Joints and Corset Creator An entity primarily responsible for making the resource Alfred W. Lehneis, CP. *