11 20 371 https://staging.drfop.org/files/original/e35faf467e1ea9e763ac08ddcf0dbfd3.pdf 1f9fe1e89568efceb15d185fd6f39011 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_001.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Harnessing- Here and Hereafter</h2> <h5>John Lyman, PhD <a style="text-decoration:none;">*</a><br /></h5> <p>However well designed the other parts of an artificial arm may be, the functional success of the upper-extremity prosthesis must ultimately depend upon the adequacy of the coupling between the human being and the inanimate mechanism. Since this man-machine linkage is intended to hold the arm on the stump and to secure from residual body sources the mechanical power necessary for operation and control of the prosthesis, the technique of constructing it has come to be known simply as "harnessing." Because body harness is such ah intimate piece of apparel, and because arm amputees exhibit the same kinds of individual differences as characterize the rest of the population, it seems likely that proper harnessing will long remain a tribute to the personal skill of the prosthetist, despite all advances in prefabricated components. Although the clinic team may prescribe the specifications for a prosthesis within the existing framework of medical and engineering knowledge, the final result depends largely upon the prosthetist's talent for constructing and fitting the harness in such a way as to meet anatomical, physiological, and functional requirements.</p> <p>Functionally, the harness may serve one or more of three purposes: it may hold the prosthesis in place; it may transmit power and excursion to produce force and movement in operating components; it may convey to the wearer the intelligence needed for arm control. In conventional construction of upper-extremity prostheses, it has been customary to rely upon the harness for the performance of all three of these services and, further, to obtain them all from a single harness system. Such an arrangement is of course grossly unlike that of the normal limb, where the control function, mediated by the nervous system, is clearly separated from the functions of suspension and of power transmission. Only in externally powered prostheses, as for examples the TBM Electric Arm and the Vaduz hand, has an attempt been made to separate the control function from the power and suspensory functions. Although to date such devices have not proved to be as useful or reliable as simpler ones, they are representative of an approach which may, in the long run, lead to far more refined limb substitutes than can be contemplated by further development of a harnessing philosophy which stresses the combining of suspension, power transmission, and control.</p> <p>The use of body power for operating an artificial arm forms an inherent control link between the neuromuscular system and the prosthesis. To the extent that a "closed loop" is effected via the sensory feedback available to the power-producing muscles, control of force and excursion through the power-transmission system is possible without the aid of external sensory-feedback loops such as vision and hearing. While the latter cues are generally present, they can at best serve only in an auxiliary capacity. The rich sensations of touch, pressure, pain, and temperature, which have been lost with the natural limb, have no substitute beyond their dim reflection in the signals from harness strap or cineplasty muscle pin of present-day prosthetics technology.</p> <p>One can argue, with considerable sustaining evidence, that the modern arm prosthesis is quite functionally adequate in most respects and that the addition of refinements in the form of further sensory cues for improved control would only complicate harnessing unnecessarily. But to take this viewpoint is paying tribute to the adaptability of the human mechanism rather than to the adequacy of today's prosthetics research and development. As facts currently stand, it appears that no clear-cut assessment has been made of the importance of sensory losses to the amputee. The effort has been to achieve prosthetic replacement of motor function, and it still is not generally recognized that this goal has been approached with the present degree of success only because sensory control loops are established incidentally in the course of harnessing for power transmission. The major inadequacies leading to failure in externally powered prostheses can be traced directly to shortcomings in the design of control loops-loops which are intrinsic even in the crudest of body-powered prostheses.</p> <p>Since in the present state of the art the optimum connection between the amputee and the operating mechanism is still so indispensable to the proper functioning of the upper-extremity prosthesis, this issue of Artificial Limbs is devoted to a summary of current harnessing technology as developed under the auspices of the Advisory Committee on Artificial Limbs. Although progress in the improvement of body harness has been substantial since World War II, even the latest techniques fall far short of duplicating the neuromuscular mechanism of the normal arm. And consequently there is still a great deal of forward-looking to be done in the research, development, and production phases of upper-extremity prosthetics.</p> <p>Where will the technology come from that may make possible "sensory prostheses" with attendant refinements in the present "motor prostheses"? Probably not directly from current trends in artificial-limb research. As is common knowledge, a very real and dynamic revolution is under way in the modern engineering sciences. It is accompanied by a plethora of popular terms like"cybernetics," "servomechanisms," "information theory," "digital and analogue computers," and "automation," to name a few. From the developments that are taking place, many new materials and processes are becoming available. Just as the aircraft industry, through the Northrop design studies, has contributed the present lightweight plastic artificial arm and the Bowden-cable transmission system, so it may be anticipated that within a relatively few years the electronics and missile industries may make even greater contributions. Compact, reliable, and lightweight items like the famed transistor may become as commonplace in the control systems for artificial arms as is presently the case in hearing aids. New products from metallurgy and chemistry may eventually make it possible to realize direct attachment of prosthetic devices to remaining skeletal members of the body through the skin and surrounding tissue, with consequent elimination of the socket and of the suspensory elements of harness. Much of the theory and much of the methodology for accomplishing the direct coupling of man to mechanism, including the all-important link to the nervous system for control, are either available already or else are promised within the foreseeable future.</p> <p>Because in the field of amputee rehabilitation there are never apt to be available the amounts of research money now characteristic of other fields of science and invention, it is fortunate that a systematic plan for the advancement of limb prosthetics has become so well established in the decade since World War II. The Artificial Limb Program furnishes an organized means of following progress in other areas and of adapting to limb substitutes new approaches and new techniques that would otherwise lie far beyond the purse of prosthetics research itself. The future in design of limb replacements is thus perhaps now greater than ever before. Even so, no matter how sophisticated upper-extremity prostheses may become, the actual utility of any given artificial arm will continue to reside largely in the degree to which the fitter can attain the optimum sensory-motor association through accomplished harnessmaking. In no other known way can so much satisfaction be afforded the individual arm amputee.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>John Lyman, PhD </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Engineering, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Harnessing- Here and Hereafter Creator An entity primarily responsible for making the resource John Lyman, PhD * https://staging.drfop.org/files/original/f97cfd5235b0aee89a8a246f3bb36a96.pdf 0611831203afbaea806f867bafac8a09 https://staging.drfop.org/files/original/c4503bd0ade204d8bd8febe76bbb6f56.jpg 19fcf5623ec96a54d6f85f8b60b2d008 https://staging.drfop.org/files/original/fb7cc1d43658e6003753aaa44c247f01.jpg 4ff3ceb12158adbee0cf9b90e7a640f2 https://staging.drfop.org/files/original/3fa04d3962c39877277abfdfa7e54654.jpg c5e9b43e7d407777ca340bd7247b7a56 https://staging.drfop.org/files/original/48dff4cea5f12c24f5a7ec7718c459fe.jpg 78b79fa22696174683179cfcb09a400f https://staging.drfop.org/files/original/01326057960c319c4b1259bcd805ddd3.jpg d07268216e98fea759014f362be88ab8 https://staging.drfop.org/files/original/d9b33408099151592c9792c42710a205.jpg 18fbe3ca5c7150b3dfecd879beced63b https://staging.drfop.org/files/original/62b4779e67198aad3af7f94c6224cfa5.jpg 97a440c22672ac2d9f3359115cf894d0 https://staging.drfop.org/files/original/14d93f4c4979723e691b143fa14c65ef.jpg 910dfa8cf554c1cb90120318e8acf61b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_099.pdf Text Any textual data included in the document <h2>Component Selection Criteria: Lower Limb Disarticulations</h2> <h5>John Michael, M.Ed., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Because disarticulations comprise only a small percentage of the lower limb amputations performed each year,<a></a> questions sometimes arise regarding the most appropriate components to select. This paper will present a brief overview in an effort to clarify the criteria involved.</p> <h3>Hip Disarticulation/Hemipelvectomy Components</h3> <p>For the hip disarticulation or hemipelvectomy case, component selection is generally analogous to the more familiar above-knee patient. Endoskeletal components are preferred for the high level amputee because they offer light-weight and enhanced cosmetic appearance. A clear trend away from steel components to the much lighter titanium or carbon fiber versions is apparent. Most systems (particularly the Otto Bock "Modular") also permit subtle realignment, even in the definitive prosthesis. This can be an advantage due to the complex interplay between the mechanical hip, knee, and foot mechanisms.</p> <h3>Hip Joint Mechanisms</h3> <p>In general, a free motion hip joint is preferred, as originally proposed by McLaurin in 1954.<a></a> Careful attention to alignment details results in a very stable configuration by virtue of the weight line and reaction line forces. This permits very safe weight-bearing, yet allows easy hip flexion during swing phase.</p> <p>Stride length is generally controlled by a spring or elastic flexion limiting apparatus, sometimes called an "extension bias." In modern practice, the joint is placed near the anterodistal quadrant of the socket, which sometimes requires a slightly shorter thigh segment for the best appearance when sitting.</p> <p>Manual locking hip joints are also available but should be reserved as the component of last resort, even for bilateral amputees. In addition to disrupting swing phase, locked joints require the use of one hand on the unlocking mechanism during sitting. This often makes a difficult task more complicated, particularly for the double amputee.</p> <p>More importantly, a locked hip joint may place the patient in a more dangerous position during a fall backwards. If the joint prevents flexion at the hips, the head rather than the buttocks may strike the ground first. In our last 50 consecutive fittings at Duke, both unilateral and bilateral hip/hemi patients have never required a locked joint to ambulate securely.</p> <p>Two variations in hip joint design warrant mention. Peter Tuil of the Netherlands advocates the use of a reversed polycentric knee disarticulation joint (Otto Bock 3R21) as a hip joint.<a></a> Benefits claimed are parallel to those expected from a polycentric knee unit: increased ground clearance during swing phase due to the inherent "shortening" of the linkage in flexion and enhanced stability at heel strike (<b>Fig. 1</b>).</p> <strong><a href="/files/original/c4503bd0ade204d8bd8febe76bbb6f56.jpg">Figure 1</a>. Prosthesis utilizing reversed polycentric knee disarticulation mechanism at the hip, as proposed by Peter Tuil of the Netherlands. (Courtesy of Orthotics &amp; Prosthetics, 38/1, p. 33.)</strong><br /> <p>This view has been corroborated in a number of fittings over the past few years at the Royal Ottawa Regional Rehabilitation Centre in Canada.<a></a> Such a technique has also worked well in our hands at Duke, although we are not certain the benefits fully justify the special effort involved.</p> <p>An even more intriguing concept is the "Hip Flexion Bias" modification promulgated by Haslem, et al. of Houston, Texas.<a></a> In this system, hip extension from heel strike to mid-stance compresses a specially selected spring, which encircles the endoskeletal pylon. At toe-off, this kinetic energy is released and the thigh segment is propelled briskly forward (<b>Fig. 2</b>).</p> <strong><a href="/files/original/fb7cc1d43658e6003753aaa44c247f01.jpg">Figure 2</a>. Hip Flexion Bias system designed by Haslam et al. of Houston, Texas. Note compression spring encircling thigh tube, which propels the limb forward during swing phase. (Redrawn from reference 5)</strong><br /> <p>Not only does this result in a much more cosmetically "normal" gait, it also significantly improves ground clearance in swing phase. One of the inherent limitations of the Canadian hip disarticulation alignment system is the prosthesis must be significantly short (1cm+) to avoid forcing the amputee to vault for toe clearance.</p> <p><b>Fig. 3</b> and <b>Fig. 4</b> illustrate the biomechanics of the Canadian design. At toe-off, the heel rises up during knee flexion and pulls the hip joint firmly against its posterior (extension) stop. The thigh segment remains vertical until the knee has reversed its direction of motion and contacted the knee stop. Only then does the thigh segment rotate anteriorly, causing the hip joint to flex. In essence, the prosthesis is at its full length during midswing. Since the patient has no voluntary control over any of the passive mechanical joints, the prosthetist is forced to shorten the limb for ground clearance.</p> <strong><a href="/files/original/3fa04d3962c39877277abfdfa7e54654.jpg">Figure 3</a>. Canadian prosthesis in early swing phase. Hip joint remains neutral as shank swings forward. (Redrawn from reference 13)</strong><br /><br /><strong><a href="/files/original/48dff4cea5f12c24f5a7ec7718c459fe.jpg">Figure 4</a>. Canadian prosthesis just after mid-swing. Hip joint does not flex until shank motion is arrested by terminal extension stop. Prosthesis is fully extended at the instant of mid-swing. (Redrawn from reference 13)</strong><br /> <p>The hip flexion bias system neatly avoids this dilemma. As a result, the prosthesis can be lengthened to a nearly level configuration in most cases. However, two potential problems have been noted with this approach. One is the development of annoying squeaks in the spring mechanism after a few months of use, which sometimes tend to recur inexorably.</p> <p>A more significant concern is that as the spring compresses between heel strike and midstance, it creates a strong knee flexion moment. Unless this is resisted by a stance control knee with friction brake or a polycentric knee with inherent stability, the patient may fall. Since the friction brake mechanisms lose their effectiveness as the surface wears, the polycentric knee is the preferred component with this hip mechanism.<a></a></p> <h3>Knee Joint Mechanisms</h3> <p>Other than the exception discussed above, knee mechanisms are selected by the same criteria as for above-knee amputees. The single axis/constant friction design remains the most widely utilized due to its light weight, low cost, and excellent durability. The friction resistance is often removed to ensure the knee reaches full extension as quickly as possible. A strong knee extension bias enhances this goal, offering the patient the most stable biomechanics possible with this mechanism.</p> <p>Although this was proposed as the knee of choice for the Canadian hip disarticulation design, more sophisticated mechanisms have proven their value and are gradually becoming more common. The friction brake stance control knee (Otto Bock 3R15 or equivalent) is probably the second most frequently utilized component.</p> <p>Because there is very little increase in cost or weight and reliability has been good, many clinicians feel the enhanced knee stability justifies this approach—particularly for the novice amputee. Mis-steps causing up to 15° knee flexion will not result in knee buckle, making gait training less difficult for the patient or therapist.</p> <p>The major drawback to this knee is that the limb must be non-weight-bearing for knee flexion to occur. Although this generally presents no problem during swing phase, some patients have difficulty mastering the weight shift necessary for sitting. It should be noted that use of such knee mechanisms bilaterally must be avoided. Since it is impossible for the amputee to simultaneously unload both artificial limbs, sitting with two stance control knees also becomes nearly impossible.</p> <p>A third class of knee mechanisms which has proven advantageous for this level of amputation is the polycentric group (Otto Bock 3R20 or equivalent). Although slightly heavier than the previous two types, this component offers maximum stance phase stability. Because the stability is inherent in the multi-linkage design, it does not erode as the knee mechanism wears during use.</p> <p>In addition, all polycentric mechanisms tend to "shorten" during swing phase, adding slightly to the toe clearance at that time. Many of the endoskeletal designs feature a readily adjustable knee extension stop. This permits significant changes to the biomechanical stability of the prosthesis, even in the definitive limb.</p> <p>Because of the powerful stability, good durability, and realignment capabilities of the endoskeletal polycentric mechanisms, they are particularly well suited for the bilateral amputee.<a></a> All levels of amputation, up to and including bilateral hemipelvectomy (hemicorporectomy), have successfully ambulated with these components.</p> <p>At first glance, a manual locking knee seems a logical choice. However, experience has shown this is rarely required, and should be reserved as a prescription of last resort. Only multiple medical disabilities (e.g. concomitant blindness) will require this mechanism. The complications in unlocking a joint for sitting by the unilateral have been discussed previously; expecting a bilateral amputee to cope with dual locking knees and dual locking hips can be an overwhelming task.</p> <p>For many years, the use of fluid controlled knee mechanisms for high level amputees was considered unwarranted, since these individuals obviously walked at only one (slow) cadence. The development of the hip flexion bias mechanism and more propulsive foot designs have challenged this assumption. Furthermore, a more sophisticated understanding of the details of prosthetic locomotion has revealed an additional advantage for the hip/hemi amputee.</p> <p>It is well accepted that any fluid control mechanism (hydraulic or pneumatic) results in a smoother gait.<a></a> Motion studies conducted at Northwestern University revealed that a more normal gait for the hip/hemi patient is also a by-product.<a></a></p> <p>The preferred mechanism has separate knee flexion and extension resistance adjustments. A relatively powerful flexion resistance limits heel rise and initiates forward motion of the shank more quickly. In essence, the limb steps forward more rapidly.</p> <p>As the shank moves into extension, the fluid resistance at the knee transmits the momentum up the thigh segment, pushing the hip joint forward into flexion. In essence, the fluid controlled knee results in a hip flexion bias effect (<b>Fig. 5</b>).</p> <strong><a href="/files/original/01326057960c319c4b1259bcd805ddd3.jpg">Figure 5</a>. Canadian prosthesis with fluid controlled knee mechanism at mid-swing. Hydraulic extension resistance allows shank momentum to flex hip joint. Increased ground clearance may result. (Adapted from reference 13)</strong><br /> <p>Sophisticated gait analyses have demonstrated that this results in significantly more normal range of motion at the hip joint during the walking cycle.<a></a> Clinical observations suggest that a more varied cadence is possible, and the prosthesis can usually be fabricated to nearly full length without swing phase difficulties.</p> <p>Richard Lehneis, et al. have reported on a coordinated hip-knee hydraulic linkage using a modified hydrapneumatic unit.<a></a> This was designed to create a hip extension bias, and resulted in a smooth gait. We have no experience with this particular component at Duke.</p> <p>Finally, a number of new components have been developed recently which combine the characteristics of some of the above classes of knee mechanisms. For example, Teh Lin manufactures a "Graphlite" knee consisting of a polycentric set-up with pneumatic swing phase control in a carbon fiber receptacle.</p> <h3>Foot Mechanisms</h3> <p>Traditionally, the Solid Ankle Cushion Heel (SACH) has been considered the foot of choice for the Canadian hip disarticulation design due to its light weight, low cost, and excellent durability.<a></a> Provided the heel durometer is very soft, knee stability with this foot has generally been quite acceptable.</p> <p>In those cases where slightly more knee stability was desired, a single axis foot with a very soft plantar flexion bumper was preferred.<a></a> Added weight, maintenance, and cost, plus reduced cosmesis are the liabilities of this component.</p> <p>Multi-axis designs (such as the Greissinger) have similar liabilities to the single axis versions, but add extra degrees of freedom via hindfoot inversion/eversion and transverse rotation. In addition to accommodating uneven ground, absorbing some of the torque of walking, and protecting the patient's skin from shear stresses, multi-motion feet seem to decrease the wear and tear on the prosthetic mechanisms as well.<a></a></p> <p>In the last five years, more sophisticated foot mechanisms have reached the market, and all have been demonstrated to function successfully for the high level amputee. The Solid Ankle Flexible Endoskeleton (SAFE) foot inaugurated a class that could be termed "Flexible Keel" designs.<a></a> Other members of this class include the STEN foot and the Otto Bock 1D10 Dynamic foot. All are characterized by a softer, more flexible forefoot, resulting in a smoother rollover for the patient. The SAFE version offers some transverse rotation as well.<a></a></p> <p>In general, a softer forefoot requires special care during dynamic alignment to ensure that knee buckle does not occur inadvertently. However, when used in concert with a polycentric knee, the reverse occurs: the prosthesis actually becomes safer during late stance phase.</p> <p>The polycentric knee mechanism strongly resists a bending moment, which leads to its powerful stability at heel strike. It flexes during swing phase only if the forefoot remains firmly planted on the floor as the body "rides" the prosthesis over it.<a></a> This creates a shearing force which disrupts the linkage and permits easy flexion of the knee. Because the softer flexible keel delays this shearing moment, the polycentric knee is actually more stable in late stance than with a more rigid foot.</p> <p>Dynamic Response feet, which provide a subjective sense of active push-off, can also be used to advantage for the hip/hemi amputee.<a></a> Carbon Copy II, Seattle foot, and Flex-Foot(tm) have all been successfully utilized for this type of patient. They seem to provide a more rapid cadence, as evidenced by one long-term hip disarticulation wearer, who stated after receiving a Seattle foot, "For the first time in my life, I can pass someone in a crowd."<a></a></p> <p>Once again, the interaction between the foot and knee must be carefully monitored. In general, the more responsive the foot mechanism, the more important the knee unit resistances become. Many practitioners prefer a fluid controlled knee, or at least one with powerful friction cells.<a></a> Otherwise, much of the forward momentum of the shank can be wasted as abrupt terminal impact of the knee. Presumed reductions in energy consumption have not yet been documented by scientific studies.</p> <p>In addition to the foot mechanisms, several ankle components have recently reached the American market. These can be paired with most of the feet mentioned above, adding additional degrees of motion as desired. Examples include the SwePro ankle from Sweden, the Blatchford (Endolite) Multifiex ankle from England, and the recently announced Seattle ankle.</p> <p>Torque absorbing units are often added to hip/hemi prostheses to reduce the shear forces transmitted to the patient and components.<a></a> Ideally, they are located just beneath the knee mechanism. This increases durability by placing the mechanism away from the sagittal stresses of the ankle, yet avoids the risk of introducing iatrogenic swing phase whips.</p> <p>The major justification for such a component is that the high level amputee has lost three biological joints and, hence, has no way to compensate for the normal rotation of ambulation. Torque absorbers can be combined with virtually any foot available, if desired.</p> <p>Finally, transverse rotation units originally developed for the Oriental world have become available. Installed above the knee mechanism, these devices permit the amputee to press a button and passively rotate the shank 90° or more for sitting comfort. They not only facilitate sitting cross-legged upon the floor, but also permit much easier entry into automobiles and other confined areas.</p> <h3>Knee Disarticulation Components</h3> <p>Although it is generally agreed that knee disarticulation offers the possibility of increased function over an above-knee amputation,<a></a> it clearly restricts patients' options in knee mechanisms and results in cosmetic compromises as well. For these reasons, its advisability remains hotly contested among knowledgeable surgeons and prosthetists.</p> <h3>Knee Mechanisms</h3> <p>The traditional knee mechanism for disarticulation has been the single pivot external hinges. Inherent disadvantages have been the lack of swing phase control (no friction adjustments) and rapid wear due to the small bearing surface compared to the typical 4" long axle of the above-knee set-up. Even with the addition of a posterior "back check" to limit extension, rapid wear of the extension stops is common.</p> <p>The major virtues of this design are its simplicity and low cost. It probably functions best for small children. Although the knee ball does not protrude when sitting, external hinges result in a slightly wider mediolateral configuration which some patients find objectionable. Heavy duty wearers can quickly destroy these relatively slender joints.</p> <p>One manufacturer provides a yoke attachment permitting the use of a fluid-controlled cylinder with these hinges (<b>Fig. 6</b>). This improves swing phase significantly, but long-term durability remains problematic.</p> <strong><a href="/files/original/d9b33408099151592c9792c42710a205.jpg">Figure 6</a>. Cut-away drawing of special hydraulic mechanism with yoke, permitting swing phase control for knee disarticulations with single pivot external hinges. (Redrawn with permission of Hosmer-Dorrance Corporation)</strong><br /> <p>The only other type of knee possible is a special polycentric design. By using longer linkage arms, the shank appears to fold back under the thigh when sitting, thus minimizing the apparent protrusion of the knee (<b>Fig. 7</b>). Since no mechanism is alongside the knee, the me-diolateral silhouette is more acceptable as well.</p> <strong><a href="/files/original/62b4779e67198aad3af7f94c6224cfa5.jpg">Figure 7</a>. Polycentric knee disarticulation mechanism flexed to 90°. Note how linkage "folds up" beneath the thigh segment, effectively shortening the shank and minimizing anterior protrusion when sitting.</strong><br /> <p>Several manufacturers offer the option of fluid controlled units along with the polycentric mechanism, and almost all have friction control options as well. For this reason, swing phase functioning is much better than the simple external hinge design (<b>Fig. 8</b>).</p> <strong><a href="/files/original/14d93f4c4979723e691b143fa14c65ef.jpg">Figure 8</a>. Example of polycentric mechanism permitting interchange of mechanical and fluid control swing phase units. (Designed by Orthopedic Hospital of Copenhagen; redrawn with permission of United States Manufacturing Company)</strong><br /> <p>All polycentrics offer powerful inherent stance phase control, and this group is no exception. However, because distal weight-bearing dramatically simplifies the biomechanics of knee control, this feature is seldom of great value to the patient. One manufacturer offers a manual locking module as well, but this should be used only as a last resort.</p> <p>One subtle problem with knee disarticulation polycentrics is that the relative "shortening" of the shank in sitting may lift the foot completely off the floor, particularly for husky individuals who are less than 5' 6" tall. The resulting sense of insecurity can be very disconcerting to the amputee and may result in rejection of the prosthesis.</p> <p>Durability can sometimes be a problem, although it is generally better than for external hinges. Most knee disarticulation polycentrics work quite well for geriatric patients but can become increasingly problematic for extremely vigorous individuals.</p> <p>In some cases, the only effective solution to chronic breakage problems is to switch to a conventional above-knee set-up. This results in protrusion of the knee ball by at least 2", making sitting in tight spaces (such as bus seats) nearly impossible. Although the function and durability are excellent, the cosmetic liability of such malalignment is obvious to the casual observer as well.</p> <h3>Foot Mechanisms</h3> <p>Knee disarticulates can utilize all the feet and ankle options of the higher level amputee, as previously discussed. Knee stability is rarely a concern, but reducing stress on the relatively fragile knee mechanism is a concern. For that reason, the author favors flexible keel designs, with or without a torque absorbing unit, since these components reduce the forces transmitted to the limb.</p> <h3>Ankle Disarticulation (Symes)</h3> <p>Like his knee disarticulate brethren, the Symes amputee has a very limited range of choices in prosthetic componentry. In addition, a significantly poorer cosmetic result is inevitable. These disadvantages must be weighed against the functional advantages of distal weightbearing and the documented reduction in energy consumption over the below-knee amputee.<a></a></p> <h3>Foot Mechanisms</h3> <p>The Symes amputation generally precludes the use of any articulated ankle mechanism, due to space limitations. The heavy metal frame of yesteryear is virtually extinct.</p> <p>Most of today's Symes amputees are fitted with a SACH foot. The specially designed Symes version suffers from reduced durability due to the greater stresses the end-bearing residual limb can exert on the prosthesis. However, it can often be replaced economically if broken.</p> <p>The external keel SACH design limits inversion and eversion almost completely but can be more durable and more cosmetically pleasing than the standard SACH. Since its use precludes any alteration of alignment after transfer and finishing, great care must be exercised during the fitting.</p> <p>The Stationary Ankle Flexible Endoskeleton (SAFE) foot, discussed earlier, has a Symes version. This offers a flexible keel and much smoother roll-over. This reduces the forces transmitted to the prosthetic socket, increasing both patient comfort and socket durability. Reliability is adequate, and replacement is possible. The author prefers this design for Symes amputees for the reasons cited.</p> <p>The Carbon Copy II has recently developed a dynamic response design suitable for many adult male Symes. Patient response has been favorable, as they sense the dynamic push-off it offers. External appearance is excellent, as is the weight reduction. Our experience at Duke is too short to comment at this time on durability of this component or its effect on socket stresses.</p> <h3>Summary</h3> <p>Although disarticulations represent less than five percent of the lower limb amputees fitted annually,<a></a> appropriate components can be selected based on logical criteria. Both Symes and knee disarticulates, however, have limited component options, often with decreased reliability plus cosmetic limitations compared to more conventional amputation levels.</p> <p>Hip disarticulates and hemipelvectomies have as broad an array of choices as the above-knee, prescribed for generally analogous reasons. As our understanding of biomechanics has improved, more sophisticated mechanisms have been successfully provided to this group of patients. Current state-of-the-art requires careful consideration of the subtle interactions between the foot, ankle, hip, and ancillary mechanisms to ensure the optimum result for each patient.</p> <p><b>References:</b></p> <ol> <li><a href="al/1963_01_005.asp">Glattly, Harold W., "A Preliminary Report on the Amputee Census," <i>Artificial Limbs</i>, 7(1), 1963, pp. 5-10.</a></li> <li>McLaurin, C.A., "Hip Disarticulation Prosthesis," Report No. 15, Prosthetic Services Centre, Department of Veterans Affairs, Toronto, Canada, 1954.</li> <li>Webster, B. and P. Tuil, "Heupexarticulates Onder De Loep," <i>Infortho</i>, August, 1982.</li> <li>Van der Waarde, Tony, "Ottawa Experience with Hip Disarticulation Prostheses," <i>Orthotics and Prosthetics</i>, 38(1), 1984, pp. 29-33.</li> <li>Haslam, T. and M. Wilson, "Hip Flexion Bias," <i>Concept</i> 80, Medical Center Prosthetics, Houston, Texas, 1980.</li> <li>Ibid.</li> <li>McLaurin, op. cit.</li> <li>Greene, Michael, "Four Bar Knee Linkage Analysis," <i>Orthotics and Prosthetics</i>, 37(1), 1983, pp. 15-24.</li> <li>Mooney, Vert, in <i>Atlas of Limb Prosthetics</i>, C.V. Mosby Company, St. Louis, 1981, pp. 391-395.</li> <li>Van Vorhis, Robert, "Clinical Analysis of Hip Disarticulation Prostheses," 31st Scientific Meeting, Midwest Chapter, AAOP, Lincolnshire, Illinois, 1981.</li> <li>Ibid.</li> <li>Lehneis, H.R. et al., <i>Prosthetics Management for High Level Lower Limb Amputees</i>, Institute of Rehabilitation Medicine, New York, New York, 1980.</li> <li>Hampton, F., <i>A Hemipelvectomy Prosthesis</i>, Northwestern University Prosthetic Research Center, Chicago, Illinois, 1964, p. 32.</li> <li>Gehl, Gunter, "Proper Selection of Prosthetic Components," Northwestern University Prosthetic Orthotic Center, Certificate course, Chicago, Illinois, 1976.</li> <li>Ibid.</li> <li>Michael, John, "Analysis of Energy Storing Feet," AAOP Annual Meeting and Scientific Symposium, Newport Beach, California, 1988.</li> <li>Campbell, J. and C. Childs, "The S.A.F.E. Foot," <i>Orthotics and Prosthetics</i>, 34(3), 1980, pp. 3-17.</li> <li>Nader, Max et al., "Polycentric, Four Bar Linkage Knee Joint," <i>Technical Information Bulletin</i> No. 45, Otto Bock Industries, Duderstadt, West Germany, 1988, p. 3.</li> <li>Michael, op. cit.</li> <li>Michael, J., "Energy Storing Feet: A Clinical Comparison," <i>Clinical Prosthetics and Orthotics</i>, 11(3), 1987, pp. 154-168.</li> <li>Leal, J., personal communication, 1987.</li> <li>Nader, Max et al., "Torsion Adapter With Tube," <i>Technical Information Bulletin No. 2.6.1</i>, Otto Bock Industries, Duderstadt, West Germany, 1986, p. 3.</li> <li><a href="poi/1983_02_119.asp">Jensen, J.S. and T. Mandrup-Poulsen, "Success Rate of Prosthetic Fitting After Major Amputations of The Lower Limb," <i>Prosthetics and Orthotics International</i>, 7(2), 1983, pp. 119-122.</a></li> <li>Waters, R.L. et al., "Energy Costs of Walking of Amputees: The Influence of Level of Amputation," <i>Journal of Bone and Joint Surgery</i>, 58A, 1976, p. 46.</li> <li>Glattly, op. cit.</li> </ol> <em><b>*John Michael, M.Ed., C.P.O. </b> John W. Michael, M.Ed., C.P.O., is Director and Assistant Clinical Professor at Duke University Department of Prosthetics and Orthotics, Duke University Medical Center, P.O. Box 3885, M04 Davison, Durham, North Carolina 27710; (919) 684-2474.<br /><br /><br /></em> Page Number(s) 99 - 108 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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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/1987_03_154.pdf Text Any textual data included in the document <h2>Energy Storing Feet: A Clinical Comparison</h2> <h5>John Michael, M.Ed., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The human foot is an exceedingly complex structure. The pair contain 52 separate bones, dozens of intrinsic muscles, and scores of extrinsic ones. The feet are composed of multiple layers of ligaments, fascia, and muscle, and contain numerous interrelated articulations.</p> <p>In combination with the ankle complex, the foot provides the dual functions of support and propulsion. Paradoxically, this is accomplished by combining the diametrically opposite characteristics of flexibility and rigidity as the foot adapts to the gait cycle.<a></a></p> <p>Despite hundreds of historical attempts to imitate this remarkable structure, very few designs have ever achieved widespread acceptance. Within the last three years, however, four new foot components have become commercially available—all in the previously unheard of class called "energy storing" designs. These intriguing new developments will be discussed in chronological order, summarizing our experience at Duke.</p> <h3>Seattle Foot™</h3> <p>In 1978, Bernice Kegal of the Prosthetics Research Study in Seattle published a paper entitled "Functional Capabilities of Lower Extremity Amputees,"<a></a> and noted that a major prosthetic limitation in sports activities was the inability to run. The vigorous amputee athlete was competing despite the components rather than because of them.</p> <p>The Prosthetics Research Study, in cooperation with engineers from Boeing aircraft, began developing a prosthetic foot specifically designed to store energy and release it at push off: the Seattle Foot™. First introduced in 1981 at a course in modern prosthetic rehabilitation presented by the American Academy of Orthopedic Surgeons, the Seattle Foot™ was later field tested by hundreds of Veterans Administration clients. Today, it should be widely acknowledged as the stimulus for the current explosion of new concepts in this area.</p> <p>The design specifics have varied over the past few years as the concept was refined. Originally, the keel was a fiberglas multi-leaf design, somewhat similar to an automobile suspension spring. The key concept was that as the patient increased his cadence, stiffer portions of the spring came into play. Various exotic materials were considered, including titanium, but were clinically impractical.<a></a></p> <p>The commercial version first became available in October, 1985 and consisted of a Delrin bolt block and integral keel, with Kevlar® toe pad (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg"><b>Fig. 1</b></a>). The entire structure is contained in a lifelike injection-molded polyurethane shape. To date, over 8,000 Seattle™ feet have been used in the United States.<a></a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg"><strong>Figure 1. Seattle Foot™ note cantilevered plastic spring keel to store energy (Courtesy MIND).</strong></a><br /> <p>Although patient acceptance has generally been good, several technical difficulties have been noted with this design. During the VA field-testing, catastrophic failure of the plastic keel occurred in some cases. This has been greatly reduced in the commercial version, provided the proper keel configuration is selected using the manufacturer's guidelines.</p> <p>Because of ongoing problems with failure of the flexible rubber toes at the keel tip, the polyurethane composition has recently been reformulated for more tear resistance.<a></a> About one third of our feet at Duke have failed in the forefoot, although all were replaced under manufacturer's warranty. We have experienced no catastrophic failures whatsoever in our series.</p> <p>The "Life-Molds," although very natural in appearance, have presented some difficulties. The first is that the forefoot is fairly wide and often difficult to fit into dress shoes, particularly narrow widths. In addition, there is no uniformity in dimensions from size to size, or even between left and right in the same size. For example, if a patient returns requesting a foot one size smaller since purchasing tighter shoes, and a 26cm foot is substituted for a 27cm foot, the prosthesis has been inadvertently shortened by 5mm (1/4"). Also, the stark contours of the original "Life-Molds" can be difficult to blend into the prosthetic ankle at the retromalleolar area, and are too muscular for some patients.</p> <p>The recently available "Ladies Molds" have effectively addressed the problems noted above. Redesign of the male version is underway, and is expected to achieve similar results.</p> <p>The Delrin keel has also been a source of problems. Because it is very slippery, inadvertent rotation and loss of toe out has occurred. Since drilling and pinning the bolt block would significantly increase the risk of breakage, the manufacturer recommends bonding the foot to the ankle block or endoskeletal adapter with hot-melt glue. This has eliminated problems with loss of toe out in our series at Duke, although we still experienced occasional problems with the keel "slipping" completely out of the polyurethane shell for active walkers.</p> <p>Problems have also been reported with occasional bolt breakage, and speculation regarding cold creep of the plastic has been voiced. The manufacturer supplies special bolts, locktite, and torque specifications to address this issue. We have experienced no bolt problems at Duke.</p> <p>Finally, this is the heaviest solid ankle design commercially available. Although most patients have no apparent difficulties, some find the weight objectionable. One volleyball player, in particular, rejected the foot for jumping activities, even though she found it excellent for jogging and similar sports.</p> <p>Despite the technical difficulties noted, our experience at Duke has generally been favorable. Patients often comment on the "lively" step permitted by the cantilevered spring design. We particularly favor this component in the smaller sizes (26cm and below), as the incidence of breakage seems reduced. One unilateral hip disarticulation amputee commented that the more active push off "lets me pass someone in a crowd for the first time since I became an amputee."<a></a></p> <h3>Flex-Foot™</h3> <p>At the same time the Seattle Foot™ was being developed, an independent collaboration between a plastics engineer and a young research prosthetist-amputee resulted in creation of the Flex-Foot™. This lightweight graphite composite structure offers a radically different approach. All are hand made from a computer-generated design specific to each individual patient. Data such as weight, activity level, and residual limb characteristics determine the specific orientation and thickness of reinforcement fibers.</p> <p>Ultra high pressure, high temperature molding insures the greatest possible strength to weight ratio, but requires several weeks for fabrication. Although this is a very costly approach, it does permit fitting the widest range of individuals. The chief restriction is that a minimum of five inches is required from the end of the residual limb to the floor, and seven inches or greater is preferred. Thus, the Flex-Foot™ is not suitable for small children, Symes and similar amputations, and very long below-knee residual limbs.<a></a></p> <p>Unlike any other component currently available, Flex-Foot™ utilizes the entire distance distal to the socket for function. Since it stores energy throughout its entire length rather than just within a four inch keel, this results in a very responsive and resilient component. It also significantly improves the mass distribution of the prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg"><strong>Figure 2. Flex-Foot™, showing full-length composite strut for energy return (Photo courtesy Flex-Foot, Inc.).</strong></a><br /> <p>Most multi-functional feet bolt onto the prosthesis at the ankle block, and are heavier than a conventional SACH foot. With the weight concentrated at the distal end, the limb swings as if it were a sledgehammer. Overcoming the inertia of this mass in order to propel it through space consumes energy, and the patient perceives it as "heavy."</p> <p>The Flex-Foot™, however, is more akin to an inverted sledgehammer. The bulk of the weight is in the socket and attachment cone, with the rest uniformly distributed in the pylon. This is analogous to holding the head of the sledge and swinging the handle through space. Even if the Flex-Foot™ prosthesis weighs nearly as much as the conventional limb, the patient finds it much easier to propel, and perceives it as "light." Actual weight savings of 10-15 percent are common, but patients typically perceive that the Flex-Foot™ weighs "half as much."</p> <p>Another advantage unique to the Flex-Foot™ is the ability to independently adjust the anterior and posterior lever arms. Overall stiffness is fabricated in at the factory, but tilting the pylon increases the anterior flexibility. Varying the length of the heel pylon independently controls its resistance. Conventional AP linear slide adjustments affect the resistances in the conventional manner: sliding the foot forward decreases posterior leverage while increasing the anterior resistance.</p> <p>Due to the complexity and magnitude of the inter-related alignment changes possible with the Flex-Foot™, we advocate use of a prototype prosthesis, at least initially. By dynamically aligning the new socket on a conventional foot using a conventional alignment fixture, mediolateral alignment and the quality of socket fitting can be easily evaluated and refined.</p> <p>Once these are satisfactory, the vertical transfer fixture can be used to permit substitution of the Flex-Foot™ pylon. A secondary dynamic alignment is then performed, permitting concentration on sagittal plane characteristics without being distracted by a multitude of adjustments in other planes.</p> <p>Although use of slow-motion video analysis has been of some value in refining the sagittal alignment, we strongly encourage an extended field trial prior to finishing the limb. Application of a PVC bag over the alignment fixture followed by several layers of fiberglass casting tape reinforcement will permit the patient to use the limb clinically for a week or two.</p> <p>Upon return to the laboratory, the fiberglass tape can be removed and the alignment further enhanced. As the patient becomes accustomed to the function of the Flex-Foot™, he will often prefer stronger anterior resistance. A knowledgeable physical therapist can be an asset at this stage, as the person must learn to shift his weight onto the Flex-Foot™ throughout stance phase and "ride it into toe off" in order to achieve maximum benefit from its push off characteristics.</p> <p>Casting tape should be reapplied and the field trial continued. Only when the patient returns, needing no additional alignment changes, can it be assumed the alignment is optimized, permitting transfer and finishing to proceed.</p> <p>A comprehensive fabrication manual is provided by the manufacturer,<a></a> and the instructions should be followed explicitly, particularly regarding reinforcement of the attachment cone. Tremendous stresses are concentrated where the resilient pylon meets the rigid socket, and structural failures of the lamination can occur if improperly fabricated.</p> <p>Cosmetic finishing is difficult and time-consuming, but results in a finished structure that is highly water resistant since the foam provided is used in life preserver construction. If immersion is anticipated, a final sealing coat of Lynadure or other flexible "skin" is recommended.</p> <p>Although our series is small, we have experienced no failures with the Flex-Foot™ system, even on very large and very active individuals. One high school athlete, who destroyed SACH and SAFE feet two or three times per year, has been playing varsity football with the Flex-Foot™ for two seasons without incident.</p> <p>The manufacturer reports an overall failure rate of less than four percent with over 2,500 units in the field. Most failures occurred where the heel pylon bolts attached to the anterior pylon. One common denominator has been a sudden increase in the patient's activity level after being fitted with the Flex-Foot™. A highly active individual (or one who has recently gained weight) using a pylon originally designed for standard duty applications is at risk, so the prosthetist must anticipate the ultimate stresses that will be applied.<a></a></p> <p>The recent announcement of a "Modular Flex-Foot™" (MFF) represents an effort to expand the usefulness of the Flex-Foot™. Available in standard configurations, these pre-made pylons can be supplied within two weeks. The heel lever arm bolts through the forefoot rather than the highly stressed ankle area, to enhance durability. A refined attachment system permits easier socket replacements, which should encourage application to more recent amputees. And, limited alignment refinements are possible even after permanent attachment to the socket, via Otto Bock "Modular" components or the "pylon connector" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg"><strong>Figure 3. Modular Flex-Foot™ (MFF), showing improved socket and heel attachment designs.</strong></a><br /> <p>We believe the cost and complexity of the Flex-Foot™ can be justified due to the degree of function offered. A competitive volleyball player reported her vertical leap nearly doubled when using the Flex-Foot™, and its low inertial drag made activities less tiring.<a></a> A severely debilitated geriatric amputee, who ambulated with a cane due to impaired balance, claimed he could walk "twice as far before my wind gives out" after fitting with the Flex-Foot™.<a></a> And a 47 year old nurse completed the New York Marathon's 26 mile race on the Flex-Foot™ one hour thirty-two minutes more quickly than with a conventional design.<a></a></p> <p>Hard data to buttress these anecdotal reports are very limited at this time. A motion analysis conducted at the University of Illinois suggests that the Flex-Foot™ allows a more normal range of motion than the SACH foot, even at normal cadences.<a></a> Several centers are reportedly conducting oxygen consumption studies in an effort to verify claims of lowered energy consumption, but none are yet published.</p> <p>Although most Flex-Foot™ prostheses have been used for unilateral and bilateral below-knee amputees, a significant percentage have been applied to above-knee amputees as well, and some hip disarticulation fittings have been completed.<a></a> Our experience at Duke has been chiefly at the below-knee level. Although higher level amputees would benefit greatly from reduced energy consumption, the addition of a passive knee mechanism may dissipate some of the potential return and bears further study.</p> <h3>Carbon Copy II</h3> <p>The Ohio Willow Wood Company introduced the original all-plastic SACH foot a decade ago called the "Marvel" foot. After its demise due to the availability of lighter and more durable feet from other suppliers, they embarked on a research and development project for what they termed the "next generation" of solid ankle feet.</p> <p>A few years ago, Mauch Laboratories approached Ohio Willow Wood to design a foot shell for Mauch's hydraulic ankle. This lead to the development of life-molds, a special micro-cellular polyurethane elastomer blend, and engineering of a carbon composite keel. The result was Carbon Copy I, a relatively rigid shell whose function comes primarily from the ankle mechanism.</p> <p>Development continued, and in May, 1986, Carbon Copy II was introduced as the latest entry into the energy storage arena. In many ways, it represents the synthesis of some of the best attributes of previous designs. This is a conventional solid ankle design, available with three durometers of heel cushion for simulated planter flexion.</p> <p>The keel, however, is a unique dual structure: a rigid posterior bolt block plus flexible anterior deflection plates. The bolt block is a special ultralight reinforced Kevlar/nylon design which recently won the plastic composite industry's "National Award of Excellence" for innovative engineering. A fiberglass/epoxy attachment plate resists deformation by both ex-oskeletal and endoskeletal ankle blocks, while very low density Styrofoam fills the cavities and prevents infiltration of the heavier polyurethane elastomer which forms the outer shell.</p> <p>The anterior deflection plates provide two-stage resistance at heel off. In normal walking, the thin primary deflection plates (which run to the PIP joints of the toes) provide a gentle energy return. At higher cadence or during more vigorous activities, the auxiliary deflection plate provides additional push off. A Kevlar™ glide sock prevents the plate from knifing through the elastomer shell (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg"><strong>Figure 4. Carbon Copy II; note rigid bolt block plus dual flexible carbon fiber deflection plates (Photo courtesy Ohio Willow Wood Co.).</strong></a><br /> <p>The exterior design shows a similar attention to practical detail. The contours are lifelike, but not as starkly detailed as the Seattle Foot™. Rather, the veins and retromalleolar undercuts are softened into a more practical "humanoid" configuration. The forefoot width is a bit wider than conventional SACH feet, but less than the Seattle Foot™ version (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg"><b>Fig. 5</b></a>). Fitting narrow width shoes can sometimes be a problem.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg"><strong>Figure 5. (Dorsal view, L to R) STEN foot, Carbon Copy II, Seattle Foot™ note retromal-leolar contours and forefoot width.</strong></a><br /> <p>The plantar surface is where the Carbon Copy II contour is most unique. Broad and flat (with a full-width carbon composite plate similar to Flex-Foot™), it is shaped to fit the shoe last. Analogous to a well-posted UCBL foot orthosis, this congruence between device and shoe offers maximum mediolateral stability (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg"><strong>Figure 6. (Plantar view, L to R) Seattle Foot™, STEN foot, Carbon Copy II; the flatter configuration enhances me-diolateral stability within the shoe.</strong></a><br /> <p>Finally, all these practical details are contained in a package that is extremely lightweight. Significantly lighter than the conventional SACH foot, Carbon Copy II is actually slightly lighter than a geriatric "litefoot."</p> <p>Currently available only in adult male sizes, Carbon Copy II should be available in female sizes in the near future. Some practitioners report that the small keel sizes are noticeably suffer than their full-sized counterparts. In response to that observation, Ohio Willow Wood is retooling for a shorter keel block as well as narrower deflection plates for the women's style, which will initially be offered only in a 10mm (3/8") heel height.</p> <p>We have experienced no failures whatsoever with Carbon Copy II thus far, even for very vigorous applications. The manufacturer reports sales of over 2,000 feet, with known failures in nine cases. Seven were rubber tears at the tips of the toes (reportedly from one particular manufacturing run), plus one split deflection plate and one broken rivet.<a></a> If this early reliability continues, this may be one of the most durable prosthetic feet available.</p> <p>The only other problem noted is insufficient threads on the Otto Bock titanium endoskeletal foot bolt, which can be identified by its bright blue color. Placing one or two spacer washers under the head of the bolt allows it to be tightened firmly without running out of threads.</p> <p>One of the key design criteria for this foot was versatility, and we have found it suitable for many levels of amputation—including unilateral and bilateral below-knee, unilateral above-knee, hip disarticulation and hemipel-vectomy, as well as above-knee/below-knee bilaterals.</p> <p>Overall, the Carbon Copy II and Seattle Foot™ seem to offer similar function to the patient, and the wholesale cost is comparable. At least in the larger keel sizes, most patients have preferred the Carbon Copy over the Seattle Foot™, due to lighter weight and the two-stage resistance. In the smaller keel sizes, the difference is less pronounced, and many prefer the responsiveness of the Seattle design. In general, we consider both Carbon Copy and the Seattle Foot™ design to be good, moderately responsive energy storing designs.</p> <h3>STEN Foot</h3> <p>STEN Foot is one of the simplest designs in prosthetic feet. Externally, it uses the familiar Kingsley foot molds and rubber. This means it is the easiest design to fit in a variety of shoe styles, and comes in the greatest selection of sizes and heel heights: from a child's 18cm keel to an adult's 30cm, including women's widths as well. Soft, medium, or firm heel durometers are available as well.<a></a></p> <p>Slightly heavier than a conventional SACH foot, the STEN Foot differs in its dual articulated keel. In addition to a metatarsal-phalangeal articulation, it also features a tarsal-metatarsal articulation, thus permitting a smoother, more gradual roll-over than a solid SACH keel (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg"><b>Fig. 7</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg"><strong>Figure 7. STEN foot; note dual keel articulations and double reinforced belting (Illustration courtesy Kingsley Manufacturing).</strong></a><br /> <p>Although the name stands for "STored EN-ergy" foot, it is our clinical impression that it does not accomplish this goal as effectively as the previous designs. The "keel bumpers" are directly analogous to the toe bumper in an old-fashioned wooden foot; both seem more to dissipate than to return energy.</p> <p>We view the STEN Foot as an additional flexible keel design, similar to the SAFE foot, permitting a smoother roll-over and somewhat greater forefoot supination and pronation than the more rigid SACH design. Since it is lighter than the SAFE foot, fits the shoe more readily, and is available in a broad range of heel heights and sizes, it may offer some advantages.</p> <p>Compared to a SACH foot, patient response has been predominantly favorable. Most preferred the smoother, "softer" roll-over it offers. Some higher level amputees complained of a slight increase in the tendency for the prosthetic knee to "buckle," although this could usually be minimized by plantarflexing or moving the foot more anteriorly.</p> <p>Reliability was a significant problem with early versions of this design, which sometimes failed catastrophically due to rupture of the plantar belting beneath the midfoot articulation. This resulted in a sudden loss of forefoot resistance, causing the amputee to stumble. When three of our initial seven STEN Feet failed in this fashion, we stopped using this component.</p> <p>It has since been redesigned with double belting reinforcements. The manufacturer reports that 3,000 feet have been sold, with no belting failures whatsoever since the reinforcement was added. With the new design, the overall failure rate from all causes is currently under one percent.<a></a></p> <p>At a recent Academy conference, Richard Carey, CP. reported on over 80 successful applications of the reinforced version of the STEN Foot, and suggested it is particularly appropriate for the new amputee as the softer rollover may facilitate gait training.<a></a> This also might allow an easier transition to a more sophisticated design later, since the flexible keel is a common characteristic of all current "energy storing" feet.</p> <h3>Other Designs</h3> <p>Although not a brand new design, the SAFE foot (Stationary Ankle Flexible Endoskeleton) has recently been advertised as "the original energy storing foot." In our view, this may be stretching the point, since we believe the flexible keel serves primarily to dissipate energy as it accommodates to irregular surfaces.</p> <p>The SAFE foot can be viewed as a solid ankle version of the multi-axis concept, and we consider it an alternate to the well-known Greissinger foot. Both provide significant transverse rotation as well as inversion and eversion, in addition to some degree of plantar flexion and dorsiflexion.<a></a> The SAFE foot has the advantage of requiring no maintenance and being moisture and grit-resistant, while the Greissinger permits independent selection of the plantar flexion and other resistances.</p> <p>We summarize the SAFE foot as an "accommodative" design. It is probably unparalleled for use on uneven surfaces, and many amputees report an increase in residual limb comfort because it absorbs much of the shock of everyday walking. But aggressive racquet sportsmen have complained that it takes a fraction of a second to "wind up" before permitting push off, thus lowering their score. Perhaps the SAFE foot and other soft keel designs should be viewed as offering increased shock absorption and comfort at the expense of responsiveness in a competitive situation.</p> <h3>Clinical Ranking</h3> <p>There are currently no accepted definitions of what constitutes an "energy storing" prosthetic foot. In fact, there is currently no hard data to demonstrate any energy savings at all, despite numerous anecdotal reports. Yet, there is a need to have some means of evaluating and ranking the various designs, to add some measure of rational justification for clinical use of a given component.</p> <p>In reviewing slides of a unilateral below-knee amputee playing competitive volleyball, it was noted that her vertical leap appeared to be noticeably higher with the Flex-Foot™ than with the Seattle Foot™. This difference is likely due to the amount of "spring return" inherent in the components, and may represent one plausible criterion to rank their effectiveness.</p> <p>To test this hypothesis, a simple "pogo stick" apparatus was constructed which permitted interchange of various prosthetic feet (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg"><b>Fig. 8</b></a>). A non-amputee subject was instructed to jump on the pogo stick for ten hops, trying to attain as much altitude as possible. It is believed that this measures the spring potential of the component as if it were loaded by body weight at midstance. Since the subject's feet both remained firmly on the foot pegs and did not contact the ground, this was felt to be more accurate than measuring unilateral amputees jumping, where the sound limb could partially compensate for the component's deficits.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg"><strong>Figure 8. Pogo stick device used to test vertical spring capabilities of various feet.</strong></a><br /> <p>Using frame-by-frame slow motion video analysis, the amount of ground clearance was measured to the nearest centimeter (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg"><b>Fig. 9</b></a>). This was not intended to be a controlled study, but rather a simple preliminary investigation; no quantitative judgments should be drawn from this data. Nevertheless, the trends were consistant over multiple trials, and are summarized in <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg"><b>Fig. 10</b></a>.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg"><strong>Figure 9. Frame-by-frame video analysis of ground clearance in centimeter increments.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg"><strong>Figure 10. Ground clearance after vertical leap using pogo stick apparatus; 175 pound male subject, men's size 10 feet.</strong></a><br /> <p>It is interesting to note that <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg"><b>Fig. 10</b></a> coincides with our subjective clinical ranking of the effectiveness of these designs. Patients given the choice between the SACH and STEN foot, for example, generally chose the more flexible STEN, but patients perferred the Carbon Copy II or Seattle Foot™ to the STEN, because the spring keels "felt more natural." Given the choice between Flex-Foot™ and other designs, the choice was generally for the more responsive composite system.</p> <p>Furthermore, the ranking also reflects the degree of sophistication of the design, and the relative wholesale cost from the manufacturer (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg"><b>Fig. 11</b></a>). The weight of the components was less straightforward. The inexpensive designs increased in weight as they increased in complexity, weighing progressively more than a conventional SACH foot. However, the two most expensive energy storing designs—Flex-Foot™ and Carbon Copy II—resulted in a lighter prosthesis than a SACH configuration (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg"><b>Fig. 12</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg"><strong>Figure 11. Relative wholesale costs for prosthetic foot mechanisms.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg"><strong>Figure 12. Weight of men's size 10 foot components, not including ankle block.</strong></a><br /> <h3>Summary</h3> <p>Thanks to the efforts of the Prosthetics Research Study in Seattle, the concept of energy storing prosthetic feet has been widely disseminated.<a></a> Although it is fashionable to claim such benefits, no clear definition of the characteristics required has been established. The author suggests that the ability to leap vertically is one simple measurement of the "springiness" of a component, while reduced oxygen consumption during a measured task would be a more precise definition of an energy-conserving component.</p> <p>All current designs seem to have merit, and have been successfully utilized clinically (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg"><b>Fig. 13</b></a>). Although limited, the Duke experience has been summarized as a first step toward more clearly delineating the indications and contraindications for each design (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg"><b>Fig. 14</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg"><strong>Figure 13. "Energy storing" feet through April 1987, Duke University experience.</strong></a><br /><strong><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg">Figure 14. Clinical comparison of prosthetic feet</a>.</strong> <p>The conventional SACH foot remains the most widely used design in North America, due to its low cost and reliability. In sports applications, it is particularly well suited for sprinting, since the rigid keel digs into the track, permitting rapid acceleration.<a></a></p> <p>Multi-axis feet (Greissinger and SAFE) accommodate uneven terrain and dissipate some of the shocks of ambulation, thereby increasing skin comfort. They have been widely used by amputee athletes, although the softer keel resistance may increase the lag between sudden movements. Except for limiting transverse rotation, the STEN foot offers similar function, and may be worth considering for the novice amputee in particular.</p> <p>The Seattle Foot™ and Carbon Copy II are solid ankle devices that attempt to store energy via a spring keel design. They have been well received for a variety of amputation levels, and seem particularly well suited for joggers and weekend athletes.</p> <p>Flex-Foot™ represents the maximum in energy storage potential, and can be individualized for a wide range of applications. It is by far the best design for vertical jumping, thereby lending itself to such sports as volleyball. It has also performed well for long distance running, as well as vigorous sports in general.</p> <p>Finally, all these components have more widespread application than originally assumed. A more flexible forefoot permits an easier roll-over. For the geriatric individual, even a modest decrease in the effort required for walking can offer a substantial improvement in ambulatory potential. The more debilitated the person, the more important the weight and responsiveness of the foot component become. Virtually any lower limb amputee could benefit from the enhanced functioning that a sophisticated prosthetic foot can offer.</p> <p>Although none of these designs will turn the amputee into Superman, each can add a significant dimension to the degree of restoration that can be offered. Jan Stokosa, CP., has noted that although conventional prosthetic limbs restore mobility rather effectively, many patients feel their <i>function</i> has not been restored, so long as vigorous activities remain difficult or impossible to achieve.<a></a></p> <p>By increasing our collective experience with the components under discussion and pooling our impressions in forums such as this, it is hoped that we can more closely approach that elusive goal: complete functional prosthetic restoration for every amputee.</p> <h3>Appendix</h3> <p><b>SAFE Foot</b>, Campbell-Childs, Inc., 105 East First Street, P.O. Box 120, Phoenix, Oregon 97535.<br /><b>Flex-Foot™</b>, Flex-Foot, Inc., 14 Hughes, B-201, Irvine, California 92714.<br /><b>STEN Foot, Litefoot, SACH, and Single Axis Feet</b>, Kingsley Manufacturing Company, P.O. Box CSN 5010, Costa Mesa, California 92628.<br /><b>Carbon Copy II</b>, Ohio Willow Wood Company, 15441 Scioto Darby Road, P.O. Box 192, Mount Sterling, Ohio 43134.<br /><b>Greissinger, Single Axis, &amp; SACH Feet</b>, Otto Bock Industries, Inc., 4130 Highway 55, Minneapolis, Minnesota 55422.<br /><b>Seattle Foot™</b>, Model &amp; Instrument Development, 861 Poplar Place South, Seattle, Washington 98144.</p> <p><b>References:</b></p> <ol> <li>Beckman, Clarence, personal communication, May, 1983.</li> <li>Brooke, Steve, Marketing Manager, Model Instrument and Development, Inc., personal communication, April, 1987.</li> <li>Burgess, et al., "The Seattle Prosthetic Foot-A Design For Active Sports: Preliminary Studies," <i>Orthotics and Prosthetics</i>, Volume 37, Number 1, pp. 25-32.</li> <li>Burgess, et al., "The VA Seattle Foot," <i>Rehabilitation Research and Development-Progress Reports 1984</i>, Veterans Administration Publications, 1984, p. 5.</li> <li>Campbell, J. and C. Childs, "The S.A.F.E. Foot," <i>Orthotics and Prosthetics</i>, Volume 34, Number 3, 1980, pp. 3-17.</li> <li>Carey, Richard, "The STENFOOT," Continuing Education Course 1-87, American Academy of Orthotists and Prosthetists, Portland, Oregon, March, 1987.</li> <li>Enoka, et al., "Below-Knee Amputee Running Gait," <i>American Journal of Physical Medicine</i>, Volume 61, Number 2, 1982, pp. 66-84.</li> <li>"Flex-Foot™ Fitting and Alignment Procedure," Flex-Foot Inc., 19600 Fairchild, Suite 150, Irvine, CA 92715.</li> <li>Fosberg, Robert, President of Flex-Foot, Inc., personal communication, April, 1987.</li> <li>Graves, J. and E. Burgess, "The Extra-Ambulatory Concept As It Applies To the Below-Knee Amputee Skier," <i>Bulletin of Prosthetics Research</i>, Fall, 1973, pp. 126-131.</li> <li><a href="cpo/1982_04_001.asp">Hittenberger, Drew, "Extra-Ambulatory Activities and the Amputee," <i>Clinical Prosthetics and Orthotics</i>, Volume 6, Number 4, 1982, pp. 1-4.</a></li> <li>Hittenberger, Drew, "The Seattle Foot," <i>Orthotics and Prosthetics</i>, Volume 40, Number 3, 1986, pp. 17-23.</li> <li>Kegal, Bernice, et al., "Functional Capabilities of Lower Extremity Amputees," <i>Archives of Physical Medicine and Rehabilitation</i>, Volume 59, 1978, pp. 109-120.</li> <li>Kegal, et al., "Recreational Activities of Lower Extremity Amputees: A Survey," <i>Archives of Physical Medicine and Rehabilitation</i>, Volume 61, 1980, pp. 258-264.</li> <li>Klenerman, Leslie, <i>The Foot and Its Disorders</i>, Blackwell Scientific Publications, London, 1976, p. 19.</li> <li>"A Material Change for Prosthesis," <i>The Orange County Register</i>, October 31, 1985, Sec.E, p. 12.</li> <li>Martin, Jeffrey, Marketing Director, Ohio Willow Wood Company, personal communication, April, 1987.</li> <li>Michael, J.W., "Prosthetic Feet for the Amputee Athlete," <i>Palaestra</i>, Volume 2, Number 3, 1986, pp. 37-41.</li> <li>Miller, Enoka, et al., "Biomechanical Analysis of Lower Extremity Amputee Running." Final Report to Veterans Administration. Contract Number V5244P-1540/VA Hospital, New York, 1979.</li> <li>Nobbe, Carol, personal communication, September, 1984.</li> <li>Rauch, Colleen, personal communication, November, 1986.</li> <li>Sethi, M.P., "Vulcanized Rubber Foot for Lower Limb Amputees," <i>Prosthetics and Orthotics International</i>, Volume 2, Number 3, 1982, pp. 125-136.</li> <li>Stokosa, Jan, "Total Surface Bearing in Lower Extremity Prosthetics," Region II-III Assembly, American Orthotic &amp; Prosthetic Association, Atlantic City, New Jersey, April, 1986.</li> <li>Truesdell, James, president, Kingsley Manufacturing Company, personal communication, April, 1987.</li> <li><a href="cpo/1987_01_055.asp">Wagner, J., et al., "Motion Analysis of SACH vs. Flex-Foot™ in Moderately Active Below-Knee Amputees," <i>Clinical Prosthetics &amp; Orthotics</i>, Volume 11, Number 1, 1987, pp. 55-62.</a></li> </ol> <em><b>*John Michael, M.Ed., C.P.O. </b> John W. Michael, M.Ed., C.P.O., is Assistant Clinical Professor and Director of Prosthetics &amp;Orthotics at Duke University Medical Center.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 154 - 168 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource Energy Storing Feet: A Clinical Comparison Creator An entity primarily responsible for making the resource John Michael, M.Ed., C.P.O. * https://staging.drfop.org/files/original/74c6246acf34d3fe13807d14ce98dc43.pdf 6441dedb6d6cc9c3408c00c008e17f34 https://staging.drfop.org/files/original/5fad73a9eef3f2a1ab53ce2f213efece.jpg 087d0de996c5b8aedb032fcd6c2b18af https://staging.drfop.org/files/original/46e79972c3cbe07d3d9a3bf9ee340543.jpg ed3a48b7a53ce8a61cd8625552177b7e https://staging.drfop.org/files/original/e6c3404c22e5309a73c20747e6ed1a13.jpg 9272df686c0c19c8ad1dda4d9c346ec6 https://staging.drfop.org/files/original/281142d97946d38fc471de221b5faf8f.jpg bf1e5c9c2e488ceb7a1e4cfe23204140 https://staging.drfop.org/files/original/c47ee86296fe96d24d9bd4f980c48f92.jpg b3b28bcd274b720de45e627bfb56fb30 https://staging.drfop.org/files/original/6428da51018c9c2b4e7abbee2e25edb7.png 1647605a0dec60c4196c094faf88d769 https://staging.drfop.org/files/original/68cd1ff085e2984407091e0d7a6c5d37.png 9904eb51a9b616c598335dfad75c4a5e https://staging.drfop.org/files/original/0615e189294ec61bfdf16988f8a7b884.png c338f0114ebb1696a89da2d560ae081c https://staging.drfop.org/files/original/7ec5171e3138ef5823db95a0fc0c969c.png b27d019d267f9fe4bf3c8a2e1dcbf8f3 https://staging.drfop.org/files/original/371c70ccf0c7354316fbbb481fe93334.png 66509ce03e3cd337dcfb9ff45cd414eb Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_057.pdf Text Any textual data included in the document <h2>Upper Limb Prosthetic Terminal Devices: Hands Versus Hooks</h2> <h5>John N. Billock, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>No one would argue that the human hand is the most complex and challenging structure of the human anatomy to replace and restore. The hand is an extremely complex structure which moves with a precision and dexterity that has long challenged the minds of researchers in medicine and engineering. Beyond its kinematic capabilities, the hand is also one of the most intricate sensory mechanisms of the human body-with unequaled proprioceptive and sensory feedback capabilities. With this in mind, it is easy to understand why prosthetic terminal devices today (hand and/or hook) offer very little in the way of true functional restoration to individuals with upper limb deficiencies.</p> <p>This is not meant to be critical of past developments, but puts into proper perspective the complexities and challenges of duplicating the human hand. Further emphasis of this is found in a commentary by Murphy<a></a> in which he stated, "Though engineers and prosthetists have made substantial contributions, they need perspective and humility to inspire and guide the very long, sustained efforts required to replace even a few of the roles of the hand." This challenge will doubtlessly keep researchers in prosthetics, and now those involved in robotics, busy with the task of trying to duplicate the kinematic and sensory capabilities of the human hand for years to come.</p> <h3>Prosthetic Terminal Devices Today</h3> <p>There exists today a significant number of prosthetic terminal devices for treating both adult and juvenile complete hand deficiencies. These terminal devices are designed as either mechanical or electromechanical systems and, as such, are either body-powered or electric powered. The body powered terminal devices function by utilizing forces generated by body movement as described by Taylor.<a></a> An electric powered terminal device functions by utilizing the electrical force stored within and generated from a battery. Further, these sources of power can activate or control a terminal device in different ways. The three most commonly used control systems are the Bowden cable control, myoelectric control, and switch control. In order to fully understand the functional potential of a particular terminal device, it is important to understand the control approach or system being used to actuate the device.</p> <h3>Prosthetic Control Systems</h3> <p>Professional opinions vary considerably regarding the most appropriate terminal device and control system to utilize in the design and development of a functional upper limb prosthesis. Bowden cable control systems harness the motions and forces generated by gross body movement to actuate and control, primarily, a mechanical terminal device. They require an adequate degree of force and excursion to actuate and control an upper/limb mechanical terminal device.<a></a> The most common example of this would be the Bowden cable control system of a totally mechanical below-elbow prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg"><b>Fig. 1</b></a>). This type of control system harnesses the body motion and forces generated by flexion-abduction movements at the glenohumeral joint to actuate and control the terminal device. It is important to note that this form of control does produce a certain degree of sensory feedback related to force and position.<a></a></p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg"><span><strong>Figure 1. Illustration of a typical conventional body powered Bowden cable controlled below-elbow prosthesis with a mechanical hook terminal device actuated by "gross" body movements</strong>.</span></a><br /> <p>Myoelectric control systems utilize the existing neuro-muscular system for actuation and control of an electromechanical terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg"><b>Fig. 2</b></a>). EMG potentials are monitored with surface electrodes placed over appropriate muscle or muscle groups within the residual limb and are used for either digital or proportional control of the terminal device. This type of control is considered to be quite natural since it utilizes the existing residual neuromuscular system for control.<a></a> This is especially true with synergistic muscle contractions, particularly related to natural hand functions, which can be selected for actuation and control of the terminal device. The use of myoelectric control enhances the feasibility of designing a totally self-contained and self-suspended prosthesis which has proven to be an acceptable and reliable design approach.<a></a></p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg"><strong>Figure 2. Illustration of a typical electric powered, myoelectrically controlled below-elbow prothesis with an electromechanical hand terminal device actuated by EMG potentials.</strong></a><br /> <p>Switch control systems are those which utilize the motions and forces generated by "fine" body movements to actuate and control an electromechanical terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg"><b>Fig. 3</b></a>). They require considerably less force and excursion than a Bowden cable controlled system to actuate and control a terminal device. Switch control systems can incorporate a variety of different types of switches, such as, pull, rocker, push-button or toggle type switch for activation of the terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg"><b>Fig. 4</b></a>). This type of control is typically indicated in situations when limited body motion and forces are available for Bowden cable control and/or when EMG potentials are inadequate or inappropriate for control of the terminal device.</p> <span><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg"><strong>Figure 3. Illustration of a typical electric powered switch controlled below-elbow prosthesis with electromechanical hand terminal device actuated by "fine" body movements.</strong></a><br /></span><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg"><strong>Figure 4. The actuation characteristics of a typical pull, rocker, push button and toggle switch are illustrated. Switches are generally designed to produce one or more functions such as opening and/or closing of an electromechanical terminal device, (a) Pull (sliding) switch for actuation of two functions; (b) Rocker switch for actuation of two functions; (c) Push Button switch for actuation of one function; (d) Toggle switch for actuation of two functions.</strong></a><br /> <h3>Mechanical Hooks And Hands</h3> <p>Following World War II and especially since the development of the APRL Voluntary Closing Hand and Hook in 1945, considerable controversy has existed regarding the functional aspects of hands versus hooks as terminal devices. Prior to the introduction and clinical use of electric hands in the early 1960's, this controversy only related to mechanical hands and hooks. Mechanical hands, although certainly more aesthetic, were felt by many professionals to be too heavy and awkward for fine prehension activities. Mechanical hooks, by way of contrast, weigh approximately one third the weight of a mechanical hand and provide dexterity comparable to a pair of tweezers. Mechanical hooks were also considered to be more durable because of their simple mechanical design, and the fact that a cover to protect internal mechanisms or provide aesthetics is unnecessary. Because of these mechanical advantages, very little regard was given to the social-psychological advantage and need for a prosthetic hand versus the hook terminal device.</p> <p>In fact, it became common practice within prosthetic clinics and teaching institutions to encourage use of a hook terminal device first before providing the individual with a hand terminal device. The purpose of this practice, which continues today, is to develop the individual's appreciation for the functional advantage of the mechanical hook over the mechanical hand. Further, it was the opinion and experience of many clinics and prosthetists that many individuals, if provided a hand and hook terminal device simultaneously, tended to reject the hook for aesthetic reasons and not develop an appreciation for its functional advantage. Conservative estimates indicate, however, that approximately only fifty percent of those individuals provided with conventional type mechanical prostheses are wearing their prosthesis as reported by LeBlanc.<a></a> This estimate does not distinguish between actual functional use versus simple wearing of the prosthesis.</p> <p>It is the author's opinion and experience that the introduction of a hook terminal device in the early stages of the prosthetic rehabilitation process may in fact be the primary cause of the high incidence of total prosthetic rejection since little, if any, attention is given to the social-psychological aspects of the individual's limb deficiency. The social-psychological aspects of an acquired or congenital upper limb deficiency should be regarded as the first and most significant problem which has to be understood and dealt with appropriately if successful prosthetic rehabilitation and functional use of a prosthesis is to be achieved. Dembo, Leviton, and Wright<a></a> clearly identified the social-psychological problems individuals, as well as those around them, have to deal with in accepting limb loss as part of the total rehabilitation process. If an individual has not accepted a limb loss, or in the case of a congenital limb deficiency, the parents have not accepted the limb loss, it is unlikely that successful prosthetic rehabilitation and functional use of a prosthesis will be achieved.</p> <p>Dr. Howard A. Rusk, recognized by many as the "father of physical medicine and rehabilitation," has identified motivation and timely rehabilitation services as the key elements to achieving successful rehabilitation of an individual's disability.<a></a> An individual can receive the best rehabilitation services available and be provided with the best prosthesis today's technology has to offer. However, if they are not motivated to overcome their disability or adjust to it, acceptable rehabilitation is unlikely. Likewise, the child born with a congenital limb deficiency will not be encouraged to adapt to or functionally utilize a prosthesis if the parents have not accepted their child's disability.</p> <h3>Electric Powered Hooks And Hands</h3> <p>The introduction of electric powered hands into clinical practice in the early 1960's brought about a new era in prosthetics. Acceptance of these "electric hands" by the American prosthetics profession was much slower than in the European countries where they were initially developed. They are, moreover, still considered by many to be not as functional as mechanical hook terminal devices. It is felt that much of this belief can be traced to the attitude that regards mechanical hands as being less functional than mechanical hooks. Electric powered hands, however, have one primary major functional advantage over mechanical hooks and hands.</p> <p>Electric hands can produce finger prehension force which is equal to, and in some cases greater than, that of an adult or juvenile human hand. The average adult male, for instance, can produce an average of 20 to 24 lbs. of finger prehension. The average tolerable amount of prehension that an adult male can generate with a Bowden cable controlled prosthesis and the more commonly used voluntary opening mechanical hook terminal device is approximately 8 to 10 lbs. Voluntary closing mechanical hands and hooks obviously are able to provide greater finger prehension than voluntary opening hooks or hands; however, they have not been widely accepted or used.</p> <p>Another key advantage of an electric powered hand is that it provides forceful "3 jaw chuck" palmar type prehension. This type of prehension has been identified as early as 1919 by Schlesinger,<a></a> to be the most commonly utilized hand-finger prehension pattern for picking up and holding objects in activities of daily living (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg"><b>Fig. 5</b></a>). <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg"><b>Fig. 1</b></a> shows the percentage of use to pick up and hold objects with an electric powered hand. The predominance of "3 jaw chuck" palmar prehension in our activities of daily living accounts for the reason all mechanical and electric powered hands of today are designed with the thumb in opposition to the second and third fingers. The forceful palmar prehension of the electric powered hand, therefore, enhances its overall functional value as a prosthetic terminal device.<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg"><strong>Figure 5. Of the six commonly used hand/finger prehension patterns, described by Schlesinger, "3 jaw chuck" palmar type, tip type and lateral type prehension are considered to be the most frequently used during activities of daily living.</strong></a></p> <p>The only electric powered hook available for clinical use at this time is the Otto Bock "Griefer"<a></a> which was introduced in the U.S. in the late 1970's. As an electric powered terminal device, it has the quality of providing "forceful" prehension. Along with this, it is uniquely designed with multi-axis fingers to keep the grasping surfaces parallel during the entire range of opening and closing (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg"><b>Fig. 6</b></a>). This design feature allows for even pressure throughout its range of opening and closing which enhances its grasping ability over mechanical hooks. The grasping surfaces of a mechanical hook angle away from one another as the active finger moves in relationship to the stationary finger (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg"><b>Fig. 7</b></a>). Therefore the larger the object to be held in the mechanical hook terminal device, the less contact with the object and, consequently, the more force required to stabilize the object, dependent upon its shape. The "Griefer," on the other hand, is heavier than the heaviest stainless steel mechanical hook and is not as durable, primarily because its design is more complex than the single axis mechanical hooks.<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-06.jpg"><b>Table 1</b></a></p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg"><strong>Figure 6. This diagram illustrates the angular relationship of the prehension surfaces and the object being held, utilizing a multi-axis prehension design approach, such as in the Otto Bock "Griefer."</strong></a><br /> <p><b><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg"><span>Figure 7. This diagram illustrates the angular relationship of the prehension surfaces and the object being held, utilizing a single-axis prehension design approach, such as in the Hosmer/Dor-rance</span></a><span><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg"> mechanical hook series.</a><br /><br /></span></b>Clinical Experience<b><span><br /></span></b></p> <p>The terminal device of the prosthesis plays an important key role in developing the motivation which will, hopefully, lead to successful prosthetic rehabilitation. It has been the author's experience, in over 300 cases involving individuals with congenital and acquired limb deficiencies from the wrist to the shoulder, that 95 percent or better of those individuals preferred to have a prosthetic hand rather than a hook terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg"><b>Table 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg"><b>Table 3</b></a>). In all cases involving juvenile subjects (which represents approximately ten percent of the total case load), the parents and children over the age of five years preferred hand terminal devices to hooks. Forty percent of the total juvenile case load involved children under the age of five years, and in all cases, the parents preferred hand terminal devices. Parents were also found to prefer a passive nonfunctional hand as opposed to the more typically used passive type nonfunctional mitten for children up to 1 1/2 years of age.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg"><strong>Table 2</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-10.jpg"><strong>Table 3</strong></a><br /> <p>One might quickly draw the conclusion that this preference was specifically related to the aesthetics of the hand and not necessarily related to function. There is no doubt that the aesthetics of the hand played a key role in the decision. However, this preference also emphasizes the strong social-psychological need for individuals, as well as the parents of children with limb deficiencies, to visually feel as normal as possible within our society. The aesthetics of a hand terminal device obviously satisfies this need more appropriately than a hook terminal device.</p> <p>Beyond this, it is also interesting to note that approximately only one percent of those provided a prosthesis with hand are utilizing a mechanical hand terminal device. Therefore, 99 percent utilize electric powered hands in their prostheses; eighty percent of these are controlled myoelectrically. It is estimated that total rejection of an electric powered hand prosthesis has been approximately 15-20 percent. Actual percentages of rejection have been difficult to verify because of lack of follow-up by the patients, and it is felt that 5-10 percent of the patients are now being followed-up elsewhere. Nevertheless, total prosthetic rejection is considerably less than those provided with conventional upper limb prostheses.<a></a> It is not felt that the acceptance rate of electrically powered hand prostheses is specifically related to aesthetics of the hand. If this were the case, one would expect more individuals to have been utilizing mechanical or passive hands prior to the development of electric powered hands.</p> <h3>Conclusion</h3> <p>Clinical experience has definitely proven, in the author's experience, that an electrically powered prosthetic hand terminal device which is proportionally controlled, utilizing myoelectrical EMG potentials from synergistically related muscles within the residual limb, is the most acceptable and functional upper limb prosthetic design for individuals with complete hand deficiencies.</p> <p>It is further felt that the terminal device is the most important component of the prosthesis; just as the hand is to the normal upper limb. Whenever possible, a prosthetic hand should be preferred to a hook terminal device, in consideration of the individual's social-psychological needs. The individual's social-psychological needs must be of primary concern initially and must be considered before vocational needs can be effectively addressed. This is also true when managing children and is especially important in addressing the social-psychological needs of parents of children born with congenital upper limb complete hand deficiencies.</p> <p>If the vocational or avocational needs clearly indicate the need for a hook terminal device, this must be clinically tested and proven, or the individual must personally desire the hook terminal device. This has been found to be true for all levels of upper limb deficiencies involving the hand, wrist, elbow, and shoulder. This criteria is obviously not the case for everyone with an upper limb deficiency; however, it is felt to be true for the majority and especially those with unilateral upper limb involvement.</p> <p>The prosthetic hand should be thought of as an assistive device to the sound limb, just as the nondominant normal hand is to the dominant normal hand. Many have felt it is important to be able to perform fine motor prehension activities with a prosthetic terminal device and this has been a major argument in favor of hook terminal devices. The fact is, the majority of those individuals with upper limb deficiencies are unilaterally involved and do not use their prosthesis for fine motor prehension activities; just as a non-involved individual does not typically utilize the nondominant hand for such activities. The prosthetic terminal device is most important for gross prehension activities, to hold and stabilize objects while the sound limb performs the fine motor prehension activities. An electrically powered hand terminal device, with adequately controlled functional prehension, best serves this need for the majority of an individual's activities of daily living. It is important to remember that we live in a world made for hands, and most everything we encounter in our activities of daily living is made to be hand held.</p> <h3>Acknowledgments</h3> <p>The author is deeply indebted to those individuals who have sought and benefited from the research which made this paper possible. Special appreciation is given to my wife, Dottie, Jean Ann Pasini, and Gordon L. Grimm for their editorial input and assistance in preparation of this paper, and to the other staff members of the Orthotics and Prosthetics Centre of Warren for their continued understanding and support of the author's professional interests. The illustrations and art work of Jean Ann Pasini are particularly appreciated.<br /><br /><em><b>*John N. Billock, C.P.O. </b>John N. Billock, C.P.O. is Clinical Director at the Orthotics and Prosthetics Centre of Warren in Warren, Ohio. He is also Chairman of the Research and Evaluation Committee of the American Academy of Orthotists and Prosthetists.</em></p> <p><b>References:</b></p> <ol> <li>Billock, J.N., "The Northwestern University Supracondylar Suspension Technique for Below Elbow Amputations," <i>Orthotics and Prosthetics</i>, Vol. 26, No. 4, pp. 16-23, 1972.</li> <li>Billock, J.N., "Upper Limb Prosthetic Management: Hybrid Design Approaches," <i>Clinical Prosthetics and Orthotics</i>, Vol. 9, No. 1, pp. 23-25, 1985.</li> <li>Childress, D.S. and Billock, J.N., "Self-containment and Self-suspension of Externally Powered Prostheses for the Forearm," <i>Bulletin of Prosthetics Research</i>, Vol. 10, No. 14, pp. 4-21, 1970</li> <li>Childress, D.S., "Powered Limb Prostheses: Their Clinical Significance," <i>IEEE Transactions on Biomedical Engineering</i>, Vol. BME-20, No. 3, pp. 200-207, May, 1973.</li> <li>Childress, D.S.; Holmes, D.W.; and Billock, J.N., "Ideas on Myoelectric Prosthetics Systems for Upper-Extremity Amputees," <i>The Control of Upper-Extremity Prostheses and Orthoses</i>, pp. 86-106, 1974.</li> <li>Dembo, T.; Leviton, G.L.; and Wright, B.A., "Adjustment to Misfortune: A Problem of Social-Psychological Rehabilitation," <i>Selected Articles from Artificial Limbs</i>, pp. 117-175, New York, July, 1970.</li> <li>Gwynne, G., "Mechanical Components," <i>Manual of Upper Extremity Prosthetics</i>, Department of Engineering, University of Southern California at Los Angeles, Second Edition, pp. 33-68, 1958.</li> <li>Le Blanc, M.A., "Patient Population and Other Estimates of Prosthetics and Orthotics in the USA," <i>Orthotics and Prosthetics</i>, Vol. 27, No. 3, p. 38-44, 1973.</li> <li>Murphy, E.F., "Commentary," <i>Selected Articles from Artificial Limbs</i>, New York pp. vii-xii, July, 1970.</li> <li>Rusk, H.A., "Rehabilitation," <i>Journal of the American Medical Association</i>, Vol. 140, pp. 286-292, 1949.</li> <li>Rusk, H.A., "Advances in Rehabilitation," <i>Practitioner</i>, Vol. 183, pp. 505-512, 1959.</li> <li>Schlesinger, G., "Der Mechanische Aufbau der kunstlichen Glieder," <i>Ersatzglieder und Arbeitshilfen</i>, Vol. 3, Berlin, 1919.</li> <li>Taylor, C.L., Schwarz, R.J., "The Anatomy and Mechanics of the Human Hand," <i>Selected Articles from Artificial Limbs</i>, New York, pp. 49-62, 1970.</li> <li>Taylor, C.L., "Biomechanics of Control," <i>Selected Articles from Artificial Limbs</i>, New York, pp. 63-84, July, 1970.</li> <li>Otto Bock "Griefer" is a registered trade mark of the Otto Bock Orthopedic Industry, Inc., Duterstat, West Germany/Minneapolis, Minnesota.</li> <li>Hosmer Dorrance is a registered trade mark of the Hosmer Dorrance Corporation, Campbell, California.</li> </ol> Page Number(s) 57 - 65 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 TABLE I http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-06.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg Figure 9 TABLE II http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg Figure 10 TABLE III http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-10.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 Upper Limb Prosthetic Terminal Devices: Hands Versus Hooks Creator An entity primarily responsible for making the resource John N. Billock, C.P.O. * 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.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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."</p> <p>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."</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <em><b>*John N. Billock, C.P.O. </b> John N. Billock, C.P.O. is with the Orthotic and Prosthetic Centre of Warren, 145 Shaffer Drive, N.E., Warren, Ohio 44484.<br /><br /><br /></em> 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/3f041b7c947e529153fa28232c237ff9.pdf d1f852ea47d629b46c047b9ae3e541ec https://staging.drfop.org/files/original/730b7c386610ac5066f7d34810d6e1cb.jpg 5d4cfcb9a11c6bdca221c13237a938da https://staging.drfop.org/files/original/7833aeed5e0f5b304177a2c2f4041545.jpg 8933a2daac139a455663a0839530e760 https://staging.drfop.org/files/original/3b3ef544eebe463014069b1f9f559617.jpg 49669d1ea09bc77fd63e098e093c5229 https://staging.drfop.org/files/original/1f0783dbf17ee81abcf3918ec110bc1a.jpg 3e6547ec9784789f1cd9426bc2316851 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_169.pdf Text Any textual data included in the document <h2>The O.K.C. Above-Knee Running System</h2> <h5>John Sabolich, B.S., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>For many years, above-knee amputees have been trying to run step over step rather than using the hop and skip running gait typified by Terry Fox in his run across Canada. This type of locomotion is still biomechanically defined as walking since it still contains a double support phase when both feet are touching the ground simultaneously. True running has no period of double support.</p> <p>One reason that above-knee amputees have had to run in this manner is that the lower shank does not accelerate forward fast enough for true running due to inertia. While the thigh segment quickly flexes about the hip, the foot tends to stay in place, causing the knee to flex beyond a desirable position and resulting in what is commonly referred to as "excessive heel rise." This excessive heel rise causes a delay in getting the foot-shank complex to move into extension which complicates the amputee's basic problem of not having active control of the knee. It seems that the harder the amputee tries to flex his hip, the worse the heel rise becomes.</p> <p>The O.K.C. system strives to solve these problems. It consists of a cable-housing arrangement (similar to that on a below-elbow prosthesis) that travels behind the hip joint and anterior to the knee axis (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg"><b>Fig. 1</b></a>). The proximal end of the cable is attached to a belt similar to a Silesian bandage by a short piece of elastic webbing and Dacron tape which is adjustable via a 4-bar buckle. The distal end of the cable is fixed to the proximal anterior shank section of the prosthesis.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg"><strong>Figure 1. Lateral views of prosthesis showing path and attachment points of the OKC running cable.</strong></a><br /> <p>When the hip joint starts to flex, just at the moment of "running toe off," tension in the cable causes a dynamic extension moment at the knee. In other words, power is being transferred to the knee joint directly from the action of hip flexion. When the thigh is fully flexed, the tension in the system is at its maximum. This turns out to be very desirable biomechanically, since the knee needs to be fully extended at heel strike. The O.K.C. system therefore supplies a dynamic force to the shank, much as the quadriceps does in the normal human leg during running (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg"><strong>Figure 2. Running sequence showing action of the cable system.</strong></a><br /> <p>It has been our experience that it is easier to start using this system on children running on grass and advance to adults later for two reasons. First, children are not afraid to try to run, especially when the practitioner tells them they are now capable of it. Second, due to lower stresses in the system, the prosthetist can use conventional upper extremity cable and housing components that are readily available rather than specially made cable and hardware which are needed for adults. It has been noted that some children are able to remove the cable after a few months, (much as training wheels on a bicycle) and still do a fair job of running step over step. They gain confidence from the system and use it to fine tune their running capabilities. However, it has been our experience that when truly fast running is required as in competitive events, the patient prefers the O.K.C. System. Parents report that their children like to keep the system in place at all times since it gives them a natural dynamic quadriceps effect. However, some adults prefer to remove the O.K.C. System for normal locomotion.</p> <p>For adult running, we have found that special aircraft grade cable and terminal ends are required due to the increased stresses in the system. It has also been discovered that monofilament fishing line (300-500lb. test line) works quite nicely as the coefficient of friction between the cable and housing is reduced. A plastic housing such as polypropylene tubing (commonly used in air conditioner drains) works best with this monofilament.</p> <p>An extension aid of surgical tubing or elastic webbing augments the O.K.C. System and provides another method of fine tuning the system. Some competitive runners also like to use a flexion limiter with the system. This consists of a 3/4" thick piece of PE-LITE® at the back of the knee joint which does not allow the knee to flex completely. This flexion limiter acts as a compressive stop which tends to bounce the knee into extension and swings out of the way during normal walking. A variety of other methods of limiting flexion can be used.</p> <p>To our knowledge, the first above-knee amputee to ever run step over step on an above-knee prosthesis was in March, 1982 utilizing an O.K.C. System. Since that day, many adults who enjoy competitive running or just sports in general have been fit. The shortest residual limb fit successfully with the O.K.C. System was on a 17 year old above-knee male with a 2 7/8" femur. The longest have been knee disarticulation amputees.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-3.jpg"><strong style="font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen, Ubuntu, Cantarell, 'Open Sans', 'Helvetica Neue', sans-serif;">Figure 3. Series of photographs taken from video screen.</strong></a></p> <p>It is easier to implement this system if the patient is using an exoskeletal prosthesis, since the cable and housing have a natural surface to ride and sit on. However, we have placed several on endoskeletal systems with a little creative rigging (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg"><b>Fig. 4</b></a>). It is also possible to laminate a track directly into the thigh portion of the prosthesis which eliminates the need for housing. However, this sometimes causes excessive breakage unless a section of housing is extended distally to reduce the bending radius distally about the knee.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg"><strong>Figure 4. OKC running cable on an endoskeletal prosthesis. Aircraft cable and terminal ends were used in fabrication.</strong></a><br /> <p>Sitting can be a problem unless the cable or monofilament is placed in such a way as to allow the cable and housing to move posterior to the knee during sitting. This prevents the creation of a knee extension moment, which could be bothersome during sitting.</p> <p>Last, we have found it most helpful that the heel portion of the prosthetic foot be soft enough to provide very easy planer-flexion so as to lessen the tendency for the knee to be forced into flexion by the ground reaction force at heel strike.</p> <em><strong>*John Sabolich, B.S., C.P.O.</strong> John Sabolich, B.S., C.P.O, is president of Sabolich Orthotic Prosthetic Center, 1017 N.W. 10th Street, Oklahoma City, Oklahoma 73106.<br /><br /><br /></em> Page Number(s) 169 - 172 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The O.K.C. Above-Knee Running System Creator An entity primarily responsible for making the resource John Sabolich, B.S., C.P.O. * https://staging.drfop.org/files/original/0f0eaf91a93d152fbbcaca14c3b43ebf.pdf 55a8a6c2698543a33379820f8c99af27 https://staging.drfop.org/files/original/9176ea93fc7422b272a48674e92598f3.jpg 64903f5b4a3cce6fe54c1ab66a83c375 https://staging.drfop.org/files/original/51e118cc092de53ecec3404a4302acab.jpg 9678319e36fff07a4dd43313518ea0b2 https://staging.drfop.org/files/original/b3a726660b994c9bbde0c48f30f4337c.jpg fb3cc03c33fbe565141cc63e008bcd97 https://staging.drfop.org/files/original/c0c5f86b34e55516bbefc6ca2d8b9f3c.jpg 0187a66c7a3b525a915dd5b9ad929a30 https://staging.drfop.org/files/original/3bb0b814dfe7768034c9b39057177e31.jpg 3520f17845a67a7b7af87cc94edfc339 https://staging.drfop.org/files/original/48af58273ca7d023d458415c3ede334c.jpg 73e1144efc791b010d100d5826ea86b0 https://staging.drfop.org/files/original/3e10a6a4eb37fe679d8d7dc788e153c7.jpg 2ac620871d4d7649e10c2cd6805c9efa https://staging.drfop.org/files/original/e190fcba30937120ad5a9a8f6b348187.jpg 7fb7b789229f3de781290a709a8c9c1c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_119.pdf Text Any textual data included in the document <h2>The CAT-CAM-H.D.(tm) A New Design for Hip Disarticulation Patients</h2> <h5>John Sabolich, B.S., C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Thomas Guth, B.A., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The innovative features of the CAT-CAM™ above-knee socket design were outlined in the Fall, 1985 issue of <i>Clinical Prosthetics and Orthotics</i>, Volume 9, Number 4. Shortly afterwards, RGP of San Diego and the Sabolich Prosthetic Research Center in Oklahoma City combined efforts to develop a CAT-CAM™ type hip disarticulation prosthetic socket design. It was intended that this new socket would hold the ischial tuberosity and descending ramus in a special compartment of the socket. RGP worked primarily on the suspension system, and Sabolich worked on the ischial ramus containment.</p> <p>The conventional hip disarticulation socket differs from the CAT-CAM™ type in that the old design has a flat inferior floor upon which the ischial tuberosity sits. Even worse, many times the tuberosity sits on the very edge of this table. As described in the original 1985 CAT-CAM™ article and in terms of the above-knee socket, this is not a desirable biomechanical situation because, first, the bone is touching a flat tangential surface rather than a contoured surface that conforms to the complex bony shape and thus distributes the load over a wider area and, second, because it does not provide medial-lateral stability. The new socket affords much more bony contact not only to the ischial tuberosity, but to the descending pubic ramus as well (<b>F</b><b>ig. 1</b>and <b>Fig. 2</b>). Experience has shown that the ramus turns out to be of more importance than the ischial tuberosity when it comes to enhancing medial-lateral and rotational stability. Only the inferior pubis-ramus is allowed to exit the socket at the medial inferior dip of the medial wall (<b>Fig. 3</b>).</p> <strong><a href="/files/original/9176ea93fc7422b272a48674e92598f3.jpg">Figure 1.</a> Demonstrates depth of ischial seat area relative to medial brim. Also shows how the ischium and ramus are in the socket.</strong><br /><br /><strong><a href="/files/original/51e118cc092de53ecec3404a4302acab.jpg" target="_blank" rel="noopener">Figure 2.</a> Postero-medial view of transparent diagnostic test socket on the patient with a patch of white paper delineating the ischial-ramus compartment.</strong><br /><br /><strong><a href="https://staging.drfop.org/files/original/b3a726660b994c9bbde0c48f30f4337c.jpg" target="_blank" rel="noopener">Figure 3.</a> Medial view with rulers at the inferior-most point in the dip of the medial brim.</strong><br /> <p>In order to better understand the new hip disarticulation design, it must first be understood that the CAT-CAM™ above-knee design is not a narrow ML socket at the proximal portion. On the contrary, the proximal ML diameter of the CAT-CAM™ above-knee socket, which contains the pelvic bones, is wider than the mid and distal portions of the socket, which then narrows to conform to the medial-lateral thigh dimension in order to supply soft tissue compression. The new hip disarticulation socket follows this SCAT-CAM™ principle. Thus, it provides a better bony locking effect. Also, these bony pelvic structures are more fully encapsulated as a result of a V-shaped medial contouring of the socket and provide the hip disarticulation patient with a feeling akin to the above-knee socket, rather than that which results simply from sitting on a flat hard seat.</p> <p>Some of the principles of the CAT-CAM™ total flexible brim are also utilized in this type of hip socket. The entire socket is flexible except in the area where the hip joint is attached. This can be accomplished in two ways: first, with a rigid frame and a flexible inner socket much like with the CAT-CAM™ and SCAT-CAM™ above-knee design; second, by a heterogeneous monolithic polyester socket that is rigid in the joint area and then gradually becomes flexible throughout the remainder of the socket (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <strong><a href="/files/original/c0c5f86b34e55516bbefc6ca2d8b9f3c.jpg" target="_blank" rel="noopener">Figure 4.</a> Laminated socket demonstrating flexibility of the contralateral portion of the socket. Superior portion of amputated side is flexible as well.</strong><br /><br /><strong><a href="https://staging.drfop.org/files/original/3bb0b814dfe7768034c9b39057177e31.jpg">Figure 5.</a> View similar to Figure 4 showing flexibility of socket. Also shows "V"-shaped contour of medial brim in sagittal plane.</strong><br /> <p>Like the SCAT-CAM™ design, the hip socket is more bone and muscle contoured than the traditional bucket shaped hip disarticulation design (<b>Fig. 6</b>). The new socket has a concave contour in the area of the ilium on the amputated side. On the contralateral side, there is a concave contour between the ilium and trochanter. This increases medial-lateral stability and results in improved gait when combined with the containment of the ilium, ischium, and ramus bones within the socket. This is contrasted to most conventional designs which bulge out and follow the flow of the soft tissue on both lateral sides of the socket rather than conforming to the body contours.</p> <strong><a href="/files/original/48af58273ca7d023d458415c3ede334c.jpg" target="_blank" rel="noopener">Figure 6.</a> Schematic cross-section through the frontal plane. Vectors 1 and 2 demonstrate the suspension principle and also refer to the dark lines which represent the socket walls. Notice how the superior edges of the socket do not come above the ilium crests and the concave contouring inferior to the illiae. Vector 3 refers to the bony lock.</strong><br /> <p>The "Inter Ilio Trochanteric Effect"<a style="text-decoration: none;">*</a> is one of the reasons it has been possible to suspend the socket in most cases without extending it above the iliac crests of the pelvis. Instead, the suspension is gained by conforming the socket into the notch between the ilium and trochanter and creating a counter pressure with the opposite concave shaped side of the socket. Of course, it is more difficult to suspend the socket in this manner when fitting heavy people with excessive adipose tissue.</p> <p>Normally with a conventional hip disarticulation, it is easy for a prosthetist to pull the prosthesis off the patient by sliding it into abduction, away from contact with the residual limb and the ischial tuberosity, when the prosthetic pylon is abducted off the floor. However, with the CAT-CAM-H.D.™ design, this maneuver is more difficult, and the socket resists this abduction tendency due to the bony lock about the ramus (<b>Fig. 7</b>).</p> <strong><a href="/files/original/3e10a6a4eb37fe679d8d7dc788e153c7.jpg">Figure 7.</a> Medial view of the transparent diagnostic test socket showing height of medial brim relative to inferior most portion of the socket.</strong><br /> <p>In the last four years, a combined number of 67 CAT-CAM hip disarticulation sockets have been fit in Oklahoma City and San Diego. These patients report that they do not feel like they are "sloshing around in a bucket" and have a "greater feeling of security and stability" (<b>Fig. 8</b>). Three of these patients can run with their new prosthesis in a hop, skip fashion which has been recorded during video gait analysis. Two patients have been able to manage limited step over step running.</p> <strong><a href="https://staging.drfop.org/files/original/e190fcba30937120ad5a9a8f6b348187.jpg" target="_blank" rel="noopener">Figure 8.</a> Posterior view of completed socket.<br /></strong><br /> <h3>Acknowledgments</h3> <p>It should be noted that Mike Wilson, C.P.O., was the first person who suggested to me the principles of lateral pressure between the ilium and the trochanter on the contralateral side. He called it an "Inter Ilio Trochanter Effect."</p> <p>Appreciation is given to Don Landis, B.S., R.P.T., for his editorial help in preparing this manuscript.</p> <p>Appreciation is also given to Glenn Hutnick, C.P.O., and Alan Finnieston, CP., who will be contributing to the next phase of research in hip disarticulation designs.</p> <b>Footnote</b> See acknowledgments.<br /> <p><em><b>*Thomas Guth, B.A., C.P.O. </b> Thomas Guth, M.D., C.P.O., is with RGP Orthopedic Appliance Co., 6147 University Avenue, San Diego, California 92115.<br /></em></p> <em><strong>*John Sabolich, B.S., C.P.O. </strong>John Sabolich, B.S., C.P.O., is President of Sabolich Prosthetic and Research Center, 1017 N.W. 10th Street, Oklahoma City, Oklahoma, 73106.<br /></em><br /> <div style="width: 400px;"></div> <div style="width: 400px;"></div> Page Number(s) 119 - 122 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The CAT-CAM-H.D.(tm) A New Design for Hip Disarticulation Patients Creator An entity primarily responsible for making the resource John Sabolich, B.S., C.P.O. * Thomas Guth, B.A., C.P.O. * https://staging.drfop.org/files/original/cdc95b02cc47b6ac5a555a1046cadadf.pdf 34ed2a18f8f3439ef880701f80f81b2e https://staging.drfop.org/files/original/ce7a2b7ad0810f0b02370d41250efccc.jpg 3a4c39847e4ec3b9bf8261686abda3a1 https://staging.drfop.org/files/original/634cb539af8eab5253faddc40f6e9d0b.jpg 37149e5deb28bbdda74066f00fe6e09d https://staging.drfop.org/files/original/ea53ec98f51b6dce71f7a77727448ef3.jpg c7ecfa8c1488b9d239aaf61306016d21 https://staging.drfop.org/files/original/679f4b61888358a86e8bf53ae8458619.jpg a163b30fed74ee555cf603bcc30ef8cd https://staging.drfop.org/files/original/9ba53dc99c34b34ebbcf6445256aaa41.jpg 3bf51c3620d99120850d76f06e54d498 https://staging.drfop.org/files/original/b9ce20332f3ef2c5febd1df36e326169.jpg a27393f6213633786a241d9f9c92ce4f 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 http://www.oandplibrary.org/cpo/pdf/1986_02_093.pdf Text Any textual data included in the document <h2>Below-Knee Prosthesis with Total Flexible Socket (T.F.S.): A Preliminary Report</h2> <h5>John Sabolich, B.S., C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Thomas Guth, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Recent efforts in Oklahoma City, and San Diego have borne fruit to a promising new way to fit below-knee amputees. The basic design consists of a thin walled thermo-plastic socket secured in a frame by nylon strapping tape so that most of the socket is left exposed and unsupported (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-01.jpg"><b>Fig. 1</b></a>). This design, named the Total Flexible Socket (T.F.S.), was conceived out of necessity with a few patients that were so difficult to fit that even aggressive techniques such as multiple transparent diagnostic sockets, alginate injections, total surface bearing modifications, and silicone gel inserts failed to provide a measure of comfort acceptable to them. It was felt that a more unconventional method would have to be implemented. Currently, this technique is being used with most of the geriatric population seen, and with time and experience it is being applied to an ever increasing proportion of the total below-knee amputee population served. Forty or more of these sockets have been fitted over the past five months to patients ranging in age from ten to 89 years with results that were beyond initial expectations. Patient reaction has been extremely positive. Plans are to submit an up-dated article when over 100 documented fittings with the described technique have been accomplished.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-01.jpg">Figure 1. Medial and lateral views of T.F.S. in an exoskeletal version. Suspension sleeve and cosmetic hose rolled down for clear view of socket secured in place with band of fiberglass tape.</a></strong><br /> <p>The idea for the T.F.S. design was prompted during the course of fitting a patient with a flexible diagnostic test socket. The patient was comfortable in this socket even when bearing his full weight on a padded fitting stool. Subsequently, when a full socket receptacle for the test socket was laminated and it was rigidly contained, this comfort was lost. The patient still complained of pressure even when holes were cut out over bony prominences.</p> <p>Finally, when the maximum amount of material was cut away and the former socket receptacle was reduced simply to a means of attaching the socket to the rest of the prosthesis, thus allowing the socket to return to its former measure of flexibility, comfort was regained.</p> <p>Several interesting phenomenons were noted:</p> <ol> <li> <p>Since the T.F.S. design is totally flexible, allowing ML as well as AP expansion and retraction, the socket finds and seeks its own level of pressure distribution. If the AP is too tight, it automatically expands, causing the ML to tighten up, wrapping around the tibial flare and the fibula. This, of course, is not true when a receptacle is only opened up over bony areas allowing no reciprocal ML-AP displacement and minimal flexibility, even over bony areas. With the T.F.S., if the ML is too tight, then the AP automatically tightens as the ML loosens, and vice-versa if the AP is too tight (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-02.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-02.jpg"><strong>Figure 2. Transverse view of a socket cross section showing, in an exaggerated fashion, the reciprocal AP-ML displacement.</strong></a></li> <li> <p>The AP-ML "Milking" action seems to have a positive effect on circulation since the residual limb seems palpably warmer when a T.F.S. is removed, as compared to when a rigid socket is used. In the case of flexible sockets thinner than 3/32 inches thick, the entire socket moves with the residual limb, seeming to expand and contract due to the open nature of the frame. This phenomenon can be felt better than seen by holding the socket as the patient alternately places weight on the prosthesis and removes it, especially after the socket warms up to body temperature. This dynamic socket movement and improved circulation could be very significant for the geriatric P. V.D. patient. This action also seems to enhance atmospheric suspension: when the patient removes weight, the socket collapses and grips the residual limb like the familiar childhood toy, a Chinese fingertrap.</p> </li> <li> <p>Atmospheric Suspension (A.S.) assorted methods of achieving suction suspension for the below-knee amputee have been tried for years, with varying degrees of success. The main reason behind this effort is the desire to solve the number one problem of the below-knee amputee, that of skin shearing and pistoning between the residual limb and socket. Another major problem has been that of the patient wanting a lighter weight, more responsive prosthesis. With the T.F.S.A.S. combination, most patients have been responding favorably with such comments as "It feels like my own leg!" and "It feels like part of me!" With atmospheric suspension, the patient no longer needs to wear a suspension sleeve to maintain full suction. The Total Flexible Socket holds suction better than a rigid socket because the socket can move and conform to the changing contours of the residual limb, through all phases of gait and sitting. A loose elastic knee cage is recommended to enhance proximal brim seal during knee flexion past 90°. For sports prostheses, use of a rubberized sleeve of choice is recommended. Cosmesis is also enhanced since the patient no longer has the extra bulk of socks or inserts increasing calf circumference. It's a little too early to tell, but it is felt that atmospheric suspension may well become the standard below-knee fitting technique for all types of patients.</p> </li> <li> <p>Use of a cuff suspension strap is improved since the cuff and socket brim can contour in about the patella (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-03.jpg"><b>Fig. 3</b></a>). Use of a suspension sleeve with the T.F.S. is also possible, and if anything, enhances the function of a T.F.S. since the suspension sleeve supports the socket brim and soft tissues, holding the two in close conformity through the full range of knee motion.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-03.jpg"><strong>Figure 3.</strong></a></li> <li> <p>Flexibility allows greater containment posteriorally in the popliteal region. The posterior wall can be higher since it flexes away during sitting. Little posterior flare is needed. In fact, this area could be rolled in slightly, similar to how the cubital fold is contained in myoelectric below-elbow arms (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-04.jpg"><b>Fig. 4</b></a>). If the practitioner desires, the socket can be made flexible all the way down to the distal tibia. This is accomplished by building a thick distal end pad (with or without an insert) inside the socket, or an extension on the exterior of the socket which extends the trimline of the frame distally, allowing total flexibility in the distal regions of socket.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-04.jpg"><strong>Figure 4. Lateral view of T.F.S. showing suggested modified contour.</strong></a></li> <li> <p>The ML measurement of the knee becomes wider as the knee flexes. This can be demonstrated by placing an ML gauge on the knee and watching the gauge as one puts the knee through its range of motion. The T.F.S. design allows for this dynamic variance.</p> </li> </ol> <p>Last but not least, overall hygiene and circulation seem to be dramatically improved. Especially impressive is the absence of red marks on the skin following doffing of the T.F.S. There are none of the usual red marks left by conventional sockets. Patients who had to have many reliefs before in their rigid sockets now require none.</p> <p>Since several prosthetists have been fitting these sockets successfully, using various modification techniques, it has been concluded that it is irrelevant which particular modification technique is used. Results from all modification techniques have been improved utilizing the Total Flexible Socket. The use of negative modifications only is recommended. One simply does not need to add positive build-ups to the model since the reciprocal AP-ML displacement dynamically accommodates the patient's anatomy. The bony areas are accommodated automatically (most of the time) as the patient ambulates. It is, of course, most exact to use multiple transparent diagnostic sockets, alignate, or oil injection procedures (as well as other means) to obtain the best fit possible.</p> <p>The flexible socket seems to work so well that it is tempting to skip the check socket stage. Do not succumb to this temptation, or you will never know just how comfortable the socket can be once you get the patient fairly comfortable in the rigid transparent socket and clone it to the T.F.S.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-05.jpg"><b>Diagram</b></a></p> <br /> <p>After the hard socket is fit, it is necessary to remove an additional 1/4" to 3/8" of plaster from the positive model around the superior brim, close to the patella, to allow a flexible clamping action about the proximal brim. Use of this extra modification can not be emphasized enough for final comfort and stability. An intimate fit must be maintained around the proximal brim with the T.F.S. design. No other additions or modifications are necessary.</p> <p>If a liner or insert is used, it is fabricated over the positive model with a thick distal end pad to provide extra distance distally. This extra length is necessary if one desires to make the distal tibia area flexible since the frame can be trimmed more distal, even past the end of the distal tibia. Alternately, as mentioned, an extension can be added to the socket following vacuum forming.</p> <p>One can use any of four materials for the flexible part of the socket: The first is Surlyn,® which is preferred in most cases. This material can be molded fairly thin, and yet it provides excellent structural strength and integrity. Surlyn® stock material of 1/8"-3/16" thick is used (depending on the degree of flexibility) for vacuum forming. A final thickness of about 1/16" or less is adequate. It is not necessary for this socket to be extremely flexible, as with a fenestrated socket, since the majority of the socket is open and flexible in all directions with two adjacent sides being able to move relative to the frame.</p> <p>The second material is polyethylene, which is more flexible and sometimes more desirable for children or geriatrics who are somewhat inactive. The third is Streifylast, which is a material that is being utilized more and more lately since it has a high level of flexibility while maintaining its structural integrity, and is especially resistant to tearing and breakage. A fourth material called Polyethylene Plus® (available through Maramed) seems to be superior even to Streifylast and has an extremely good tear resistance.</p> <p>Once the socket is vacuum formed, a fiberglass nylon polyester frame is fabricated. Carbon fiber and acrylic resin can be used, if one desires greater strength and less weight, but is not necessary in most cases. The thickness of this frame depends on the activity level of the patient, but usually ranges in thickness from 1/16" to 1/8".</p> <p>As in<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-06.jpg"> <b>Fig. 5</b></a><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-05.jpg"><b></b></a>, there are two basic frame designs: one for geriatrics, and one for active or sports oriented patients. The geriatric type extends proximally to the medial tibial flare and is cut away everywhere else except around the distal end pad (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-07.jpg"><b>Fig. 6</b></a>). The sports type frame for younger patients comes more proximal pos-teriorally, lending more strength. It maintains total AP-ML flexibility since it still has only two sides adjacent to each other. As long as one does not place a third wall on the frame, reciprocal AP-ML flexibility is preserved and provides for automatic pressure distribution. It must be emphasized that these are only guidelines and the actual trimlines of the frame are variable and modified as the patient's needs dictate.<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-06.jpg"><strong>Figure 5. Four views of the T.F.S. showing sports and geriatric trimlines and distal end pad or buildup. Distal buildup is especially useful when it is desired to cut the anterior trimline below the distal tibia.</strong></a></p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-07.jpg"><strong>Figure 6. T.F.S. showing geriatric trimline. Ultralite construction.</strong></a><br /> <p>The flexible socket can be attached to the rest of the prosthesis by using two or three bands of nylon fiber tape wrapped circumferen-tially about the frame and socket to provide strength, while not affecting flexibility. If one desires even more strength, pressure sensitive tape can be wrapped over the nylon tape or even over the whole frame and socket. The socket can be riveted or fastened with Chicago screws in addition to the tape, for additional security.</p> <p>The final finishing of the prosthesis is relatively simple. If an endoskeletal approach is used, the soft foam cover hides the socket frame interface as well as the nylon strapping tape and results in a very cosmetic prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-08.jpg"><b>Fig. 7</b></a>). The T.F.S. prosthesis finishes especially well as an endoskeletal since it feels more life-like all the way up the prosthesis. If one desires an exoskeletal finish, one can easily use polyurethane foam for shape, laminate the outer covering, remove the flexible socket, and grind the foam away from around the frame and cosmetic shell as desired. This leaves a void or hollow of about 1/8" (all that is necessary) between the flexible socket and cosmetic shell. Alternately, the prosthesis can be shaped and finished about the socket in the same fashion as an endoskeletal prosthesis. The proximal external contours can then be established with a soft fairing of PE-LITE® or Plastazote glued to the flexible socket and frame.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-08.jpg"><strong>Figure 7. T.F.S. with soft cosmetic covering.</strong></a><br /> <p>Fabrication of an Atmospheric Suspension Socket is the same as for any T.F.S., except for the placement of either an expulsion valve or a small suction valve on a 45° angle at the distal posterior of the total flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-09.jpg"><b>Fig. 8</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-09.jpg">Figure 8. T.F.S.-A.S. showing placement of valve distally</a>.</strong><br /> <p>Modification on the other hand, is a little different than a non-atmospheric suspension T.F.S. The socket must be a little snugger to accommodate total self-suspension. After achieving the "perfect skin fit" with a clear diagnostic socket and the alginating procedures, the model is poured and modified the same as any T.F.S. by slightly tightening it about the patella area. The technician then takes the modified model and laminates a two layer cotton rigid socket over it, which is rolled or slushed twice with promoted liquid polyester resin to tighten all areas of the socket equally. This socket, with reduced internal dimensions, is then poured with plaster of Paris and the T.F.S. socket is subsequently vacuum formed over the resulting positive model. It is felt that this extra tightening is necessary to compensate for the fact that a rigid diagnostic socket cannot be donned as easily as a T.F.S. of equal or greater tightness.</p> <p>In conclusion, a new concept for the fabrication of a below-knee prosthesis has been described, as well as the preliminary results of fitting some 40 patients for up to five months. It is sincerely hoped that other prosthetists will find it as beneficial to their patients as it has been found to be in both Oklahoma City and San Diego.</p> <h3>Acknowledgments</h3> <p>We would like to thank one of our own prosthetists, Bill Etheridge in Oklahoma City for forcing John out of conventional thinking so we could aggressively research this interesting phenomenon.</p> <p>We would like to thank Mary Healy, San Diego, for her help in Atmospheric Suspension Technique.</p> <p>We also wish to thank Alan Finnieston, CPO for materials research and for finding an appropriate tear resistant thermoplastic.</p> <b><b>Thomas Guth, CP.<br /></b></b><em>Thomas Guth, CP is Secretary Treasurer at RGP Orthopedic Appliance Company, 6147 University Avenue, San Diego, California 92115.</em><b><b><br /><br /></b></b><b>John Sabolich, B.S., C.P.O.</b><br /><em>John Sabolich, B.S., CPO is with Sabolich, Inc. at 1017 N.W. 10th Street in Oklahoma City, Oklahoma 73106.</em> Page Number(s) 93 - 99 Year 1986 Volume 2 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-09.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Below-Knee Prosthesis with Total Flexible Socket (T.F.S.): A Preliminary Report Creator An entity primarily responsible for making the resource John Sabolich, B.S., C.P.O. * Thomas Guth, CP. * https://staging.drfop.org/files/original/d58593ef39362194114423665e739f0c.pdf fcbe907f83e666b1ec1ef034e62a0e0e 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/1982_01_010.pdf Text Any textual data included in the document <h2>Professionalism Or What?</h2> <h5>John Sabolich, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>Editor's note: This article originally appeared in the September, 1981 issue of the AOPA Almanac. Mr. Sabolich has kindly given his permission to reprint the article so that it may be shared with a larger audience.</i></p> <p>Are you a professional? If so, how do you know? Our field is struggling with this question. There must be more to being a professional than wearing a white lab coat!</p> <p>Let's start with us, the Prosthetist or Orthotist. Sometimes the words that come out of our own mouths are the greatest obstacles to being fully recognized as professionals. We are engaged in advertising and are placed next to store ads in many publications that medical personnel read. We call our patients "customers," our lab and office a "shop" or "store"; our fee schedules are called "price lists." We go to hospitals to "sell our wares" without even charging a consultation fee! Prostheses and orthoses are called "appliances." (Does this sound professional, or like a washing machine and dryer?) We are called "low bidder" on contracts in which we need not even be involved. Maybe we would be happy to move up one more notch to a "vendor"! I hope we shudder at the term!</p> <p>There are other areas in which we could improve our professional status in the community, such as what we call our facilities. The words "artificial limb," "brace" or "shop" are not conducive to our professional status. We refer to a patient's leg or residual leg as a "stump," prosthetic socks are called "stump socks." Patients feel rushed in clinical or office situations. Interoffice conduct, such as loud talk in patient care areas, the manner in which we answer our phones, or allowing patients in the lab, all reflect on our professionalism. Seemingly insignificant things are important, such as parking areas that say "customer parking" instead of "patient parking." Yes, we present ourselves to the patient in many ways. One of the most important is the appearance of our front offices, reception areas and examination rooms. Many times there are items for sale or on display, even prostheses and orthoses. This does not make us look professional to the patient but rather gives our office a store front appearance and lends to uncomfortable and impersonal feelings.</p> <p>A professional practitioner should be opposed to anything or anyone who blocks patient care. We avoid calling the doctor if we disagree with prescription rationale, when the patient is the ultimate beneficiary. All medical as well as paramedical people must realize they are not the most important person in a clinical situation. It must be made clear, the patient reigns supreme!</p> <p>The patient and medical community could view us as paramedical professionals. In this setting, it can be better understood that payment is not being made for a "piece of plastic" but for expert knowledge, ability and education. The device itself only represents a contributing factor in designing and implementing an efficient and successful prosthetic and orthotic program. A prosthesis or orthosis is the only tangible thing the patient sees, therefore patients tend to equate the fee charged with the plastic object provided for him. When a doctor operates, does he charge $5000.00 for the $1.50 worth of cat gut? Again, this is the only thing the patient can actually see and feel.</p> <p>The public at large is not familiar with the terms "Prosthetics" or "Orthotics". It would force them to become educated to these more professional terms if, under Artificial Limbs and Braces, the telephone books across the country referred the public to Prosthetics or Orthotics in a cross reference. Suppose you are John Doe looking up artificial limbs in the yellow pages. You simply would not find it because you would be referred to the word Prosthetic. Think how far that would go on a national scale to educate people to these important terms. In Oklahoma we were able to accomplish this goal. The practitioners in this state all agreed to be moved to the more professional title and even reduce their listings to only three lines. We will all feel more professional this year!</p> <p>We must strive to increase our credibility by being more precise in our practices, turning away from the empirical and moving toward the scientific and quantitative approaches by increasing our support dramatically which can effectively increase our knowledge and technology. Our educational criteria must remain high. Board certification exams should remain comprehensive with lower level technical schools to supply the manpower.</p> <p>I realize that I am also guilty; yet if we care enough, we must attempt to correct these problems for ourselves, our profession and, most importantly, for the patients who seek our help. My fellow practitioners, I suggest to you, this problem lies with us; our attitudes, what we say, what we do.</p> <h3>Acknowledgements :</h3> <p>I express my sincere appreciation to these people for directly influencing the contents of this article.</p> <p>Steven D. Prock, CPO<br />Michael T. Wilson, CPO<br />Henry L. Schufletowski, CO<br />William J. Barringer, CO<br />Thomas Haslam, CO<br />Alvin C. Pike, CP<br />Charles Pritham, CPO<br />Lester Sabolich, CPO<br />Melvin Stills, CO<br />Lorene Sabolich<br />Lee Sabolich<br />Karen Mondie<br />Tina Prince</p> <em><b>*John Sabolich, CPO. </b> Sabolich Inc., Artificial Limb and Orthopedic Appliance Co. Oklahoma City, Oklahoma<br /><br /><br /></em> Page Number(s) 10 - 10 Year 1982 Volume 6 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 Professionalism Or What? 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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_04_015.pdf Text Any textual data included in the document <h2>Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles</h2> <h5>John Sabolich, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Since 1969, it has become increasingly evident that quadrilateral sockets have serious bio-mechanical problems. Even my old-timer above-knee prosthetic patients seem to be more comfortable in their ancient plug sockets, although transverse rotational stability was not as good. Fundamental to these objections is the lack of adequate stabilization in the frontal plane, which results in the gluteus medius gait most AK amputees demonstrate.</p> <p>In order to stabilize the upper trunk and pelvis in normal gait, the gluteus medius and abductors on the stance side must fire vigorously when the contralateral side is in swing phase. However, we are dealing with a patho-mechanical situation when we consider the case of the above-knee amputee. No longer are bones and ligaments positively connecting the hip to the floor. There is an intervening pseudo-joint, "the patient socket interface." We now have part of the femur inside a gelatinous semifluid mass, the human thigh.</p> <p>When the abductors fire, what is most likely to occur in a rectangular socket with a wide M-L dimension and no bony areas for the socket to lock against medially? The answer we have discovered, is that the femur tends to abduct. In quadrilateral sockets, the ischial tuberosity is sitting on top of the ischial seat and is free to shift about (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg"><b>Fig. 1</b></a>). As the gluteus medius pulls the femur into abduction, the pelvic slides medially on the ischial seat and makes the abduction worse. The unsupported femur has little choice than to drift into an abducted attitude within the wide M-L quadrilateral container. Pain at the distal femur and at the proximal medial area is due to this abducted position and excessive soft tissue pressure medially.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg">Figure 1. No bone block and no real force system to prevent femoral or ischial drift. Ischial tuberosity acts as a fulcrum. Pelvis can rotate as well as the femur abduct.</a></strong><br /> <p>We now have a perfect set-up for the classical above-knee "lateral trunk leaning" gait familiar to prosthetists. The patient has to lean to the side to position his upper torso over the base of support (the abducted distal femur) during stance phase, since the prosthesis is falsely placed under him (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg"><b>Fig. 2</b></a>). The patient executes this maneuver to prevent excessive pressure on the lateral distal femur and the medial proximal soft tissue. In essence, the patient must walk in a fashion similar to a person who has two sound legs with one leg out to the side in abduction.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg"><strong>Figure 2. Patient must lean lateral over distal abducted femur, use inertia, or muscular tightening to prevent pain on lateral distal femur.</strong></a><br /> <p>To the best of my recollection, I began questioning the validity of the quadrilateral socket theory in 1969 when I was a student at New York University. Dr. H. Richard Lehneis, C.P.O., of that institution taught that it is not necessary to put most of the patient's weight on the ischial tuberosity and, if the truth were known, most of the weight is probably borne by the peripheral tissue and gluteal mascula-ture. Moreover, at heel strike, when the largest inertial forces are placed on the above-knee residual limb, the ischial tuberosity is not on the ischial seat due to the flexed hip.<a style="text-decoration: none;">*</a></p> <p>This concept was reinforced in my mind by the idea that if the majority of the amputee's weight was borne by the ischial tuberosity on the quadrilateral socket's flat ischial seat, one would only be able to obtain a tangental force at best, which would bring to bear tremendous force on a very small part of that bony prominence, and consequently cause great discomfort. Placing extra force in the neurovascular bundle anteriorly, Scarpa's triangle, with the purpose of pushing the ischial tuberosity up onto the ischial seat, has never made much sense to me. This seems to be the worst place to apply pressure and can not have a positive effect on circulation. These thoughts confirmed my concern that the quad socket theory had serious biomechanical problems and spurred my subsequent efforts.</p> <p>We began to close the M-L dimension of the socket by adding material to the lateral and medial sides to try to force the femur into adduction. We also began opening up the A-P dimension, not only to reduce the pressure on the neurovascular structures of the Scarpa's triangle, but also to compensate for the reduced diameter in the M-L dimension, and thus to maintain the original circumference. (Prosthetists naturally tend to be fearful of such modifications since they have been taught to tighten the A-P to keep the ischial tuberosity on the ischial seat.) In addition, I began to slant the ischial seat in the frontal plane upward laterally at about a 30° angle, rather than leaving it horizontal, so as to increase the weight bearing of the gluteal muscles, and thus rely less on the ischial tuberosity. These are some examples of early attempts to change the quadrilateral design and may be considered as our first generation efforts.</p> <p>In early 1981, the Sabolich Prosthetics Center sponsored a seminar to investigate non-quadrilateral alternatives for A.K. management. Participating in this seminar, among others, was Ivan Long, CP., developer of the concept of Long's Line and an associated socket design.<a></a> The information learned from Mr. Long was of the greatest benefit in advancing our efforts. However, for reasons that will become apparent in this article, we found it essential to proceed on a different track that experience has shown was necessary to make this program work for us. After this seminar, the Sabolich Center continued research study of non-quadrilateral above-knee designs.</p> <p>Over 900 non-quadrilateral sockets have been fit on a documented basis in Oklahoma City to patients ranging from six months to 103 years of age. X-rays (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg"><b>Fig. 3</b></a>) and Xerography have been impressive, showing the femur to be in a much improved adduction attitude. We have made major changes in shape and contour, especially in the last three years. We have coined the acronym CAT-CAM, which stands for Contoured Adducted Trochanteric-Con-trolled Alignment Method, to describe the second generation design which is covered in the remainder of this article.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg"><strong>Figure 3. Weight bearing x-rays comparing CAT-CAM and quadrilateral sockets.</strong></a><br /> <p>This design includes undercutting of the trochanter and a special fossa in which the ischial tuberosity and descending ramus can rest, giving this bony prominence three-dimensional support within the socket. No more consideration is given to the transverse angle of the posterior wall relative to the medial wall (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg"><b>Fig. 4</b></a>). The Scarpa's triangle is virtually eliminated, as are the adductor longus and rectus channels, and the ischial seat. The ischial tuberosity still bears some measure of vertical loading since it rests on an angled surface. The old principles of the quadrilateral design simply do not function, since we are dealing with a completely different design in shape, contour, and biome-chanical principles. The socket is so different that it looks somewhat like a quadrilateral socket turned sideways with a large A-P and narrowed M-L.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg"><strong>Figure 4. Comparison of CAT-CAM and quadrilateral sockets in a transverse view. Since the femur and ischial tuberosity are fixed in position, the adductor longus tendon has to shift a small amount. Note mild O.K.C. (Oklahoma City) channel about the femur.</strong></a><br /> <p>A number of prosthetists have come to our facility to learn these techniques on a one-on-one basis. We have gained much information and feedback from the other prosthetists who have participated in these informal educational efforts. However, this process is not altogether appropriate and has come to be tremendously time consuming. We feel that in the future, education should be administered to several prosthetists at once in an organized and structured course by one or another of the schools. In March, 1985, a preliminary course was taught at UCLA after two years preparation and the writing of a manual. This effort confirmed, in the minds of those involved, the necessity of such a course, and also the necessity of further efforts upon the part of the teaching staff involved to perfect techniques and teaching material. Moreover, it should be borne in mind that the acronym CAT-CAM embraces a number of varying concepts advanced by a number of prosthetists working in common directions and these differences must be reconciled into one technique to be taught. In the strongest possible terms, and in view of the problems some prosthetists have had, we can not recommend using the CAT-CAM method without a hands-on instructional course.</p> <h3>CAT-CAM Theory</h3> <p>The CAT-CAM holds the femur in adduction primarily by two means. First, the ischial tuberosity and part of the inferior ramus of the ischium rest inside the socket proper, and bear laterally directed forces which work in conjunction with medially directed forces borne by the femur (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg"><b>Fig. 5</b></a>). Medially directed forces bearing on the proximal portion of the femur in the trochanteric and sub-trochanteric region act to hold the ischial tuberosity on an inclined medial-posterior surface within the socket, while forces on the mid and distal portion of the femur act to maintain the proper adduction angle. Actually, it could be described as a wedging or "locking effect." (Imagine yourself holding the ischial tuberosity of a skeleton in the cupped palm of your hand and pushing the femur into adduction with your opposing hand; thus, the "locking effect.") The lateral surface of the socket proximal to the greater trochanter is contoured intimately into the soft tissue distal of the iliac crest. It is hypothesized that medially directed forces in this area, working in conjunction with the medially directed forces on the lateral surface of the femur and laterally directed forces borne by the ischial tuberosity, create a three-point pressure system to lock the femur into adduction and reduce motion that can occur when the ischium is free to shift about.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg"><strong>Figure 5. Ischial tuberosity is locked in the socket to provide a counter force against femoral shift.</strong></a><br /> <p>Second, the narrow socket means that the pressure bearing areas of the socket bear directly against the skeletal elements, thus reducing motion lost through intervening soft tissues. A wide socket M-L cannot provide this locking phenomenon since the femur can fall away from the supporting surfaces.</p> <p>In the transverse plane, the medially directed force of the ischial tuberosity is posterior to the laterally directed force of the trochanter and femoral shaft. One might assume, therefore, that the socket would twist or whip about its long axis. This does not happen, and apparently the adductor longus tendon and other medial proximal tissues anteriorly generate enough counter force to resist this tendency. Also, the ischial tuberosity creates a posteriorly directed force (since it is nestled in the posterior medial corner of the socket), resisting this tendency. Last, this tendency is checked by a new medial trimline (described later) which captures the medial portions, or the inferior ramus of the ischium, which are almost exactly opposite the trochanter.</p> <p>The exact weight bearing mechanism of the CAT-CAM socket with its wide A-P diameter and decreased emphasis on ischial tuberosity weight bearing is unclear. However, it is assumed that the femur is capable of bearing some measure of the patient's weight due to the increased adduction angle. It is also assumed that hydrostatic weight bearing plays an important role and that the ischial tuberosity still bears a measure of weight.</p> <p>In general, we have discovered that the prosthetic foot should be placed considerably lateral of a plumb line through the ischial tuberosity, but not always under the center of the hip joint or distal femur as with "Long's Line." This line changes position with how well the ischial tuberosity is locked in the socket and how narrow the mid and distal M-L dimensions can be molded. This alignment line also changes from patient to patient and depends on gluteal muscle strength, ischial ramus shape, femoral length, and subcutaneus tissue thickness. The prosthetist is now able to align the prosthesis in a normal physiological and anatomical fashion because the femur is no longer in abduction.</p> <p>The Berkeley Adjustable Shank is very useful in determining this critical relationship. By outsetting the foot more than with quadrilateral designs, the patient must adduct his femur to get his feet close together again. With the femur in abduction, as in the quadrilateral socket, a patient would be standing with his prosthesis scissored over his sound leg if he tried to stand with his femur in normal adduction angle. One cannot use a standard unchangeable line and always obtain the same adduction angle as with the contra-lateral femur, since the shorter the femur, the greater the adduction angle must be in order to place the distal femur under the center of the hip joint resulting in hyper-adduction. This was the reason I abandoned this line in favor of an adjustable line utilizing the Berkeley Adjustable Shank. This has resulted in much better alignment.</p> <p>One may ask, "If everything is stabilized in the M-L direction, then what about in the A-P plane?" Afer all, this is of the utmost importance at heel strike in order to stabilize the prosthetic knee and to help propel the patient over the foot. Our experience has not shown this to be a problem. In fact, if anything, an increase in A-P stability has been noted. We hypothesize two ways by which this might be explained.</p> <p>First, the majority of the muscle activity about the hip is in the A-P direction. The flexors and extensors are allowed to expand naturally, filling the socket quickly, and thus firmly stabilizing it (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg"><b>Fig. 6</b></a>). Also, this change in contour allows the A-P muscles to function naturally, increasing their size and strength. We have noted many cases of hypertrophy of the A-P muscle groups rather than atrophy. No longer are these muscles being squeezed, stifling their motion and effectiveness. Even suction sockets seem to hold on better since the tissues are not being deformed in an unnatural fashion, causing air pockets and channels to form. Second, the ischial bone is inside the socket, creating a solid posterior stop as opposed to simple soft tissue pressure, aiding A-P control at heel strike (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg"><b>Fig. 7</b></a>). Distally, CAT-CAM's become more round, again aiding A-P control.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg"><strong>Figure 6. Most muscles function in the A-P plane. The CAT-CAM socket gives these muscles room for their normal dynamics.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg"><strong>Figure 7. The ischial tuberosity is free to shift about in the A-P plane as well as the M-L plane when sitting on top of the ischial seat.</strong></a><br /> <p>We have noted several interesting phenom-enons during this research effort. The first I have dubbed the "lateral pylon lean syndrome." Sometimes during dynamic alignment on the adjustable shank, the pylon has to lean laterally in order for the patient to be comfortable. The pylon can be brought vertical by increasing the socket adduction. This turns out to be a temporary solution and does not solve the real problem. This eventually results in pain in the perineum. What is actually happening is that the ischial tuberosity is slipping out of the socket proper and migrating medially on the proximal brim. As a result, the femur falls into abduction, or more realistically, the superior lateral portion of the socket drifts laterally on the patient, the medial superior brim digs in, the pylon leans laterally, and the proximal lateral brim gaps. The problem is not one of alignment at all, but of ischial containment (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-08.jpg"><b>Fig. 8</b></a>). This happens when the socket is too tight in the M-L plane. This happened with sockets fitted after the 1981 seminar when circumference charts were used to determine socket M-L. These resulted in the ischial tuberosity being on top of the medial brim and that is why the brims of such sockets were so wide and thick. The intention was to get the ischium in the socket, but in actual practice it invariably ended up on top. This is no longer necessary due to improved measurement techniques used to determine true M-L.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-08.jpg"><strong>Figure 8. When the CAT-CAM socket is too tight, the ischial tuberosity shifts medially, the femur abducts and the lateral superior brim gaps.</strong></a><br /> <p>Secondly, it seems that the shorter the femur and the greater the volume of the residual leg, the more noticeable is the "CAT-CAM effect." This is due to the favorable comparison of the CAT-CAM sockets versus quadrilateral sockets. The shorter the femur and the greater the relative amount of soft tissue in which it can move, the more obvious the problems of the quadrilateral socket become. However, even with long and lean residual legs, patients still notice the difference in comfort and adduction associated with the CAT-CAM method. A common statement is "it feels more solid," "it feels like its under me again," or "my leg goes where I want it to go." Also, the short residual limbs simply have much more peripheral tissue containment in which to bear vertical and horizontal loading, since the CAT-CAM extends much higher and contains more tissue, especially gluteal.</p> <p>Third, we have virtually eliminated use of hip joints even on very short sub-trochanteric above-knee patients. The adducted femur and the high lateral wall, snugly pressing into the intraillio-trochanteric region, help stabilize the M-L and tend to reduce the need for external support.</p> <p>Fourth, to the question of sitting: will there be a lot of gapping anteriorly? Not if the socket is dimensionally correct. Bending forward at the hip is actually enhanced due to increased room anteriorly, and with the new flexible brim described next, the problem is completely eliminated.</p> <p>Fifth, both the modified version of the Swedish Flexible design, with medial and lateral framing, and the new Total Flexible Brim (T.F.B.) mesh with CAT-CAM principles perfectly as both allow increased function of the A-P muscle groups (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg"><b>Fig. 9</b></a>). The CAT-CAM with T.F.B., is preferred because of its superior sitting comfort, adaptability, and dynamic comfort without sacrifice of A-P muscle freedom. The T.F.B., which allows the entire upper three-fourths of the posterior wall and the entire proximal portion of the socket to be flexible and allows a flexible anterior window, is actually opposite of the Swedish Flexible design, which has its greatest measure of flexibility concentrated in the mid-thigh. The T.F.B. is possible because the ischial bone is no longer on top of the posterior or medial seat, but down in the socket, so it does not tend to collapse or push the flexible seat distally. Instead, the tuberosity forces out against the side of the socket as does the trochanter, adductor longus tendon, and peripheral tissues. This can be thought of as one trying to hold his body in place in a V-shaped vertical tunnel or shaft by pushing out on the walls of the tunnel with one's hands and feet. The residual leg pushes out in all directions at once, thus there is no collapse of the flexible posterior brim. For the first time in prosthetics, the proximal thigh is actually allowed to deform naturally during sitting and to change contour dynamically while ambulating. I feel this is important since a great deal of pain complaints are related to the proximal areas. This flexible brim has also allowed us to become much more aggressive and make a major change by extending the posterior and posterior-medial brims higher to capture the ramus and ischial tuberosity more effectively. It has also allowed us to actually slant the medial brim superiorly to better capture the ischium and ramus while relieving the pubis.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg"><strong>Figure 9. Three views of the Total Flexible Brim (T.F.B.) CAT-CAM.</strong></a><br /> <p>Sixth, bilateral above-knee patients gain additional benefit from the CAT-CAM design. Our bilateral patients who rejected their quadrilateral socket accept the CAT-CAM enthusiastically. They benefit from the extra space provided in the perineal area by the narrowed M-L (especially with male patients). Even the old round plug sockets gave more room in the perineal area (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg"><b>Fig. 10</b></a>). The shaded area in <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg"><b>Fig. 10</b></a> demonstrates the extra area available for the genitalia from plug sockets over the quadrilateral socket represented by the rectangles. The CAT-CAM, of course, allows even more room in this area due to its opposite shape and contour.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg"><strong>Figure 10. Graphical representation of the amount of room afforded in the perineum by a non-quadrilateral socket.</strong></a><br /> <p>Seventh, the CAT-CAM has great advantages for the geriatric patient for several reasons. We have had our worst difficulties with quadrilateral socket on people with poor muscle tone. The shortcomings of the quadrilateral design become more obvious in the older population. The sharp angles of the adductor longus channel, the posterior medial corner, the medial brim, and the Scarpa's triangle of the quadrilateral socket were almost never really comfortable. With the CAT-CAM, these patients seem to have improved vascular flow; their residual limbs feel warmer after removing the prosthesis. This seems reasonable since the neurovascular bundle is not being choked off with a large bulge in the Scarpa's triangle. The A-P is not being choked but opened up. We hope to conduct comparative temperature and later Doppler blood flow analysis of this phenomenon. For the extremely large geriatric patient population, this alone might be one of the single greatest benefits of research with CAT-CAM design. When the Total Flexible Brim is added, we have not only greater comfort, but further increase in circulation.</p> <p>Eighth, we have noted that a large percentage of patients who were switched to CAT-CAM comment about energy savings. They do not seem nearly as tired after walking the same distance in the CAT-CAM as with their old prosthesis. This is probably first due to less lateral displacement of the center gravity. Second, patients do not have to fight to keep the femur from hitting painfully against the socket distally by tightening their musculature. Third, with more boney contact inside the socket and thus a more solid purchase, the prosthesis moves quickly without delay from false motion.</p> <p>Ninth, we have found that by undercutting the greater trochanter, a much better purchase and counter force to the ramus and tuberosity can be generated with less M-L play and, I suspect, some vertical component of weight can be borne on the flare of the trochanter much like that of the medial tibial shelf in the below knee. Also, now that the femur is actually adducted, we are now probably picking up a vertical component of force on the lateral shaft of the femur.</p> <p>Tenth and most important, after the 1981 seminar, we used a chart that related circumference of soft peripheral tissue to the desired medial lateral dimension of the socket. We found many fallacies with this method. The reason for this is that one cannot rely on circumference measurements to indicate the proper diameters between the ischial tuberosity and sub-trochanter, or the ramus and sub-tro-chanter. In our work, we found that it was absolutely necessary to obtain both of these measurements to obtain consistent results. A patient may be very fleshy and obese, but that in no way changes the anatomical dimension of the bony structures. The reverse is true with a thin patient. This was one of the most difficult stumbling blocks to obtaining truly good results. It seemed that when using this chart, the tuberosity was usually up on top of the medial superior shelf, which acted as an ischial seat, and this explained why the medial brims at the 1981 seminar were flat and 1 1/2" to 2" wide. In effect, the medial brim became an ischial seat. The sockets fabricated at the 1981 seminar still had the ischial tuberosity out of the socket proper and superior medial lateral diameters that were too narrow, resulting in M-L socket shift. True, the ischial tuberosity was no longer on the posterior shelf, but we had simply moved the tuberosity to the top of the medial shelf. The narrow M-L did provide better adduction of the femur, but not as good as when the ischial tuberosity and ramus are totally locked in the socket, providing a medial stop.</p> <p>The reason for this was discovered with more research. Namely, that it is incorrect to rely on what a patient measures in circumference at the perineal or ischial level, and to expect to extrapolate the medial-lateral dimension of the socket. I had two years of severe problems in this area until we dropped the circumference chart and adopted methods to determine exact measurements through xerography, x-rays, and anatomical measurements. Only then was I able to obtain consistent results, symmetrical adduction of the femur, and stabilization of the proximal socket to prevent lateral socket shift.</p> <p>Eleventh, through the course of our research, we have defined three ischial tuberosity-ramus types. We call these different configurations: alpha, beta, and gamma types (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg"><b>Fig. 11</b></a>). These classifications are valuable since they can be used to predict to what extent we will be able to control femoral adduction comfortably. The more purchase one can obtain by locking against the medial border of the ischial-ramus, the less the pressure that comes to bear on the soft medial proximal tissues, and the less the M-L shift of the socket.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg"><strong>Figure 11. The well defined high slope of the alpha type usually results in improved femoral adduction and M-L control. At the other extreme is the gamma type which is more difficult to grasp properly with the socket.</strong></a><br /> <p>The alpha type is the most desirable, since it has a medial side which slants up at a sharp angle, making it more appropriate for good M-L purchase, and also making it easier to slip into the socket. The beta type has more sloping sides, making purchase somewhat more difficult.</p> <p>The gamma is the poorest type for purchase. We tend to have some pressure problems in the medial proximal area with the gamma types due to M-L socket shift. It is difficult to get this wide bone inside the socket proper. This necessitates widening the medial lateral dimensions of the socket so the wide gamma tuberosity will slip into the socket. With the gamma types, we usually have to settle for a less ad-ducted femur than the patient exhibits on the contralateral side.</p> <p>Another very important point that finally emerged as research continued was that, not only ischial tuberosity, but medial inferior ramus containment was very important to stabilize the socket from lateral shift. The reason for this is that, while the ischial tuberosity is more posterior, and thus helps prevent anterior shift of the socket at heel strike, the ramus is a greater asset when it comes to prevention of M-L shift of the socket and is in a much better anatomical and mechanical position to provide a true medially directed force to the socket, since it is more diametrically opposite the trochanter and sub-trochanteric regions than is the ischial tuberosity.</p> <p>We have had some problems in the beginning with CAT-CAM due to inexperience. However, these have fallen below the one percent range. I find this one percent figure extremely interesting since most patients, especially older people, tend to reject new designs. We found almost none of this phenomenon, however, in switching from quadrilateral to CAT-CAM. We did experience problems due to low back pain in two very old patients. This problem is probably due to the fact that the quadrilateral sockets worn for years and associated with an abducted femur, allowed the lumbar spines to drift to one side. Apparently, fitting the CAT-CAM sockets suddenly pulled the lumbar spines in the opposite directions, inducing low pack pain.</p> <p>During the early years, we sometimes had to fit many transparent check sockets to the same patient before we had successful outcomes. With increased experience and the formulation of rational guidelines and more exacting anatomical measurements, this necessity has been greatly reduced. However, one should expect to spend a great deal more time fitting CAT-CAM design sockets due to the intimate bony contouring.</p> <p>A comprehensive CAT-CAM program should include use of comparative x-rays, which aid in modification and establishment of the angle of correction, as well as transparent diagnostic sockets, video gait analysis, and biofeedback as described in the next paragraph. We also recommend that previous quadrilateral patients undergo an intensive program of abductor strengthening with a prosthetically knowledgeable physical therapist, who will also later teach them not to laterally trunk bend from habit. The full benefit of the CAT-CAM socket is not achieved if the patient has been using a quadrilateral socket long enough to weaken his gluteus medius and abductor mechanism. If the femur tends to be in abduction (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg"><b>Fig. 12</b></a>), the gluteus medius is slack and not under normal tension, causing it to have a poor mechanical advantage and makes this muscle effectively weak.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg"><strong>Figure 12. The gluteus medius is not effective when the femur is in abduction.</strong></a><br /> <p>We have developed a CAT-CAM program to strengthen the gluteus medius muscle through the use of myoelectric biofeedback during gait training. Pressure sensitive electrodes are mounted to the patient over the gluteus medius, and the biofeedback unit emits an audible signal proportional to the electrical activity generated by the muscle when it fires. Using this method, the patient can actually listen to the muscles fire and begin to force himself to use the abductors more. The stronger this abductor mechanism becomes and the more training the patient receives, the less the classical A.K. "lateral trunk lean" during stance phase is observed. This is an important phase of the program and a very effective way to not only strengthen the gluteus medius, but to do so dynamically while the patient is ambulating. We also explain to the patients the reason why they must trunk lean laterally in a quadrilateral socket and use a video system to provide visual feedback to enable them to see themselves walk. This works very well since people seem to react better to watching themselves walk incorrectly and correcting it voluntarily, than to have a practitioner telling them what they are doing wrong. With former quadrilateral patients, do not expect this lean to go away completely because the habit is so well entrenched; however, it can be greatly reduced if not eliminated.</p> <h3>Future Plans</h3> <p>In late 1985 or early 1986, we will introduce the SCAT-CAM, or Skeletal CAT-CAM, which is a highly bone and muscle contoured design. We have been working on this design for three years and it looks considerably different than CAT-CAM (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg"><b>Fig. 13</b></a>). We feel this approach is the next logical step with the evolution of CAT-CAM and are very pleased with the results. SCAT-CAM is actually a third generation CAT-CAM exhibiting, among other refinements, a highly relieved lateral wall with Oklahoma City channel (O.K.C.), which is actually a trough for the entire femoral shaft along with full length of the lateral wall (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.jpg"><b>Fig. 14</b></a>). I feel this is a major advance, since it attempts to capture the femur in the A-P direction and to prevent A-P and transverse pseudo movement.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg"><strong>Figure 13. Evolution in shape from the quadrilateral socket (right) to the SCAT-CAM socket (left).</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.jpg"><strong>Figure 14. Cross-sectional view of the SCAT-CAM socket.</strong></a><br /> <p>The O.K.C. fossa is provided in a SCAT-CAM to place the ischial tuberosity in a hollowed out relief as opposed to the angular shelf of the second generation CAT-CAM. This fossa enhances the locking effect A-P and M-L. A transparent diagnostic socket is very helpful to properly locate this fossa placement. Also, the medial superior wall has undergone drastic changes to allow relief for the pubis, but still quickly slant superiorally posterior of the pubis to trap even more of the inferior ramus of the ischium and tuberosity. This gives a much improved medial superior locking counter force than a horizontal medial brim. It takes on the shape of a letter "V." With the SCAT-CAM, the pubis can be relieved in the vortex of the "V," while the medial border of all but the inferior apex of the ramus and all of the ischial tuberosity are caught in the arms of the "V."</p> <p>The use of direct anatomical measurements instead of the circumference chart has resulted in a drastic change in general contour where the superior medial-lateral dimension is wider to catch the bony areas, then quickly reduces in M-L dimension and becomes very narrow distal to the sub-trochanteric area, resulting in superior adduction control of the femur. Another important change was with the radius of the superior medial brim. We have changed from a 90° to a gentle upward sloping brim, which prevents the ramus and tuberosity from sliding or shifting out of the socket. With the SCAT-CAM, even more vertical loads are possible on the ischium than with quads sockets since the forces can be wrapped around this complex and curved ischial-ramus bone, which in essence can now be used for vertical posterior and medial loading.</p> <p>We are planning a research program which we hope will contain the following studies:</p> <p><i>Quantitative</i></p> <ol> <li> <p>X-ray with comparative study of femur adduction-abduction angles.</p> </li> <li> <p>Digitally timed video comparison of gait A-P and lateral analysis.</p> </li> <li> <p>Myoelectric measurements of major muscle groups, especially the abductors.</p> </li> <li> <p>Dynamic oxygen consumption rates to monitor energy expenditure.</p> </li> <li> <p>Relative Doppler blood flow in distal residual leg.</p> </li> <li> <p>Temperature of skin in both sockets after controlled time factor.</p> </li> <li> <p>Data on acceptance rates.</p> </li> <li> <p>Atrophy data or hypertrophy comparisons.</p> </li> <li> <p>Determination of the weight bearing mechanism.</p> </li> </ol> <p><i>Qualitative</i></p> <ol> <li> <p>Video comparisons.</p> </li> <li> <p>Patient comments.</p> </li> </ol> <h3>Conclusion</h3> <p>Even though the CAT-CAM and SCAT-CAM are diametrically opposite to the quadrilateral in design and precept, I believe these new principles will eventually be widely accepted and deeply penetrate the prosthetic field. I encourage practitioners to insist on weight bearing x-rays as part of a comprehensive prosthetic program, which lend credibility to our premise by exposing internal problems which result in external manifestations. My sincere hope is that the prosthetic community will not take this article to be controversial, but as a statement of what we have discovered and felt compelled to share.</p> <h3>Acknowledgments</h3> <p>The main source of strength in perpetuating my interest in CAT-CAM has come from the support of my father, Lester J. Sabolich, C.P.O., Thomas Guth, CP., Mike Wilson, C.P.O., and Dr. Ernest Burgess. These people have supported this project from early on and deserve much credit.</p> <p>I would also like to credit Ivan Long, C.P. who defined his alignment principles in 1975 and thus started us on the right track. Enough credit cannot be given this man!</p> <p>Also I thank my wife Lee, who has not complained about many lonely evenings during this research project.</p> <p>I thank the entire staff of Sabolich Prosthetics Orthotic Center. Without these people, none of this research could have been achieved. Only they understand the grit of many failures and garbled plastic in the trash.</p> <p>I thank all of the prosthetists who have worked with us and tried this method. Their feedback has been invaluable.</p> <p>Last, special credit goes to Chuck Childs, C.P.O., who could see the profound effect of this method and was in hot pursuit of it when he was taken from us.<br /><br /><b>Footnote</b> Dr. Lehneis states that the first person to indicate that the ischial tuberosity was more efficient biomechanically if it was in the socket proper was a German man by the name of Schnur in the early 1950's.<br /><br /><em><b>*John Sabolich, C.P.O. </b> John Sabolich, C.P.O., is Vice-President of Sabolich, Inc., 1017 N.W. 10th Street, Oklahoma City, Oklahoma 73106.<br /><br /></em></p> <p><b>References:</b></p> <ol> <li>Long, I., "Allowing Normal Adduction of Femur in Above-Knee Amputations," <i>Orthotics and Prosthetics</i>, Vol. 29, No. 4, pp. 53-54, December, 1975.</li> </ol> Page Number(s) 15 - 26 Year 1985 Volume 9 Issue 4 Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.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 Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles Creator An entity primarily responsible for making the resource John Sabolich, C.P.O. * https://staging.drfop.org/files/original/6c2c63ddffe3d550de617cddd2fd3dd0.pdf a968d5b9bd58a10b866f2865888702c4 https://staging.drfop.org/files/original/f79b3b23e95dbeb5afa6c8473cde777c.jpg 8fb5942309fbf39e9a7f9d5b0faa3ad4 https://staging.drfop.org/files/original/c220a5b7800edb8c2f03fbae92a1461e.jpg 87cbf6d646ea79dfe843e1acabdda96f https://staging.drfop.org/files/original/c51a8772e852e3c455899c6ff2c762ce.jpg 33046249d3204db97c4c086dfd5599b3 https://staging.drfop.org/files/original/6900141d8663452725d64428373f8d50.jpg 53e19138614db7dc6c7fb8957ab80aae https://staging.drfop.org/files/original/d95b5a36a5716b9d244ed4df81c74f3e.jpg 4b6a6d211a5d773b43c6faab345690df https://staging.drfop.org/files/original/c9e2d2419431e40d357277310450bc3e.png afc4e7e2abd9dbe853ea3aae3159c753 https://staging.drfop.org/files/original/7097692bfc548e8b707cf8c2c5d4cd0d.png 5eceeff5f79d833e8f2e3a8c26694e06 https://staging.drfop.org/files/original/90edd7a8ef69e6ec44df2371f663927a.png c617fbfef726b1388adcfd1e4d2c584e https://staging.drfop.org/files/original/d1b765c7055d84a8a7222ccbc9c30ff1.png 7cbeda763ee9076246a237debce1071b https://staging.drfop.org/files/original/584c3a08b5ad54660112b465920dd0d6.png d9a078f202590efd229a906944609682 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_066.pdf Text Any textual data included in the document <h2>Upper Limb Powered Components and Controls: Current Concepts</h2> <h5>John W. Michael, M.Ed., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In order to review the current offerings in powered upper limb components, it is necessary to agree upon certain standardized terms. The following suggestions, based upon a survey of the existing literature, are intended to help insure we are all speaking a common language.</p> <p>Practitioners with strong opinions regarding alternate definitions are encouraged to publish their views as well. It is critical that we agree upon some definition; which particular version is of much less importance.</p> <p>The focus of this paper will be on externally powered prostheses—specifically, those that are electrical in nature. The opposite concept is the familiar body powered prosthesis, which is powered by muscular action and transmitted from remote body locations.</p> <p>Many prosthetists have some experience at the below-elbow level with the components produced by Otto Bock, and assume they have fitted myoelectric devices. Technically, that is not completely correct.</p> <p>The MyoBock system is most accurately termed "Myoswitch" control. This is a much simpler version than true myoelectric control. In the Otto Bock system, the residual myoelectric signal does not directly control the terminal device. Instead, the patient must generate a sufficiently strong signal to cross a threshold, which triggers an electronic switch.</p> <p>A good analogy would be that of sound-activated devices which can be installed in lieu of a standard light switch. Clapping one's hands turns the light on. If the clap is too faint, nothing will happen, but an extremely loud clap has no more effect than one just loud enough to trigger the switch. This is sometimes described as "digital control."</p> <p>This approach does not allow proportional control. That is, the light is either all on, or all off. There is no in-between. Proportional control is provided by a rheostat, which allows one to gradually dim or brighten the lights as the mood dictates.</p> <p>Proportional control is, in this author's opinion, the key distinction in true myoelectric systems. The below-elbow system marketed by Fidelity Electronics is an example of such a design. In this version, a mild myoelectric impulse causes a slow, gentle movement of the hand, while a strong impulse creates a rapid, powerful movement of the hand. Many authorities feel this is the most physiologically natural control, and offers the greatest degree of prehension control as well.<a></a></p> <p>A good analogy is the accelerator in an automobile, which allows proportional control of the speed of the vehicle. Imagine a switch-controlled car with the throttle either at idle or wide open! Otto Bock has a very clever solution to this dilemma: the automatic transmission.</p> <p>The MyoBock prosthesis has two speeds: a quick, gentle motion when opening and closing, and a slow, powerful motion once the fingers grip an object. This might not be a reasonable solution for the auto industry, but it has proved to be clinically acceptable in prosthetics.</p> <p>The third available control mode is pure Switch Control. This is the least expensive approach and generally requires less bulky electronics. For these reasons, it is often used in juvenile below-elbow designs (for example, Variety Village). It also does not require any myoelectric signals, which can be helpful when control sites are limited or unavailable.</p> <p>Switch controls come in three basic varieties.</p> <ol> <li> <p><b>Rocker Switches</b> are similar to the on-off control for stereo equipment, and are sometimes used where a mobile acromion is present.</p> </li> <li> <p><b>Button Switches</b> are also adaptable for acromion control, for use with phoco-melic digits, and any other mobile body parts. They are the electronic analogue of mechanical nudge control.</p> </li> <li> <p><b>Pull Switches</b> are useful when harness control is desired. Most are multiposi-tional, where initial excursion will cause one motion, and further excursion the opposite motion. These are somewhat analogous to the alternating lock used in the conventional elbows with one motion controlling two or more functions.</p> </li> </ol> <p>These are simply the most common types; literally hundreds of variations can be obtained from electronic supply stores. On rare occasions, they can be arranged in a piano keyboard array, allowing several degrees of freedom to be controlled from one location.<a></a></p> <p>Another set of related concepts are "site and state."12 Site refers to the number of distinct muscle signals required. Thus, the original Myobock system was a "two site" version, requiring one myosignal for hand opening and a separate signal for hand closing.</p> <p>The University of New Brunswick (UNB) was one of the first groups to develop a commercial system that required only one myosignal. This is particularly advantageous when dealing with young congenital below-elbow patients. Very often they can only generate one mass contraction in the residual limb, and space considerations alone may preclude more than one electrode. UNB termed their system "Single Site/Three State" control. The term "Three State" means that the myopulse both opens and closes the hand; the "third" state is "off."</p> <p>In the last couple of years, Otto Bock has introduced their version of this concept. As in the UNB design, it is a digital "Myoswitch." A quick, hard myopulse causes the hand to open, while a slow, gentle myopulse causes closure. Bock calls this "Double Channel Single Site" control. "Double Channel" accurately identifies the capabilities: one channel opens and the other closes.</p> <p>Unfortunately, the word "channel" has established meanings in other fields that may be a source of confusion. For maximum clarity, the term "Function" is probably preferable.<a></a> This has a clear intuitive meaning. Thus, the system just described would be termed a "One Site-Two Function" system.</p> <p>With suitable changes in the terminal device electronics, Otto Bock can offer what they term "Grip Force" control which is a kind of psuedo-proportional control. In this application, the patient can use the quick, strong pulse to automatically downshift the transmission, thereby increasing the grip strength.</p> <p>A logical extension of this approach is Bock's "Four Channel" design. One electrode controls terminal device opening and closing while the other controls electric wrist pronation and supination—four distinct functions.</p> <p>Clearly, if suitable sites could be found, additional degrees of freedom could be controlled using existing technology. Experience has shown, however, that this is rarely feasible.</p> <p>In the above-elbow realm, the developers at Motion Control argue strongly that proportional control is the ideal. Therefore, they avoid the digital control mentioned thus far. Yet, they have developed a system permitting only two muscle sites to operate elbow raising and lowering, as well as terminal device opening and closing. Thus far, their solution is unique in the field of powered components.</p> <p>The Motion Control design uses a very clever method of electronic switching to separate elbow and terminal device functions. When the arm is first powered on, the two muscle sites proportionally control elbow flexion and extension. (In an ideal candidate, biceps and triceps are the remnant muscles yielding physiologically normal control as well.) Whenever the elbow is in motion, things remain in this mode.</p> <p>However, if the elbow is stopped in a flexed position and held steady for a moment, the arm "senses" that one intends to perform a grasping function. It then locks the elbow and automatically switches itself into a "grasping" mode. The same two sites now control proportional, bidirectional grasp. To return to the "elbow" mode, the patient co-contracts in a specific fashion. The co-contractures cancel each other out so that no motion of the TD occurs, and the electronic switch senses this and changes modes.</p> <p>This strategy can be termed "Sequential Control", and is directly analogous to the familiar mechanical elbow joint where the same shoulder motion moves first the elbow and then the terminal device.</p> <p>The most sophisticated control for a high level amputee would be Simultaneous Proportional Control. Northwestern has done some fascinating work in this area,<a></a> as has the Illinois Institute of Technology and others.<a></a> This would be the most natural-appearing motion, since our biological arms move through multiple degrees of freedom simultaneously with every gesture.</p> <p>However, there are numerous technical and control difficulties with this approach, and all seem to be far from commercial production right now. One major issue is control site availability. Even if one conceives of an arm offering twenty simultaneous degrees of freedom, where on the high-level amputee are twenty independent controlable sites to be found?</p> <p>Much of the current research involves reading data from a few sites and using computer algorithms to simulate multi-degree control.<a></a> Most currently require a mainframe computer to process the data in real time, but perhaps the future will see microchip processors with these capabilities built into upper limb devices.</p> <p>But, for now there are less spectacular components to choose from. What follows is an overview of currently available hardware. Specific details change almost weekly; contact the manufacturer for the latest updates.</p> <p>The final caveat is: the ideal system does not exist. All the components have strengths and weaknesses. When prescribed correctly, one can achieve very satisfying results. When used inappropriately, failure is the inevitable result. As prosthetists gain more collective experience and confidence in the realm of powered upper limb prosthetics, perhaps we can learn to "mix and match," as we do in body powered fittings, to maximize the benefits for our patients.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-01.jpg"><b>Fig. 1. <span>Otto Bock electric hand and electric hook (Greifer). Bilateral powered fittings can be successful in carefully selected cases. (Courtesy of Otto Bock Industries.)</span></b></a></p> <h3>Otto Bock</h3> <p>In the United States, Otto Bock is viewed as the "father" of electrically controlled prostheses. Although all their current designs are digital controls, they offer one of the largest arrays of interchangeable electric components of any manufacturer. At this time, all Otto Bock components are designed for below-elbow use, although they are equally adaptable for higher levels.</p> <p>One ramification of this is that since 1976, they have been using six volts as their standard. (Twelve volt terminal devices can be obtained for use with other manufacturers' systems.) Six volts offers lower battery weights while still providing adequate power for terminal device operation.</p> <p>Otto Bock's battery is a relatively small package, easily interchangeable, but for slow recharge only. Their "Griefer" is the only adult-sized powered hook currently on the market, and it readily interchanges with their adult hands. They also have the only electric wrist rotator currently available.</p> <p>They currently offer four hand sizes, for older children, teens and ladies, standard adult, and large adult males. These have become the <i>de facto</i> standard in the industry; virtually every other company can interface their system with a MyoBock hand. An assortment of wrists are also available.</p> <p>All their electrodes are digital, myoswitch types, as already discussed. They offer optional floating electrode mounts for cases where a change in residual limb volume is anticipated.</p> <p>Since their terminal devices are set up for myoswitch control, it is relatively easy to use regular switch control as well. Otto Bock offers both a rocker switch and a harness pull switch version.</p> <p>With their typical attention to detail, a complete set of <i>Technical Information Bulletins</i>, courses, and specialized tools are available. Otto Bock also offers a variety of well thought out accessories, such as a tweezer (pincer) for the hands, blank Griefer tips for machining custom gripping surfaces, and so on.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-02.jpg"><b>Fig. 2. <span>Variety Village VV2-6 electric hand: the smallest and lightest powered hand commercially available. (Courtesy of Variety Village Electrolimb Production Centre.)</span></b></a></p> <h3>Variety Village</h3> <p>Variety Village components complement Otto Bock's nicely, as they are targeted for smaller children, and include a powered elbow. All their components are switch controlled.</p> <p>They market three switch types: a toggle for phocomelics, a button type, and a pull strap version. In addition, their elbow can have the pull switch built in, or be ordered for use with remote switches.</p> <p>Their elbow is available in either 6 or 12 volts; their hands are 6 volts exclusively. Their smallest hand (for 2-6 year olds) has just been redesigned. Although similar to the Swedish hand, it is three ounces lighter.</p> <p>Their original hands (Models 105 and 106) have been discontinued. Research is currently underway to create the smallest electric hand yet available: thirty percent smaller than their VV2-6. Only prototypes exist at this time, however.</p> <p>They market several battery configurations, including a "Battery Saver Circuit" designed to prevent children from draining the electrical charge by stalling the motor. None are of the quick-charge variety, however.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-03.jpg"><b>Fig. 3. <span>Electric hands imported by Liberty Mutual. The smallest is the System-Teknik from Sweden; balance are Steeper hands from England. (</span><i>Courtesy of Liberty Mutual Research Center.</i><span>)</span></b></a></p> <h3>Hugh Steeper Limited</h3> <p>Steeper is the British corporation responsible for upper limb prosthetics in the United Kingdom. They have recently announced the availability of powered hands for small children.</p> <p>These are now being distributed by Liberty Mutual in the United States. The sizes complement the Swedish hand, in that the Steeper hands are a bit larger than either Swedish version. Sometime in 1986, they will probably offer a larger hand for the early teen.</p> <p>These are 6 volt, switch controlled devices for the most part. However, Steeper also offers a "Servo-Control" option. This is a unique kind of proportional switch control: the harder the child pulls on the switch cable, the stronger the grasp. With minor adaptations (which Liberty Mutual will make), they can also be controlled by Otto Bock or UNB myos witches.</p> <h3>System-Teknik</h3> <p>System-Teknik is a Swedish company with two children's hands on the American market. Production rights for these hands have just been aquired by Steeper, so design changes can be expected. Liberty Mutual is the American distributer.</p> <p>At the present time, two Swedish hands are available: one for 2-6 year olds and another for 5-9 year olds. Both are 6 volts, and they use the same size forearm laminating ring for easy interchange.</p> <p>They can be controlled by either the UNB or Otto Bock myoswitches and switch controls. UNB designed its batteries to be mounted within the forearm shell. If space permitted, Otto Bock's could be used as well.</p> <p>To simplify the fitting procedure, Liberty Mutual plans to offer a special wrist unit option, containing all necessary electronics. Planned for use with both the System Teknik and Steeper hands, it will come in one version containing the battery supply, and a shorter version for longer residual limbs with remote battery mounting.</p> <p><b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-04.jpg">Fig. 4. <span>Variety of powered components supplied by Liberty Mutual, including the UNB Toy Controller. (</span><i>Courtesy of Liberty Mutual Research Center.</i><span>)</span></a><br /><br /></b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-05.jpg"><b>Fig. 5. <span>Fidelity components, including harness pull switch, electric elbow, and VANU hand. (</span><i>Courtesy of Fidelity Biomedical Products.</i><span>)</span></b></a></p> <h3>University Of New Brunswick</h3> <p>All UNB products are available through Liberty Mutual in the United States. When ordering their "Single Site" system, there are three options for battery placement: built-in to the electronics package, mounted inside the forearm section, or mounted externally. As is the case with all manufacturers, you must purchase their particular myotester/trainer to properly adjust their system.</p> <p>In addition, UNB offers a unique single site system with built-in sensory feedback. To aid in myotraining small children, they also market a "Toy Controller," which can be adapted to run with Otto Bock electrodes as well.</p> <h3>Fidelity Electronics</h3> <p>Fidelity Electronics distributes the proportional below-elbow system originally developed at Northwestern University. At one time the United States Manufacturing Company also carried these components, but Fidelity is currently the sole source. This is sometimes referred to as the "VANU" hand.</p> <p>Several things are unique about this product. First, it is a 12 volt system. Secondly, all the electronics are located in a "wrist module," including the battery. Therefore, it is self-contained with minimal risk of wire damage. However, this also prevents fitting very long residual limbs and concentrates all the weight at the distal portion of the prosthesis.</p> <p>Long residual limbs require the use of a switch-controlled version, thus eliminating the wrist module. This hand is sized for adult males only (7 3/4).</p> <p>Fidelity also offers a switch-controlled elbow (again, in adult size only). This is an 8.75 volt system, with its own built-in battery pack. It utilizes an exoskeletal soft foam forearm set-up.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-06.jpg"><b>Fig. 6. <span>The Prehension Actuator provides powered opening for a variety of conventional hooks. Closing force is controlled by the number of rubber bands applied. (</span><i>Courtesy of Hosmer Dorrance Corporation.</i><span>)</span></b></a></p> <h3>Hosmer Dorrance</h3> <p>As the "grandfather" of upper limb prosthetics in North America, Hosmer is in a unique position to develop a system of powered components. Their basic philosophy has been to focus on light-weight, straightforward, relatively inexpensive designs.</p> <p>For years, they have offered the "Michigan Hook," which is the familiar child's hook, closed by a rubber band, but opened with a small motor winding a string. Last year, they announced an adult version of this concept, called the "NYU Prehension Actuator." This is a conventional forearm set-up with an electric "winder" included. It can be mated with a variety of voluntary opening hooks, using up to five rubber bands or so. Although it is currently switch-controlled, a single-site "MyoPack" will soon be available, offering the option to convert both the Michigan Hook and the Prehension Actuator to myoswitch control.</p> <p>Hosmer has also released the "NYU Hush" elbow. This is unique in several respects. First, it is designed to permit the familiar mechanical elbow to be substituted for the electric one, even in a finished prosthesis. Secondly, they elected to use standard "grocery store" nickel cadmium batteries to power the system. This dramatically reduces the cost to the consumer. Four AA NiCad cells yield a 5 volt system; if desired, five can be used for 6.25 volts. Either version is rechargable with an inexpensive "dimestore" trickle charger.</p> <p>Hosmer hopes to offer in 1986 a "Free Swing" option for their elbow, which could be retro-fitted to existing units in the field. Once the elbow attains full extension, it would automatically enter the free-swing mode. In addition to enhancing the dynamic cosmesis during ambulation, this may offer some special benefits to bilateral patients. Those who depend on the prosthesis for feeding would then have the option of resting the forearm against the table and using "body English" for elbow flexion.</p> <p>Finally, it can be used with either an endo-skeletal or exoskeletal forearm, as desired. This is a switch-controlled elbow, again keeping the costs lower, which is currently available in a large and medium size, corresponding to the familiar E-400 and E-200 mechanical elbows. Thus, it is suitable for many older children as well as adult men and women.</p> <p>Hosmer's switches have recently been redesigned to increase reliability. In addition to the familiar button and harness switches, they also offer a "Three-Position Harness Switch," permitting one control motion to operate both elbow flexion-extension and the NYU Prehension Actuator.</p> <p>The latest addition to the Hosmer line is an adult male (7 3/4) switch-controlled hand to complement their elbow. This also uses readily available NiCads for 5 or 6.25 volt operation. The "Synergetic Hook" designed by Dr. Dudley Childress at Northwestern University<a></a> should be available sometime in 1986. Beyond that, work is ongoing for a myoelectric elbow and hand, but neither is presently available.</p> <p><b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-07.jpg">Fig. 7. <span>Boston elbow, combined with a Hosmer mechanical shoulder joint and Otto Bock electric hand. Combining various international components can enhance prosthetic restoration. (Prosthetic Design by John C. Hodgins, C.P.O.; (</span><i>Courtesy of Liberty Mutual Research Center.</i><span>)</span></a><br /><br /></b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-8.jpg"><b>Fig. 8. <span>Exploded view of the Utah elbow. Highly modular construction facilitates servicing in the field. (</span><i>Courtesy of Motion Control, Inc.</i><span>)</span></b></a></p> <h3>Liberty Mutual</h3> <p>Liberty Mutual is the world's largest workmen's compensation insurer. In the United States, one in fifteen workers is insured by this company. Thus, they have a dual motivation in offering sophisticated prosthetic components: both to help the clients they insure, and also to enable the clients to return to work, thus reducing the company's liability.</p> <p>The 12 volt Liberty Mutual "Boston Elbow" can be categorized as a working man's device. And, in fact, it is one of the most durable electric elbows on the market. Although the original version was widely criticized because of the noise it made when operating, the current generation is markedly improved.</p> <p>This is the only elbow offering dual battery chargers. Although Liberty Mutual recommends overnight "trickle" charging for longer battery life, they offer a "quick charge" option, in case the internal battery becomes discharged before the day is over.</p> <p>This is also the only elbow designed to easily convert from proportional myoelectric control to switch control. Simply altering one wire makes the conversion. This can be very useful, for example, in fitting patients early with switch control, then later upgrading to myo-control as their residual limb matures.</p> <p>As mentioned elsewhere, Liberty Mutual also distributes the UNB, System-Technik, and Steeper components.</p> <h3>Motion Control</h3> <p>Motion Control is marketing the powered elbow system originally developed by the University of Utah. In contrast to Hosmer's strategy, this group sought to offer the most technologically advanced components possible. Undoubtedly, they have succeeded in this goal.</p> <p>However, most sophisticated does not necessarily mean best; simpler technology is often more reliable than state-of-the-art. Nevertheless, Motion Control has a unique addition to the prosthetic armamentarium.</p> <p>Their electronic locking mechanism and Sequential Proportional Control have already been discussed. Originally designed for mechanical terminal device operation, this 12 volt elbow can also be ordered with an Otto Bock hand. In this case, however, Motion Control discards the electronics and substitutes their own, thus offering true proportional myoelectric control of the Otto Bock hand.</p> <p>Of all the systems on the market, particularly above-elbow systems, this is the most "pros-thetist friendly." All the inner components are modular and easily exchangeable in the field. The quick-change battery pack is built into the humeral section, but below the elbow axis. This permits fitting longer residual limbs than is possible with other systems, and means there are no external wires to fray and fail.</p> <p>Further, this version offers by far the most adjustments to "fine tune" the elbow for a particular patient. There is a price to pay for this degree of technology, of course. In addition to being the most sophisticated, the Utah Arm is also by far the most expensive powered device available today.</p> <p>It is now possible to add an Otto Bock powered wrist rotator to the Utah Arm, using a variety of control strategies, including UNB or Otto Bock's single-site electrodes, two-site electrodes, and assorted switches. If a mechanical terminal device has been used, the Utah Arm mechanism can be modified to provide dedicated proportional control of the wrist unit. Also, their highly sensitive myotester is finally a commercial reality.</p> <p>Beyond that, Motion Control has just announced the availability, to prosthetists trained in the elbow fitting procedures, of a proportionally controlled below-elbow system, using Motion Control electronics to power an Otto Bock hand with 12 volts in a below-elbow prosthesis. Currently, this requires mounting two Otto Bock batteries, which can present some difficulties, although other battery sources can be utilized in selective cases.</p> <p>Finally, and perhaps most significantly, Motion Control has become the first supplier to offer a rental program for myoelectric components. In marginal cases, if funding has been conditionally approved, the components can be rented on a monthly basis for about ten percent of the total cost. Most of the rental is applied toward purchase of the arm if the fitting proves successful; if not, the parts are returned to Motion Control.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-09.jpg"><b>Table 1</b></a>, <b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-10.jpg">Table 2</a><br /><br /></b><strong>Summary</strong></p> <p>Our powered upper limb armamentarium is now surprisingly complete. Although one must select components from all over the world, it is possible to fit virtually any patient from two years old to adulthood with an externally powered prosthesis.</p> <p>Otto Bock components remain the most widely utilized, and their hands and connectors are becoming the <i>de facto</i> standards in the field. Their own components are designed for below-elbow use, but are routinely adapted to higher levels. Otto Bock has chosen to develop a variety of myoswitch controls, but does not offer true proportional control.</p> <p>Although several voltages are used, a general trend toward 12 volts for above-elbow systems and 6 volts for below-elbow is apparent. And, switch control is used almost exclusively for very small children, progressing to myoswitch control as they mature; proportional control is most commonly reserved for adults.</p> <p>The children's components are all from outside the United States: Sweden, England, and Canada currently offer toddler hands. American designs are often targeted to adults: the Hosmer and VANU hands and Boston Elbow toward males, in particular.</p> <p>Hosmer is aggressively pursuing the inexpensive, low-tech end of the market, emphasizing interchangeability with the familiar mechanical counterparts. Motion Control is equally aggressive in pursuing the high tech, high cost end.</p> <p>Lack of funding is probably the major factor limiting the number of powered fittings currently undertaken. With the ready availability of various switch, myoswitch, and proportional controls, virtually any patient could operate an electric prosthesis.</p> <p>Questions about who is a suitable candidate for powered fittings are still largely unanswered. The evidence suggests that the highest failure rate is with bilateral fittings.<a></a> Perhaps the simplicity and resultant reliability of body powered prostheses makes mechanical solutions more succcessful here.</p> <p>The best system cannot be found, and few practitioners are brave enough or experienced enough to freely mix these international components. The issues of proportional vs. digital control, high tech vs. low tech design, hybrid vs. purely mechanical vs. purely powered fittings are all open to debate.</p> <p>And some very provocative data is emerging suggesting that the issue of when to fit is at least as significant as the issue of what to fit.<a></a></p> <p>It is beyond the scope of this paper to resolve these complex issues. Rather, the intent is simply to bring into focus the basic concepts, components, and controversies in the field of powered upper limb fittings. It is hoped that clarifying these issues will encourage prosthetic practitioners to deepen their involvement and understanding in this rapidly evolving area. As we struggle collectively with these problems, our patients and our profession will ultimately reap the benefits.</p> <h3>Appendix</h3> <p><i>V.A.N.U. Products</i><br />Fidelity Biomedical Products<br />6000 N.W. 153 Street<br />Miami Lakes, Florida 33014<br />(800) 327-7939</p> <p><i>Hush Elbow; Prehension Actuator</i><br />Hosmer-Dorrance Corporation<br />561 Division Street<br />P.O. Box 37<br />Campbell, California 95008<br />(800) 538-7748</p> <p><i>Boston, UNB, Steeper, Systek Products</i><br />Liberty Mutual Research Center<br />71 Frankland Road<br />Hopkinton, Massachusetts 01748<br />(617) 435-9061</p> <p><i>Utah Elbow, BE System</i><br />Motion Control, Inc.<br />1005 South 300 West<br />Salt Lake City, Utah 84101<br />(800) 621-3347</p> <p><i>MyoBock Products</i><br />Otto Bock Industry<br />4130 Highway 55<br />Minneapolis, Minnesota 55422<br />(800) 328-4058</p> <p><i>Variety Village Products</i><br />Variety Village Electrolimb Production Centre<br />3701 Danforth Avenue<br />Scarborough, Toronto<br />CANADA MIN 2G2<br />(416) 698-1415</p> <p><em><b>*John W. Michael, M.Ed.</b>,<strong> C.P.O.</strong> John W. Michael is Director of Prosthetics and Orthotics, Duke University Medical Center, Box 3885, Durham, North Carolina 27710.<br /></em><b><span><br /></span><br />References:</b></p> <ol> <li><a href="poi/1981_02_092.asp">Agnew, J.P., "Functional Effectiveness of a Myo-Electric Prosthesis Compared with a Functional Split-Hook Prosthesis: A Single Subject Experiment," <i>Prosthetics and Orthotics International</i>, 5(2), pp. 92-96, 1981.</a></li> <li><a href="cpo/1985_01_023.asp">Billock, John N., "Upper Limb Prosthetic Management-Hybrid Design Approaches," <i>Clinical Prosthetics and Orthotics</i>, 9(1), pp. 23-25, 1985.</a></li> <li>Childress, D.S., "An Approach To Powered Grasp," <i>Proceedings of the Fourth International Symposium on External Control of Human Extremities</i>, Dubrovnik, Yugoslavia; pp. 159-167, 1973.</li> <li>Doubler and Childress (1984), "Design and Evaluation of a Prosthesis Control System Based on the Concept of Extended Physiological Proprioception," <i>Journal of Rehabilitation Research and Development</i>, 10(39), pp. 19-31.</li> <li><a href="http://www.acpoc.org/library/1983_04_001.asp">Ferguson, Shirley, "Electric Power In Upper Limb Prosthetics: The Michigan Experience," <i>Inter-Clinic Information Bulletin</i>, 18(4), pp. 1-8, 1983.</a></li> <li>Graupe, et al., "A Multifunctional Prosthesis Control System Based on Time Series Identification of EMG Signals Using Microprocessors," <i>Bulletin of Prosthetics Research</i>, 10(27), pp. 4-16, 1977.</li> <li>Jacobsen, et al., "Development of the Utah Artificial Arm," <i>IEEE Transactions on Biomedical Engineering</i>, BME-29, (4), pp. 249-269, 1982.</li> <li>Malone, et al., "Immediate, Early, and Late Post-surgical Management of Upper-Limb Amputation," <i>Journal of Rehabilitation Research and Development</i>, 21(1), pp. 33-42, 1984.</li> <li>Millstein, Heger, and Hunter, "A Review of Failures in Use of the Below-Elbow Myoelectric Prosthesis," <i>Orthotics and Prosthetics</i>, 36(2), pp. 29-34, 1982.</li> <li>Murphy and Horn, "Myoelectric Control Systems- A Selected Bibliography," <i>Orthotics and Prosthetics</i>, 35(1), pp. 34-47, 1981.</li> <li>Northmore-Ball, et. al., "The Below-Elbow Myo-Electric Prosthesis: A Comparison of the Otto Bock Myo-Electric Prosthesis with the Hook and Functional Hand," <i>Journal of Bone and Joint Surgery</i>, 42-B(3), pp. 363-367, 1980.</li> <li>Scott, Robert NL, "My?-Electric Control of Prostheses," <i>Archives Of Physical Medicine and Rehabilitation</i>, 47(3), pp. 174-181, 1966.</li> <li>Scott, R.N., <i>An Introduction to Myoelectric Prostheses</i>. Bio-Engineering Institute, University of New Brunswick, Fredricton, N.B., pp. 37, 1984.</li> <li>Spaeth and Klotz, <i>Handbook of Externally Powered Prostheses for the Upper Extremity Amputee</i>, C. Thomas, Springfield, IL, p. 107, 1981.</li> <li>Wirta, Taylor, and Finley, "Pattern-Recognition Arm Prosthesis: A Historical Perspective-A Final Report," <i>Bulletin of Prosthetics Research</i>, 10(30), pp. 8-35, 1978.</li> </ol> Page Number(s) 66 - 77 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-8.jpg Figure 9 TABLE I http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-09.jpg Figure 10 TABLE II http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-10.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 Upper Limb Powered Components and Controls: Current Concepts Creator An entity primarily responsible for making the resource John W. Michael, M.Ed., C.P.O. * https://staging.drfop.org/files/original/134d9851f6fd34f10b98fac119946d9b.pdf c9a03496075767605fc06bd5d6ac4780 https://staging.drfop.org/files/original/fea6766a6495664f5260b51cbff436da.jpg 2e5dfdcbd0b96f663f5470b95ebe80a0 https://staging.drfop.org/files/original/b0db79c79f26f20be00e643367cdaa15.jpg 33873f40f357926954a3ccc9907a4e72 https://staging.drfop.org/files/original/3a7f8361eb473cf4b078c9f8d8c050a5.jpg 0ce7d7a42e382acb91b859f476cc606c https://staging.drfop.org/files/original/ca3ca8e14a2047103f815a282222d402.jpg 0606d742b82c86d87ae8e3750f3f4ce5 https://staging.drfop.org/files/original/ba4b3555b1b4d3697712c9583451c279.jpg 4dd8248ec379a7a364390de2dd9e4097 https://staging.drfop.org/files/original/0a4be97418198a9f496239b0614dbc9f.jpg 0ece3b4b41b32030ebfd864956ad1720 https://staging.drfop.org/files/original/b5afeb1c4d62e046282c3d489417b9be.jpg c67123038b2fd3fd5c451d5fa83d1552 https://staging.drfop.org/files/original/819880245c9711ba14636f81f2b4dfbb.jpg 32a971bc21c5714eaf7d010fd9ebf314 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_005.pdf Text Any textual data included in the document <h2>The Stat Limb: A Prosthesis for Immediate Postoperative Fitting of AK and BK Amputations</h2> <h5>Joseph CM. Sheehan, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Michael J. Quigley, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> <p>Postoperative care of amputation wounds varies significantly ranging from simple daily dressings to rigid immobilization. These variations make it difficult for the occasional surgeon to judge the virtues of each method from available literature. A basic prefabricated plastic supportive structure is described here to simplify the use of an immediate postoperative prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg"><b>Fig. 1</b>)</a>.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg"><strong>Figure 1. The Stat Limb is a prefabricated high density polyethylene shell that can be applied in less than ten minutes in the operating room.</strong></a><br /> <p>Although immediate post surgical fittings (IPSF) were in common use 20 years ago, they are used only in isolated areas today. The reasons for the decline of IPSF were both educational and logistical. Most amputations today are done by general and vascular surgeons who are not trained in IPSF principles or rehabilitation, and who do not have a working relationship with a prosthetist. Secondly, to use the conventional IPSF technique as taught by Weiss and Burgess, a prosthetist needs to be available at surgery with a number of special socks, attachment plates, tubes, padding materials and the associated tools needed to apply the prosthesis. Scheduling the prosthetist caused logistical problems, so physicians began to simply apply a rigid dressing in surgery and call the prosthetist in a week or so later to apply a shrinker. A preparatory prosthesis is not usually prescribed until three to four weeks post-surgery.</p> <h3>Advantages Of Early Mobilization</h3> <p>The postoperative disease problems of the amputee are typical of any long term illness encountered in medical practice. Thinking solely of the amputated limb is a grave mistake, not only for the mental health of the patient, but also for the surgical wound itself.</p> <p>Early mobilization after surgery is a necessity in preventing bowel, bladder and cardiopulmonary complications. The post-amputated patient is usually a high risk patient. Often, severe diabetes with restricted cardiopulmonary reserve is a common associated medical problem. Small pulmonary emboli cause major cardiac changes, and bladder/bowel stasis of recumbency may lead to recurrent septicemias. Each day of postoperative immobilization adds a significant risk to ultimate survival. First or second day mobilization into the standing position is a necessity to reduce basilar atelectasis, reduce the residual urine volume in the bladder, and allow feces to move into the rectum for evacuation.</p> <p>Even without the psychological and balance effect of a second limb, the process of getting a weak postoperative patient to stand on the unaffected leg alone is next to impossible. However, a rigid locked knee above a "weightless" prosthesis gives the patient more stability than when they had a painful necrotic leg before surgery. It is possible to mobilize a patient within 24 hours post-surgically or to at least have the patient stand and transfer to a commode or wheelchair using a limb, even though they have been bedridden entirely for many weeks preoperatively. Minimal ambulation in therapy from the second day onwards is important. The wound risk involved with minimal weight bearing and the brief stance phase on the amputated leg is outweighed by all the general advantages to the patient for ultimate survival.</p> <p>The Stat Limb was designed to allow even the surgeon doing an occasional amputation to apply an immediate postoperative prosthesis himself following surgery. The Stat Limb comes in one size that fits both right and left legs, eliminating the requirement for inventory. The patient receives all the advantages of a rigid dressing, with the added advantages of early weight bearing. The psychological boost given to a patient who wakes up following surgery with two feet under the covers cannot be easily measured, but is definitely a positive factor. In addition, the medical team working with the patient (physician, nurse, therapist, etc.) automatically become rehabilitation oriented. The patient is no longer laying in bed week after week waiting for his new leg. Early ambulation is safe and is encouraged as early as one day postoperatively. The lack of knee flexion in the prosthesis poses no particular problem to the patient during walking, and the extremely light prosthesis allows the patient to move the leg around easily in the sitting and supine positions.</p> <p>Patients who have worn the Stat Limb make the transfer to a preparatory prosthesis very easily; they already know how to walk and are not afraid to place weight on the residual limb.</p> <h3>Application Procedure</h3> <p>The major advantages of the Stat Limb immediate postoperative fitting are as follows:</p> <ol> <li> <p>a rigid dressing,</p> </li> <li> <p>the knee fixed in hyperextension,</p> </li> <li> <p>rapid application of the prosthesis while the patient is under anesthesia,</p> </li> <li> <p>light weight due to the structural strength at the periphery of the prosthesis, and</p> </li> <li> <p>modification of the limb as rehabilitation continues.</p> </li> </ol> <p><i>Rigid Dressing</i></p> <p>The application of a rigid protective dressing is important to the survival of a poorly perfused limb. By surrounding the limb in a soft, heat-insulated environment, free of shearing forces, the limb is maintained at near 37 degrees centigrade, which is optimal for almost all physiological functions of wound healing, tissue resistance, and arteriolar dilation, and gives the surgery its best chance of success. Daily opening of the wound by tearing off adherent, coagulated dressings is not only painful, but rarely indicated unless for observation of unexplained pyrexias or blood loss.</p> <p>The dressing is nothing other than a gauze dressing over the wound site, to allow for any drainage which might occur, followed by multiple layers of cotton, giving a total of about two centimeters of thickness of cotton from groin to the distal end. A thin layer of fiberglass casting material is then applied to provide a rigid outer layer, preventing knee flexion and maintaining the residual limb shape, and protecting the wound (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg"><b>Fig. 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3jpg"><b>Fig. 3</b></a>). If plaster is used for the rigid dressing, it must be allowed to dry 24 hours before the Stat Limb is applied. At no stage is compression ever applied in the application of the rigid dressing. The speed of limb application is important in the critically ill, and with prior experience of one or two applications, it should be successfully applied in less than eight minutes (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg"><strong>Figure 2. A simple dressing creates pressure between the skin and bone and forces the weight of the gastrosolei flap to pull on the wound against the amputated distal tibia.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3.jpg"><strong>Figure 3. The rigid dressing maintains the knee in extension.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg"><strong>Figure 4. Left, a bulbous residual limb after compression wrap. Right, a cylindrical residual limb after rigid dressing.</strong></a><br /> <p><i>Stat Limb Application</i></p> <p>Following the application of the rigid dressing, the Stat Limb is applied. The Stat Limb is designed to fit both left and right legs and can be cut to fit around the rigid dressing in nearly all cases.</p> <p>The desired length of the Stat Limb is approximated by either measuring the sound side, or by laying the Stat Limb next to the patient and marking the section to be cut off. The top edge of the Stat Limb should be trimmed a few inches short of the top of the rigid dressing (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg"><strong>Figure 5. The rigid dressing consists of a gauze bandage over the wound, about two centimeters thickness of cast padding, and two layers of fiberglass casting tape to mid-thigh. The Stat Limb should be one centimeter shorter than the sound side, and the knee cast in extension.</strong></a><br /> <p>Six vertical cuts are then made in the Stat Limb to allow it to form around the rigid dressing (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg"><b>Fig. 6</b></a>). Alignment is approximated while wrapping the Stat Limb onto the rigid dressing. The Stat Limb should be about a half inch shorter than the sound limb to allow toe clearance with an extended knee (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg"><b>Fig. 7</b></a>). Toe out, foot in-set and out-set, and the anterior-posterior positioning of the foot should be held in a normal position as the casting material sets (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg"><b>Fig. 8</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg"><strong>Figure 6. A scissors or cast saw is used to cut off excess length and multivalve the Stat Limb. Six longitudinal cuts are recommended. The cuts may have to extend past the end of the rigid dressing if a bulbous end is present.</strong></a><br /><strong><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg">Figure 7. For most applications, the vertical cuts can stop two centimeters from the distal end of the rigid dressing, and the proximal edge of the Stat Limb should be a few centimeters distal to the rigid dressings upper edge. A drain hole can be punctured through the Stat Limb, allowing removal in 24-48 hours.</a></strong><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg"><strong>Figure 8. A double layer of fiberglass material is used to fasten the Stat Limb to the rigid dressing. All of the vertical slits should be covered. For heavy duty users, reinforce the ankle area with casting material as well. Normal toe-out and foot positioning should be maintained while the casting material sets.</strong></a><br /> <p><i>Knee in Extension</i></p> <p>Keeping the knee in extension, or locking it in about two degrees of hyperextension, makes the knee stable at the tibiofemoral joint. Subsequently, the quadriceps, hamstrings, and gastrocnemius are reflexly relaxed. Pain and associated spasms are reduced. The reduction of spasm of the gastrocnemius reduces the stress placed upon the distal myodesis and, indirectly, on the wound itself.</p> <p>With the knee in extension, the distal residual limb can be molded to prevent posterior migration of the long posterior flap. In extension, limb application is easier and it is easier to judge valgus, varus, rotation, and length of the limb. Application under anesthesia is justifiable because the patient is relaxed and this avoids fighting with a flexed knee joint four days later.</p> <p><i>Lightweight Due to Exoskeletal Construction</i></p> <p>Using the mechanical principles of the square area of inertia, the prosthetic material and the intended forces acting through the prosthesis are distributed to the periphery. This allows the use of a minimum amount of material while gaining the maximum strength to the prosthesis. A semi-pliable thermoplastic of high density polyethylene is used to give toughness to the prosthesis, to reduce the chance of any brittle failures, and to allow for cold forming of the prosthesis around the rigid dressing.</p> <h3>Modification As Rehabilitation Continues</h3> <p>As the patient's healing improves and rehabilitation continues, the thigh length rigid dressing is changed for a padded P.T.B, socket, also made of fiberglass cast material and attached to the limb. Depending on the strength of the quadriceps and hamstrings, the suspension is either a supracondylar strap or a simple single axis hinge from a knee orthosis; this usually occurs at the end of the second week. At the end of the seventh week, the residual limb is usually mature enough for a standard P.T.B, prosthesis. In a similar manner, the prefabricated limb can be used with less complexity for an above-knee prosthesis.</p> <p>A non slip sole material should always be worn when a patient is using the Stat Limb, as the plastic foot section is very slippery. A hospital slipper can be used as can elastoplast adhesive tape.</p> <p>On some occasions, buckling of the plastic at the ankle has occurred. This is usually a sign that the patient has become either very active or is wearing the prosthesis for a longer time than for which it was designed. Reinforce the ankle and foot with fiberglass tape during the original application process if it is felt that the patient will be a heavy user.</p> <p>The same Stat Limb module can be used for cast changes. However, it is important to cut off the cast carefully to prevent damage to the Stat Limb. It is not recommended to reuse the Stat Limb on other patients since it is designed for limited use.</p> <p>The earlier a prosthesis is applied, the more successful and pain free is the final fitting. The problems encountered in the use of any system have to be recognized, but it is difficult to scientifically explain why a minimally weighted limb can impede wound healing. If the prosthesis is not applied to the patient for a few days, we note the rate of progress is retarded. This is detrimental to the functional recovery of wound healing and the entire patient.</p> <h3>Case History</h3> <p>Although over 1,000 Stat Limbs have been used to date, one case history will be presented to illustrate the benefits of the Stat Limb in a community hospital setting.</p> <p>Patient A.B. is an 80 year old woman who had a right below-knee amputation, secondary to diabetic gangrene, two years ago. She was fit with a Stat Limb immediately and began weight bearing in physical therapy two days later. A cast change was made 12 days postoperatively when the stitches were removed. The Stat Limb was reapplied and the patient was discharged home with a walker and wheelchair. Two weeks later, a second cast change was made and measurements were also taken for a preparatory prosthesis. The following week, the Stat Limb was removed and the patient was fitted with her prosthesis. She walked six full lengths of the parallel bars without hesitation.</p> <p>One year later, the same patient lost her left leg below the knee and was immediately fit with a Stat Limb. Within two weeks she was home with a walker using a definitive right below-knee prosthesis and her Stat Limb. Without the availability of the Stat Limb in this case, this patient would have been wheelchair bound for weeks, the time needed for physical therapy would be lengthened, and many activities of daily living would have required assistance.</p> <h3>Summary</h3> <p>With the decline in use of immediate postsurgical fitting of prostheses, most amputees do not walk for several weeks post-surgically. The Stat Limb is designed for easy application by even the occasional surgeon and allows weight bearing within days following surgery.</p> <p>The Stat Limb does not provide the answer to every amputation. Each patient is entirely different from another in any series, and many other factors must be taken into account, including the initial pathology, age, cooperation of the patient, availability of nursing and physical therapy care, and other associated problems.</p> <p>The Stat Limb does remove most of the logistical and educational problems that are associated with IPSF, and should allow many new amputees to benefit from early weight bearing and walking.</p> <p><em><b>*Michael J. Quigley, C.P.O. </b> Michael J. Quigley, CPO is President of Oakbrook Orthopedic Services, Ltd., 1 South 132 Summit Avenue, Oakbrook Terrace, Illinois 60181.</em></p> <p style="width: 400px;"><em><b>*Joseph CM. Sheehan, M.D. </b> Dr. Joseph CM. Sheehan is Associate Clinical Professor for Orthopedic Surgery and Rehabilitation at Loyola University in Chicago, Illinois. He is also Attending Surgeon at Marianjoy Rehabilitation Center in Wheaton, Illinois.</em><br /><br /><br /></p> Page Number(s) 5 - 10 Year 1987 Volume 11 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Stat Limb: A Prosthesis for Immediate Postoperative Fitting of AK and BK Amputations Creator An entity primarily responsible for making the resource Joseph CM. Sheehan, M.D. * Michael J. Quigley, C.P.O. * https://staging.drfop.org/files/original/0fa05d6068c4d9c2c30ab2adf76bb0aa.pdf deefaab5793bb40f246278d00e8ccc28 https://staging.drfop.org/files/original/156df68bab8e0e67d6486f1c12d72e33.jpg 6afb18c555faff017f2713757a472544 https://staging.drfop.org/files/original/ab11f9a0172e3e77c4a779876507f1ec.jpg 953c6d12e2f388522a9851ae0b7342c1 https://staging.drfop.org/files/original/39765be2abc491c73fbb77f348b80811.jpg 75738c583a9d5fa06b2b9cc98ec8bc8a https://staging.drfop.org/files/original/8b190de4debac89f24143367201adc54.jpg afed0ba76e9ca50e2977297894f48191 https://staging.drfop.org/files/original/af863b7df0cad2ab58bb6e8daddd1fae.jpg 90d61436ff957d9a832970284d907b05 https://staging.drfop.org/files/original/f35503438fe05e1cdbc250b4e82f94d5.jpg 99c5889626100eef344a612d0ef0144b https://staging.drfop.org/files/original/b6385b9e916c2dc4ec8d882d296ffbec.jpg 903e5a50735dddcf70b53d421d8535f1 https://staging.drfop.org/files/original/cc1bcdcf0aa82448482125d7233c2050.jpg 54761632a865da1bb94d6a98a6490944 https://staging.drfop.org/files/original/d947b49fd92dd2f0d72c609efb65047e.jpg fbbe8888586ee697db72bd6897bfedbf https://staging.drfop.org/files/original/989181df6cb3cb6b55290a5bec7bf202.jpg a10287ef2e996756c2aa320a34f8dcd2 https://staging.drfop.org/files/original/b766abead8153e3f82f59b077962e0d6.jpg d553d8b4fe2b3d70ec894cad702d03f9 https://staging.drfop.org/files/original/2e918fb95e99cacf4c82973b0212bccc.jpg 005e417a4aafce0105f700f8a6515eef https://staging.drfop.org/files/original/613b9a4452de0437198cd813baaa61e1.jpg acd412db35de4685ce2b71355c40d708 https://staging.drfop.org/files/original/0e7cc252f4b3a1626acbb5dc867a5025.jpg 32c10baf22ef8472383f3c2360990a4a https://staging.drfop.org/files/original/30c3612232851dc3f8d5431dbfe34810.jpg 0a6ff1698181ad1d40fdafef9b9b5b68 https://staging.drfop.org/files/original/087223721d10e6073542b807509106fd.jpg aa7e8d1c20b1c29b8149b00326d1aa1d https://staging.drfop.org/files/original/a4305ebe705f8f02e0602b51a3c82b45.jpg c7376f54499e82996efdbdf24e3aa938 https://staging.drfop.org/files/original/8b3557f24cd0dcb0ef944b5f9d6bbdbe.jpg ad65f6bd2df274a4e558eaadbf017a68 https://staging.drfop.org/files/original/565202e80a39f6169372423c5e5c3957.jpg 31958624e459cec8528a2897b3ecdb11 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_001.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 1 - 14 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Premodified Casting for the Patellar-Tendon-Bearing Prosthesis</h2> <h5>Joseph H. Zettl. C.P <a style="text-decoration:none;">*</a><br />Joseph E. Traub. C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>Methods for producing a functional, comfortable, and well-fitting patellar-tendon-bearing prosthesis have been the subject of considerable discussion, and in fact some controversy, since the prosthesis was first introduced several years ago. Prosthetists use a variety of techniques to cast below-knee stumps, and there is an extensive literature on the subject, not excluding the technicians' differing viewpoints. There is agreement, however, that the effectiveness of the prosthesis depends to a great extent upon how well the wrap-cast (negative) was taken and, subsequently, how precisely the male plaster mold (positive) was modified.</p> <p>The positive mold is modified in order to relieve pressure-sensitive areas by the addition of build-ups, and to increase the pressure to the pressure-tolerant (or natural weight-bearing) areas of the stump by the judicious removal of small amounts of plaster. These alterations prevent vertical displacement during stance and provide for comfortable accommodation of the stump during full weight-bearing. The precise amount of plaster removed varies with the individual patient, depending upon the muscle tone and the amount and resilience of the subcutaneous tissue. The procedure is by no means a difficult one, but timing is a complicating factor.</p> <p>Authorities on the subject encourage immediate rather than later modification of the positive cast in order to prevent improper interpretation of the individual stump characteristics. Consequently, the well-qualified prosthetist who finds himself with a large number of plaster positives to be modified, or the less experienced prosthetist who is just developing a keen sense of technical judgment, is at a disadvantage because, even with the best memory and with detailed prosthetic information, he is limited by techniques which involve nothing more than intelligent guesswork and which are conducive to at least an occasional error, regardless of the individual's experience and skill.</p> <p>This difficulty can be overcome by modifying the cast on the patient's stump when the negative-cast impression for the permanent prosthesis is taken. This paper describes such a procedure, essentially initial socket fitting during casting, which provides a plaster negative-positive that requires only a final smoothing to be ready for socket lamination. The method includes the application of felt pads to strategic areas of the stump. Elastic plaster bandage is used for the negative plaster wrap because it effectively conforms to the irregular stump surfaces, controls tissue compression and displacement, and yields a precise stump impression. The resulting positive plaster mold resembles the stump contours accurately, thus providing the basis for a comfortable, well-fitting, and functionally acceptable PTB prothesis.</p> <p>Provision of a total-contact, hard PTB socket, without a soft end or the customary insert, is the standard procedure at the Prosthetics Research Study, and the pre-modified-casting procedure results in a precise reproduction of the stump socket, so essential in hard-socket prostheses. This method has been used routinely at this facility since 1964, during which time several hundred PTB prostheses have been effectively fitted.</p> <p>The premodified-casting procedure can be used, with but relatively minor modifications, for the patellar-tendon supracondylar or the patellar-tendon supracondylar-suprapatellar (PTS) prosthesis, with wedge suspension. We have also used this technique, with promising results, for the production of interim prosthetic sockets using both synthetic rubber, Polysar X-414 (TM), and Lightcast (TM). Both these materials will produce an effective interim prosthetic socket for immediate and early fitting.</p> <h3>Procedure</h3> <h4>Negative Plaster Wrap</h4> <p><i>Prosthetic Information</i></p> <p>Examine the stump to obtain all pertinent prosthetic information. Measurements of the normal leg can also be recorded at this time on page B of the prosthetic information form, but measurement of the stump is postponed until all felt relief pads have been applied to the stump.</p> <p><i>Materials and Equipment</i></p> <p>Materials required for the premodified plaster cast for a PTB prosthesis are:</p> <ul> <li>One lightweight cast sock</li> <li>One heavyweight cast sock</li> <li>Dow Corning Medical Adhesive Spray Type B</li> <li>Two rolls of 4- or 5-in. elastic plaster bandage</li> <li>One roll of 4-in. conventional plaster bandage</li> <li>Four plaster splints, 4 in. x 15 in., extra-fast-setting</li> <li>Soft felt, approximately 5 in. x 10 in. x 1/8 in. thick</li> <li>Medium felt, approximately 5 in. x 10 in. x 3/8 in. thick (or a right or left set of prefabricated felt relief pads, as used in immediate postsurgical prosthetic fitting)</li> </ul> <p>Equipment required for this procedure is:</p> <ul> <li>Two 48-in. lengths of 1-in. elastic webbing</li> <li>Four Yates clamps</li> <li>One pair medium-size scissors</li> <li>Skiving knife</li> <li>Inside calipers</li> <li>Measuring tape</li> <li>Combination square</li> <li>VAPC knee-measuring caliper</li> <li>Preshaped piano-felt, hamstring-tendon relief pads</li> <li>Below-knee casting fixture</li> <li>Bucket or basin of clear water, approximately 70 degrees F</li> </ul> <p><i>Preparation of Patient</i></p> <p>Have the amputee sit on a table approximately 30 inches high, with the knee of the amputated leg extending six to eight inches beyond the table edge (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Roll the heavy cast sock onto the stump and attach the proximal portion of the cast sock with two Yates clamps to the 1-in. elastic-webbing strap which encircles the amputee's hips and crosses the amputated leg approximately four inches proximal to the patella (<b>Fig. 2</b>). The strap should exert considerable tension on the cast sock in order to support all soft tissues of the stump, particularly those located distally. <i>This is most important </i>because improper tissue support would result in too large a cast, necessitating modifications of the positive model or prosthetic socket to achieve proper fit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Direct the amputee to flex his knee approximately 35 degrees and to maintain this flexion in a relaxed attitude throughout the entire casting procedure.</p> <p><i>Preparation of Pressure-Relief Pads</i></p> <p>By palpation, locate the surface areas of the stump which require pressure relief.</p> <p>For the <i>tibial crest:</i></p> <ol> <li>Measure the entire length of the crest of the tibia from the proximal border of the anterior tibial tubercle to 1/2<i> </i>in. beyond the posterior edge of the transected tibia.</li><li>Measure the width of the anterior tibial tubercle and the cut end of the tibia.</li><li>Cut a piece of <i>soft </i>felt, 1/8-in. thick, to the length dimension taken in step 1 and width dimension taken in step 2. This results in a felt relief pad (<b>Fig. 3</b>) which has a long rectangular form and widens in its distal aspect into a well-rounded teardrop shape, approximating the contours of the cut end of the tibia.</li><li>Neatly skive the periphery of the tibial relief pad to assure a smooth transition between the stump sock and pad.</li><li>Usually, additional relief of the distal anterior tibial area is indicated. The additional relief pad should represent the contours of the cut end of the tibia, resulting in the general shape of a large metatarsal pad. The periphery of the pad is smoothly skived to blend in with the tibial relief pad (<b>Fig. 4</b>).</li></ol> <p>For the <i>head of the fibula:</i></p> <ol> <li>Measure the proximal-distal and anterior-posterior dimensions of the head of the fibula.</li><li>Fashion a piece of <i>soft </i>felt, 1/8-in. thick, to those dimensions, rounding off all corners and neatly skiving the periphery. The fibular relief pad should have a shape similar to a large metatarsal pad.</li></ol> <p>VARIATION: If the cut end of the fibula is prominent, sensitive, or close to the surface, provide another felt relief pad according to its dimensions and skive all edges.</p> <p>For the <i>anterolateral condylar ridge of the tibial plateau:</i></p> <ol> <li>Measure the length and width of this area.</li><li>Fashion a piece of <i>soft </i>felt, 1/8-in. thick, to the dimensions obtained in step 1 (<b>Fig. 5</b>).</li><li>Round off all corners and neatly skive the entire periphery. This results in an oval-shaped condylar-ridge relief pad.</li></ol> <p><i>Application of Pressure-Relief Pads</i></p> <ol> <li>Spray all felt relief pads with Dow Corning Medical Adhesive Type B on the reverse, or unskived, side and allow the adhesive to dry for five seconds.</li><li>Spray the appropriate areas on the cast sock where the relief pads will be located and allow the adhesive to dry for five seconds.</li><li>Apply the felt relief pads in their pre-established locations and recheck to be sure they adequately cover the bony prominences on the stump (<b>Fig. 6</b> and <b>Fig. 7</b>).</li></ol> <p><i>Stump Measurements</i></p> <ol> <li>Remind the patient to maintain his stump in an attitude of 35 degrees of flexion, with the stump musculature relaxed.</li><li>Place the appropriate portion of the VAPC knee-measuring caliper on the femoral condyles. Measure the mediolateral stump diameter and record on the prosthetic-information form (<b>Fig. 8</b>).</li><li>Place the appropriate portion of the VAPC knee-measuring caliper on the patellar tendon and the popliteal tissues. With the stump relaxed, measure the anteroposterior diameter and record on the prosthetic-information form (<b>Fig. 9</b>).</li><li>Mark the apex of the patellar tendon with an indelible pencil (<b>Fig. 10</b>). Place one end of the combination square rule on the patellar tendon and rest the blade of the rule against the long axis of the tibial-crest felt relief pad. Square the distal stump end and record the resulting stump-length measurement in the appropriate box on the prosthetic-information form.</li></ol> <p><i>Second Cast Sock and Hamstring-Tendon Relief</i></p> <ol> <li>The second cast sock, lightweight, is applied very wet. Carefully roll the sock onto the stump without displacing the previously applied felt relief pads.</li><li>The posterior socket brim line should have a well-rounded flare for comfort during prolonged sitting. Appropriate relief for the hamstring tendons provides additional comfort when the knee is maintained in an attitude of 90 degrees of flexion. For this purpose, two standard sets of relief pads in sizes large and average are fashioned from one-inch-thick piano felt. Each set consists of a right and left relief pad. They must resemble the finished rounded contours of the posterior socket brim and include skived distal projections for medial and lateral hamstring-tendon relief. Pad selection is based on matching the distal projections against the hamstring tendons.<br />Select a right or left piano-felt hamstring-tendon relief pad of the proper size (<b>Fig. 11</b>) and place it at the approximate level of the posterior socket brim behind the knee, between the first and second cast socks (<b>Fig. 12</b>). The projections on either side of the relief pad should be located directly over the hamstring tendons behind the knee. Maintain the knee in 35 degrees of flexion.</li><li>With the hamstrings relief pad in place, the second, or lightweight, cast sock is pulled up tight and attached with Yates clamps to a second 1-in. elastic-webbing strap which encircles the amputee's hips and crosses the amputated leg approximately 4 in. above the patella (<b>Fig. 13</b>). This elastic-webbing strap must also exert considerable tension on the second cast sock, without creating wrinkles.</li><li>Recheck all felt relief pads for retention of their proper locations and adjust if indicated.</li></ol> <p><i>Preparation of Compression Pads</i></p> <p>By palpation, locate the surfaces of the stump which are pressure tolerant.</p> <p>For the <i>pretibial area lateral to the tibial crest:</i></p> <ol> <li> Measure the length of the crest of the tibia from the inferior border of the anterior tibial tubercle to within 1/2<i> </i>in. of the anterior cut end of the tibia.</li><li> Measure the distance between the lateral edge of the previously applied tib-ial-relief pad to the anterior border of the fibular head.</li><li> Cut a piece of 3/8-in. <i>medium </i>felt to the dimensions recorded in steps 1 and 2.</li><li> Round off all corners of the pad. The entire periphery is now provided with a 1/2-in. skived border, with a uniform gradual taper, finishing in a feathered edge (<b>Fig. 14</b>).</li></ol> <p>For the <i>pretibial area medial to the tibial crest, </i>including the medial tibial condylar flare:</p> <ol> <li>Measure the length of the crest of the tibia from the inferior border of the tibial tubercle to within 1/2<i> </i>in. of the anterior cut end of the tibia.</li><li>Measure the distance between the medial border of the previously applied tibial relief pad at the level of the tibial tubercle and the medial head of the gastrocnemius muscle.</li><li>Cut a piece of <i>medium </i>felt, 3/8-in. thick, to the dimensions recorded in steps 1 and 2.</li><li>Measure down from one end of the felt compression pad 2 in. and mark that point with chalk.</li><li>Palpate the width of the tibia medial to the crest and measure this distance.</li><li>Mark the felt compression pad at the same distance from the long edge one inch below the mark made in step 4 (<b>Fig. 15</b>). Mark on the felt compression pad a smooth S curve from the posterior edge of the felt to the marks in steps 4 and 5.</li><li>Continue the mark made in step 5 with a straight line to the distal end of the felt compression pad (<b>Fig. 16</b>).</li><li>Cut the felt along the marked lines made in steps 4, 6, and 7 (<b>Fig. 17</b>).</li><li>Round off all corners. The entire periphery of the felt compression pad is now provided with a 1/2-in. skived border, with a uniform, gradual taper, finishing in a feathered edge.</li></ol> <p>For the <i>long shaft of the fibula:</i></p> <ol> <li>Measure the length of the fibula from the inferior border of the head to within 1/2 in. of the distal cut end of the bone.</li><li>Measure the anteroposterior dimension of the head of the fibula.</li><li>Cut a piece of <i>medium </i>felt, 3/8-in. thick, to the dimensions recorded in steps 1 and 2 (<b>Fig. 18</b>).</li><li>Round off all corners. The entire periphery of the fibular compression pad is now provided with a 1/4-in. skived border with a uniform, gradual taper, and finished in a feathered edge.</li></ol> <p><i>Application of Compression Pads</i></p> <p>Apply the felt compression pads to the second (lightweight) sock.</p> <ol> <li> Spray all felt relief pads with Dow Corning Medical Adhesive Type B on the reverse, or unskived, side and allow the adhesive to dry for five seconds.</li><li> Spray the corresponding areas of the cast sock where the felt compression pads will be located and allow the adhesive to dry for five seconds.</li><li>Carefully locate the felt compression pads in their pre-established positions on the thin cast sock (<b>Fig. 19</b>, <b>Fig. 20</b>, and <b>Fig. 21</b>). These pads <i>must not overlap </i>the areas of the previously applied pressure-relief pads. The felt compression pads should be in firm smooth contact with the thin cast sock to avoid reproduction of wrinkles, rough edges, or other irregularities in the plaster wrap.</li></ol> <p><i>Application of Elastic Plaster Bandage</i></p> <p><i>Wraps One and Two. </i>The wrap is always started on the distal lateral aspect of the stump, approximately 1 in. from the distal stump end, to avoid medial displacement of the gastrocnemius muscle (<b>Fig. 22</b>). Minimal tension is applied to the bandage with this circumferential wrap, which is applied clockwise for a right stump and counterclockwise for a left stump (viewed anteriorly). One and three-quarter circumferential wraps will secure the felt compression pads and anchor the elastic plaster bandage to itself (<b>Fig. 23</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wrap Three. </i>The wrap is now at a posterior-lateral point on the stump. Bring it anteriorly in a diagonal direction over the distal <i>lateral </i>portion of the stump, pulling the plaster bandage almost to its limit of elasticity. At the anterior stump margin, release the tension slightly and carry the wrap medially and then posteriorly, with only a slight pull to the plaster bandage (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wrap Four. </i>This wrap is almost identical to wrap three, except that now the bandage covers the distal <i>center </i>of the stump, bandaging in an anteroposterior plane. The direction of the wrap is altered anteriorly and carried toward the lateral side of the stump, as if to resume circumferential wrapping.</p> <p><i>Wrap Five. </i>The wrap is brought anteriorly up over the distal <i>medial </i>stump aspect with the same controlled tension to the plaster bandage (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wrap Six. </i>To achieve sufficient cast strength, a second layer of elastic plaster bandage is applied by repeating wrap five.</p> <p><i>Wrap Seven. </i>Repeat wrap four, again altering the direction of the wrap to the medial side, which will cover the distal <i>center </i>of the stump with a second layer of plaster bandage.</p> <p><i>Wrap Eight. </i>Repeating wrap three will now cover the distal <i>lateral </i>stump aspect with a second layer of plaster bandage. The remainder of the elastic bandage is wrapped in a circular manner to a level 1/2 in. superior to the adductor tubercle of the femur.</p> <p>A second roll of elastic plaster bandage is applied when indicated. Pull the plaster bandage firmly so that it conforms smoothly to the stump without leaving wrinkles or ridges. Maximum tension should be applied to the bandage distally, with gradually decreasing tension as the wrap is extended proximal to the knee joint. Smooth the plaster gently to assure complete adherence of all layers, but avoid molding of the plaster as it hardens (<b>Fig. 26</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Application of Below-Knee PRS-Model Casting Fixture</i></p> <p>With the plaster still wet, apply the BK casting fixture (<b>Fig. 27</b> and <b>Fig. 28</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Open the casting fixture and place the patellar bar on the patellar tendon.</li><li>Push the patellar bar into the joint space until firm resistance is felt, then release slightly. Push in a direct line with the femur (<b>Fig. 29</b>).</li><li>Attach the posterior popliteal section to the anterior portion of the casting fixture. Contouring of the plaster cast in the area of the popliteal space is achieved by joining the two sections of the casting fixture in proper relationship to the casted stump (<b>Fig. 30</b>).</li><li>Be sure that the patient is completely relaxing his stump musculature and that the knee-flexion angle is maintained at 35 degrees.</li><li>Adjust the casting fixture to the patellar size by rotating both halves of the patellar inverted-horseshoe section.</li><li>Recheck and maintain the outline of the patella. Makes necessary adjustments by means of the thumbscrews as indicated.</li><li>Hold the casting fixture in place until the plaster has hardened completely. Check the distal end of the cast to determine final firmness of the plaster wrap.</li><li>Open the casting fixture and remove carefully (<b>Fig. 31</b>).</li></ol> <p><i>Reinforcement of Negative Plaster Wrap</i></p> <p>Apply conventional plaster bandage to reinforce the cast.</p> <ol> <li>Two double layers of 4 in. x 15 in. plaster splints are applied over the distal portion of the cast, one anteroposteriorly and one mediolaterally (<b>Fig. 32</b>).</li><li>Reinforcement of the plaster wrap is completed with a roll of 4-in. conventional plaster bandage, starting at the distal stump aspect (<b>Fig. 33</b>) and wrapping prox-imally with even, overlapping, circular wraps.</li></ol> <p><i>Removal of Negative Plaster Wrap</i></p> <p>Remove the cast negative only after the plaster wrap has completely hardened.</p> <ol> <li>Release both elastic-webbing straps which hold the cast socks suspended.</li><li>Roll the proximal portion of the second (or thin) cast sock down over the brim of the cast negative.</li><li>Remove the posterior piano-felt hamstring-relief pad from between cast socks 1 and 2. If necessary, use a pair of long-nose pliers or the equivalent (<b>Fig. 34</b>).</li><li>Roll the top of the first (or heavy) cast sock down over the brim of the plaster wrap.</li><li>Place your fingers in the popliteal space and your thumbs in the patellar-tendon depressions. Direct the amputee to completely relax his stump.</li><li>With the amputee's knee flexed and relaxed, pull the proximal portion of the plaster wrap towards you to release the area of the patellar tendon by compression of the posterior soft tissue (<b>Fig. 35</b>).</li><li>Carefully remove the first (or heavy) inner cast sock from the negative (<b>Fig. 36</b>). Be extremely careful not to disturb the thin cast sock that adheres to the inside of the plaster-cast negative.</li><li>Inspect the cast critically to be sure that it is smooth and well contoured throughout (<b>Fig. 37</b>).</li></ol> <p><i>Negative Plaster-Cast Measurements</i></p> <p>To check the inside dimensions of the cast negative:</p> <ol> <li>Place the inside calipers in the cast to measure the anterior-posterior dimensions between the patellar-tendon shelf and the posterior popliteal bulge. Record this measurement on the prosthetic information form, side B. The measurement should be the same as the AP dimension plus 1/8<i> </i>inch.</li><li>Place the inside calipers in the cast at the level of the medial and lateral condyles of the femur. Record this measurement on the prosthetic information form, side B. The dimension should not be more than 3/8 inch larger than the ML stump dimension.</li></ol> <p>To check the length of the cast:</p> <ol> <li>Place a ruler in the socket and measure the dimension from the deepest point of the cast to the center of the patellar-tendon bar. Keep the edge of the ruler parallel to the line of the crest of the tibia.</li><li>Compare this measurement to the length of the stump dimension on the prosthetic information form. It must be within ! <i>s </i>inch of the recorded length.</li></ol> <p>NOTE: If any of the measurements recorded in steps 1 and 2 are not within the tolerances stated and cannot be reconciled by remeasurement of the stump, it will be necessary to make a new negative plaster wrap. Also, a new plaster negative must be taken if the plaster wrap has collapsed or if the wrap shows deep ridges or other severe irregularities.</p> <p>The Negative-Positive Plaster Mold</p> <p><i>The Positive Cast Model</i></p> <ol> <li>Fill the negative wrap cast with liquid plaster of paris in the usual manner.</li><li>As the plaster begins to harden, insert a length of vacuum pipe to a sufficient depth, but avoid contacting the negative plaster wrap.</li><li>After the plaster has set for 20 to 30 minutes, cut and strip off all wraps, exposing the positive model. Be careful not to disturb the contours of the model (<b>Fig. 38</b>).</li><li>If necessary, fill all holes in the model left by air bubbles in the plaster. Usually, this will not be necessary if proper care has been taken when filling the negative-cast wrap.</li><li>With a Surform (TM) rasp, smooth off all minor bumps and the irregularities on the model caused by the seam in the cast sock.</li><li>Provide a final smooth finish over the entire model with screen wire and finish with wet-or-dry Fabricut (TM) silicon carbide, 180 grit (<b>Fig. 39</b>). (Screen-baked Durite [TM] would be equally satisfactory.)</li><li>Seal the completed plaster model positive with Hosmer-Lac or the equivalent to prevent the dampness in the plaster from affecting the inner PVA bag during lamination.</li></ol> <h4>Socket Fabrication</h4> <p>Proceed with the standard PTB lay-up used for fabricating a polyester hard-socket laminate. The resulting prosthetic socket accommodates the stump very snugly, in most instances with a three-ply wool stump sock. If preferred, the conventional Kemblo (TM) insert can be prepared in the usual manner prior to the polyester lamination procedure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fajal, Guy, Stump casting for the PTS below-knee prosthesis: prothese tibiale supra condylienne, <i>Prosthetics International</i>, 3:4-5:22-24, 1968.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, <i>Artif. Limbs</i>, 6:2:25-73, June 1962.</li> <li>Gardner, Henry, A pneumatic system for below-knee stump casting, <i>Prosthetics International</i>, 3:4-5:12-14, 1968.</li> <li>Hampton, Frederick L., The suspension method for casting of below-knee stumps,<i> Prosthetics International</i>, 3:4-5:9-11, 1968.</li> <li>Murdoch, George, The "Dundee" socket for the below-knee amuptation, <i>Prosthetics International</i>, 3:4-5:15-21, 1968.</li> <li>Radcliffe, C. W , and J. Foort, <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley andSan Francisco, 1961 (rev. ed.).</li> <li>Wilson, Leigh A , and Erik Lyquist, Plaster bandage wrap cast: procedure for the below-knee stump, <i>Prosthetics International</i>, 3:4-5:3-7, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Joseph E. Traub. C.P. </b></td></tr><tr><td class="clsTextSmall">Consultant, Rehabilitation Engineering, Social and Rehabilitation Service, Department of Health, Education, and Welfare, Washington, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Joseph H. Zettl. C.P </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Research Study, Seattle, Wash.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-22.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-23.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-24.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-25.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-26.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-27.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-28.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-03.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-04.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-05.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-06.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-07.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-08.jpg Figure 16 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-09.jpg Figure 17 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-10.jpg Figure 18 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-11.jpg Figure 19 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-12.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 Premodified Casting for the Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Joseph H. Zettl. C.P * Joseph E. Traub. C.P. * https://staging.drfop.org/files/original/c1b212e5569be3980845775e2e5a8a20.pdf b5411e7663896df2ca89672710d0c1cb Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_03_001.pdf Text Any textual data included in the document <h2>Irreversible Contractures: An Impediment to Prosthetic Rehabilitation</h2> <h5>Justin Alexander, Ph.D.&nbsp;</h5> <p>Prosthetic rehabilitation of patients with severe contractures of the remaining joints of the affected lower extremity has been generally viewed as being difficult due to biomechanical problems in fitting, increased energy costs of ambulation and poor cosmesis of the prosthesis. As a result, attempts are often made to "stretch out the contracture" with minimal success, or suggestions are made to the patient to remain in the wheelchair. Our experiences with a number of patients who presented with "irreversible" contractures, indicate that another choice may be available.</p> <p>In 1965(1) we reported our experience in the management of a 59 year old man who had undergone bilateral amputations (BK and AK). Following a herniorrhaphy, he developed occlusions of both iliac arteries and despite attempts to reconstruct the vascular supply, he developed gangrene necessitating the amputations. When he was examined by us, he presented with bilateral hip flexion contractures of about 60° and a knee flexion contracture on the BK side of 90°. In addition, there was limited mobility of the lumbar spine. Primarily because the patient refused our recommendation for wheelchair independence, pylons were constructed. For the left, a bent knee pylon was fabricated and for the right the device was built to hold the stump in about 50° hip flexion with weight bearing on the posterior thigh. Since the patient demonstrated that this solution was a realistic one, prosthetic devices incorporating the features of the pylons were made. When the patient was discharged, he was able to ambulate with the aid of Lofstrand crutches.</p> <p>The patient was re-examined periodically, and <i>after about 2 years</i> it was noted that the contractures had decreased to a point where he was able to wear a PTB prosthesis on the left and a conventionally aligned AK quadrilateral socket prosthesis on the right.</p> <p>Lippman(2) described his observations of a 72 year old man who lost his right leg as a result of trauma, complicated by a long history of arteriosclerosis obliterans. Because of a 40° hip flexion contracture, his prosthetic treatment followed the course outlined above.</p> <p>In our prosthetics clinic (Bronx Municipal Hospital Center), we have seen a number of patients who had undergone below knee amputations and presented with severe knee flexion-hip flexion contractures to a degree which precluded fitting with a standard PTB or condylar bearing prosthesis. We have frequently fitted them with bent knee pylons followed by a similar prosthetic device after they had demonstrated their ability to function with the temporary device. On follow-up we again noted reduction of the "irreversible" contractures to the point where a more conventionally aligned prosthesis could be prescribed.</p> <h3>Discussion</h3> <p>Delagi and co-workers(3) (1955) as well as Blau, <em>et. al</em>(4) (1951) reported their impressions of the benefits of ambulation with a temporary device. Both emphasized the stretching effect of early ambulation. In the devices described in this article, however, stretching has been purposely minimized because the contractures were believed to be "irreversible." Despite the lack of active stretching, the contractures were relieved to a considerable degree.</p> <p>Partridge and Duthie (1963) (5) reviewed the literature describing the effect of immobilization on acutely inflamed rheumatoid joints and cite Hunter (1835) "nothing can promote contraction(s) of a joint so much as motion before the disease is removed." Hunter's observations were confirmed by Thomas (1878), Duthie (1951, 1952) and Partridge and Duthie. Harris and Copp(6) (1962) immobilized acutely inflamed knee joints, keeping one completely immobilized and the other being exercised intermittently. They noted that when the fixed knee lost more than 15° of motion, the mobile knee also lost range, thereby suggesting that some factors other than immobility might be a contributing factor. In their opinion immobilization produced a decrease in muscle spasm, thus permitting restoration of motion.</p> <p>Fried (1969) (7) concurs "complete immobilization is not only <em>not</em> harmful but frequently beneficial, provided that splinting is done judiciously, especially when a joint is inflamed and painful." Under those conditions when patients are likely to dread motion, immobilization leads to decreased pain and inflammation and "it is not unusual for immobilization to result in increase in motion."</p> <p>It seems that those amputees who experience considerable pain pre-operatively or in the immediate post-operative period, might react with a response similar to that described above and when pain is relieved, inhibition, spasm or another mechanism is decreased and motion can be restored.</p> <p>In addition, it appears that the judgment of "irreversible contractures" may be applied too quickly. Patients are treated for a finite period of time and if during that period no appreciable change is observed, a decision must be made based on demonstrable facts.</p> <p>It can, therefore, be concluded that for some patients interim solutions as outlined may be appropriate and that the clinic staff must accept the responsibility for regular, periodic and long term follow-up of patients in order to facilitate accommodation to changes in the patient's condition.</p> <p><b>References:</b></p> <ol> <li>Alexander, Justin and Herbison, Gerald, "Prosthetic Rehabilitation of a Patient With Bilateral Hip-Flexion Contractures: Report of a Case." <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 46, 708-711, October, 1965.</li> <li>Lippmann, Heinz I., "Rehabilitation of the Lower Extremity Amputee with Marked Flexion Contractures: Report of Two Cases." <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 48:3, 147-149, March, 1967.</li> <li>Delagi, Edward F., Abramson, Arthur S. and Tauber, Arthur N., "Use of Temporary Plaster Pylon in the Management of the Lower Extremity Amputee." <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 36: 784-786, December, 1955.</li> <li>Blau, Leslie, Phillips, Joseph J. and Rose, Donald M., "Value of the Pylon in Pre-prosthetic Management of the Lower Extremity Amputee." <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 32: 585-589, 1951.</li> <li>Partridge, R. E. H. and Duthie, J. J. R., "Controlled Trial of the Effect of Complete Immobilization of the Joints in Rheumatoid Arthritis." <i>Ann. Rheum. Dis.</i>, 22: 91, 1963.</li> <li>Harris, R. and Copp, E. P., "Immobilization of the Knee Joint in Rheumatoid Arthritis." <i>Ann. Rheum. Dis.</i>, 21: 353, 1962.</li> <li>Fried, David M., "Splints for Arthritis." <i>Arthritis and Physical Medicine</i>, S. Licht (edit.), 1969, pp 285-314.</li> </ol> Page Number(s) 1 - 2 Year 1980 Volume 4 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 Irreversible Contractures: An Impediment to Prosthetic Rehabilitation Creator An entity primarily responsible for making the resource Justin Alexander, Ph.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.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p><b>References:</b></p> <ol> <li>Harris, R. and Copp, E.P., "Immobilization of the Knee Joint in Rheumatoid Arthritis," <i>Ann. Rheum. Dis.</i>, 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," <i>Ann. Rheum. Dis.</i>, 22:91, 1963.</li> <li>Alexander, J., "Irreversible Contractures: An Impediment to Prosthetic Rehabilitation" <i>Newsletter Prosthetics and Orthotics Clinic</i>, 4:3, 1, 1980.</li> </ol> <div style="width: 400px;"><em><b>*Justin Alexander, Ph.D. </b> 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.</em><br /><br /><br /></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/. Title A name given to the resource The Nature of Contractures Creator An entity primarily responsible for making the resource Justin Alexander, Ph.D. * https://staging.drfop.org/files/original/892690a8157d28658a834c3528307f12.pdf 46635f9f3a0bd0099000df31390bb18f https://staging.drfop.org/files/original/f83483273e4ca873c2b6c4b749295b36.jpg 1806cb232e00d7f2e1aa8c0d43cf5030 https://staging.drfop.org/files/original/44ad63daa60b63d3e5eb235ee4bed6af.jpg b941ec42fb9f33e4b53d6e8c3131f2e8 https://staging.drfop.org/files/original/538baa25b4c0b8a6e366d350ab8efe22.jpg ca48e869ff98e23bdfbe302f048a00d3 https://staging.drfop.org/files/original/1313f2ed2e7ca5cfacff0dcb7183e6ea.jpg 35d3f849afd43c43e0b9995145ac60cf https://staging.drfop.org/files/original/7a5327ee43eb8d131b9d230581c3ea78.jpg 92bc8538f3959fb74b71e0fc01066b25 https://staging.drfop.org/files/original/168dba5c3df51c517fed3c05cf7259a2.jpg c5c8829fa389af76f59224e172c0874a https://staging.drfop.org/files/original/c4ec5d68676dafe3a670f1224ebea94b.jpg 7bdd0b16e025474332d2b91468b6828c https://staging.drfop.org/files/original/7dd172ac59d2034ee24963329d2b08c4.jpg 1ad409c2443e6aaee7fc0cfbad0b89e0 https://staging.drfop.org/files/original/7fa6c4953b72189fd674a1df2dfc7a94.jpg e6d74833e34b051102932b0497b62db5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_044.pdf Text Any textual data included in the document <h2>Clinical Analysis of Foot Problems</h2> <h5>Karen S. Seale, M.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Orthotists are vital members of the foot care team. Their expertise and special interests in materials and biomechanics add a unique dimension to the management of foot problems.</p> <p>It is hoped that the principles of clinical assessment of foot problems set forth in this article will foster even greater interest in and understanding of the pathophysiology of foot problems. The purposes of this article are threefold:</p> <ol> <li> <p>To familiarize the orthotist with the general concepts of clinical analysis of the foot.</p> </li> <li> <p>To assist the orthotist in designing the most appropriate orthosis based on clinical assessment of the problem.</p> </li> <li> <p>To give examples of clinical analysis of the following common foot problems for which an orthotic treatment may be prescribed:</p> <ol> <li> <p>Heel pain</p> </li> <li> <p>Pes planus</p> </li> <li> <p>Metatarsalgia</p> </li> <li> <p>Ankle instability</p> </li> </ol> </li> </ol> <h3>Discussion</h3> <p>Clinical analysis of the foot consists of obtaining a pertinent history and performing a physical examination of the lower extremity. The medical history is an opportunity to gather as much information as possible by asking the patient to describe the pain, problem, or deformity. Specific information is sought by asking about the type of pain, its duration, onset (whether insidious or abrupt), location of the pain, and activities that help or aggravate the pain (such as rest, walking, or wearing or removing certain shoes).</p> <p>Physical examination involves inspection, palpation, and manipulation. Observe the patient, first with and then without his typical footwear, both standing and walking, with arms hanging freely at the sides. The patient should be observed from the front and from the back. With the patient seated at a height comfortable for the examiner and the shoes removed, palpation and manipulation can be performed. Palpation is not intended to inflict pain, but rather to identify areas of discomfort. For example, applying direct pressure in the center of the heel pad may cause discomfort in a patient with "heel spur" syndrome.</p> <p>In addition to palpation, manipulation is used to assess range of motion of the various joints and to determine the biomechanical relationships of the component parts of the lower extremity. Although a description of a comprehensive foot examination is beyond the scope of this paper, clinical analysis of four common foot problems is included in the next section.</p> <h3>Heel Pain</h3> <p>A very common clinical problem for which shoe modifications may be prescribed is heel pain. Although many causes of heel pain exist, common etiologies include, (1) fat pad atrophy, (2) plantar fascitis or "heel spur" syndrome, and (3) neuritis of the medial calcaneal or lateral plantar nerves.</p> <p>Atrophy of the fat pad is particularly common among older individuals who will complain of localized pain about the heel brought on by walking, especially in hard soled shoes. Varying degrees of fat atrophy of the metatarsal area as well as the heel pad are observed on physical examination and the underlying tubercle of the calcaneous can be readily palpated. The key to successful shoe modification in treating this condition is to increase the padding beneath the heel.</p> <p>The onset of chronic heel pain due to plantar fascitis or "heel spur" syndrome may be either acute or insidious. It is often most severe upon arising in the morning, but improves after a period of "warming up." However, it may worsen if the patient remains on his feet during the day or with intermittent periods of rest and activity. The patient is usually tender to palpation at the origin of the plantar fascia on the plantar tubercle of the calcaneus and about one centimeter distally (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg"><b>Fig. 1a</b></a>). The principles of shoe modification management are soft soles, relief in the center of the heel, and a soft arch support to better distribute the weight and relieve the painful heel area.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg"><strong>Figure 1A. Point of tenderness in patient with plantar fascitis.</strong></a><br /> <p>Neurologic causes of heel pain include neuritis and/or compression of the medial calcaneal nerve, the lateral plantar nerve, or the nerve to the abductor digiti quinti, which is a branch of the lateral plantar nerve.<a></a> The pain is usually not well localized as with plantar fascitis, but tends to be diffuse. On physical examination tenderness may be found on the medial aspect of the heel over the origin of the abductor hallucis (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg"><b>Fig. 1b</b></a>). Occasionally, the examiner can elicit pain or tingling along the medial aspect of the heel with light tapping or pressure in this area. For these patients, an orthosis which limits excessive pronation, and thereby decreases the pull of the abductor hallucis across the nerves, is useful.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg"><strong>Figure 1B. Point of tenderness in patient with neuritis of medial calcaneal and/or lateral plantar nerve.<br /></strong></a><br /> <h3>Pes Planus</h3> <p>Pes planus, or flat foot, is a descriptive term indicating the loss of height of the medial arch, but is a more complex entity than the name implies. There are many causes of symptomatic flat feet, including posterior tibial tendon rupture, Charcot joint degeneration secondary to neuropathy, rheumatoid arthritis, and generalized ligamentous laxity.<a></a> The specific complaints vary depending on the etiology, but in general, pes planus leads to diffuse aching of the foot and early fatigue. Patients with inflammation or early rupture of the posterior tibial tendon will note pain on the medial aspect of the foot and ankle early on, but as significant deformity develops, pain occurs on the lateral aspect of the hindfoot due to impingement of the fibula against the valgus-tilted calcaneus.<a></a> The rheumatoid patient may have a great deal of diffuse pain, whereas the patient with Charcot joint degeneration secondary to neuropathy may have little or no pain in the presence of very severe deformity.</p> <p>Pes planus is best observed seen while the patient is standing. One notes the decrease in the medial arch height, the increase in forefoot abduction and external rotation as well as the presence of heel valgus (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg"><b>Fig. 2a</b></a>). Observations, made from behind as the patient walks, are (1) the excessive external rotation of the foot relative to the line of progression, and (2) the lack of significant heel inversion motion from foot flat to heel lift.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg"><strong>Figure 2A. Note loss of longitudinal arch, with the excessive forefoot abduction and external rotation.</strong></a><br /> <p>Further biomechanical evaluation is performed by sitting in front of the seated patient to observe the relationships of the hindfoot to the leg and of the forefoot to the hindfoot. The subtalar joint motion is assessed by grasping the heel and tilting it laterally (into valgus or eversion) and then medially (into varus or inversion). Not infrequently, the patient with pes planus will demonstrate excessive eversion, greater than the normal excursion of 10°.</p> <p>The foot is then placed in its "neutral position," which is the point at which the calcaneus is centered under the tibia and the talar head is adequately covered by the tarsal navicular. This is done by the examiner's holding the heel in alignment with the long axis of the tibia or in a few degrees of valgus and then adducting the forefoot approximately halfway between maximum forefoot abduction and maximum adduction. The position of the plantar aspect of the forefoot relative to the perpendicular axis of the tibia is noted. There is usually a component of forefoot varus which means the plantar aspect of the foot is facing medially (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg"><b>Fig. 2b</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg"><strong>Figure 2B. Forefoot varus-plantar aspect of foot facing medially.</strong></a><br /> <p>The principles of orthotic management of pes planus include correcting the valgus tilt of the calcaneous, providing a medial arch support, and posting of the first ray to control the hyper-pronation.</p> <h3>Metatarsalgia</h3> <p>Metatarsalgia is pain in the forefoot area for which a wide variety of etiologies have been identified. For the purposes of this article, which is aimed at the practicing orthotist dealing with foot problems, the discussion will be limited to the following:</p> <ul> <li> <p>Fat pad atrophy</p> </li> <li> <p>Sesamoiditis</p> </li> <li> <p>Disorders of the lesser metatarsophalangeal joints</p> </li> <li> <p>Interdigital neuroma</p> </li> <li> <p>Rheumatoid arthritis</p> </li> <li> <p>Pes cavus</p> </li> </ul> <p><i>Fat Pad Atrophy</i></p> <p>As in heel pad atrophy, the soft tissue padding under the metatarsal heads may become atrophied with age, causing diffuse pain under the metatarsal heads due to the lack of sufficient padding for shock attentuation. The patient may complain of pain especially when walking on a hard floor without shoes. The atrophy is apparent on general inspection; palpation reveals the prominence of the metatarsal heads plantarly. The patient may be tender to palpation directly under the metatarsal heads. Soft soled shoes and soft inner soles with metatarsal pads proximal to the metatarsal heads are beneficial modalities.</p> <p><i>Sesamoiditis</i></p> <p>Patients with inflammation of the sesamoids of the first metatarsophalangeal joint will complain of well localized pain on the medial aspect of the foot just proximal to the first metatarsal head upon weight bearing. There may be a history of repeated jumping or running on the balls of the feet or of a crush injury due to a heavy object falling on the foot. The patient may walk by rolling his foot into supination and inversion, thus bearing the majority of the weight on the lateral border of the foot. Palpation directly over the involved sesamoid will cause localized tenderness beneath either the tibial or the fibular sesamoid (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg"><b>Fig. 3a</b></a>). Look for associated edema and swelling under and around the first metatarsal head. Passive extension of the first metatarsophalangeal joint will aggravate the pain. Placing the patient in low heeled shoes with padding devices which relieve weight bearing under the first metatarsal head are indicated.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg"><strong>Figure 3A. Area of point tenderness of fibular sesamoiditis.</strong></a><br /> <p><i>Disorders of the Lesser Metatarsal Joints</i></p> <p>Disorders such as subluxation or dislocation, isolated synovitis, or Freiberg's disease can cause pain limited to a single metatarsophalangeal joint.<a></a> The onset of pain may be insidious and there may or may not be a history of trauma associated with the onset of pain. The patient is usually able to point to the involved area. Pain can be elicited upon palpation of the involved joint and with passive manipulation. Synovial thickening may be appreciated when comparing the thickness of the involved joint to the normal joint of the opposite foot.</p> <p><i>Interdigital Neuroma</i></p> <p>The well localized pain associated with an interdigital, or Morton's, neuroma is caused by a thickening of the soft tissues surrounding the common digital nerves on the plantar aspect of the foot and occurs most frequently between the third and fourth metatarsal heads. This entity occurs frequently in women and probably results from the repeated trauma to the metatarsal region caused by the wearing of high heeled shoes. The patient is usually able to point out the area of maximum pain on the plantar aspect of the foot, pain which occasionally radiates to the toes, and which is worse with weight bearing when wearing snug, thin soled shoes. Removing the shoes and massaging the foot usually affords some temporary relief.</p> <p>The physical examination will be normal to inspection, but upon palpation pain can be elicited by squeezing the soft tissues between the involved metatarsal heads. This is done by using the thumb and forefinger of one hand to simultaneously press from dorsal and plantar while compressing all the metatarsal heads medially and laterally with the opposite hand (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg"><b>Fig. 3b</b></a>). Occasionally, the enlarged nerve tissue can actually be felt to roll between the finger and the thumb.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg"><strong>Figure 3B. Technique for eliciting tenderness of interdigital neuroma between third and fourth metatarsal heads.</strong></a><br /> <p>Keeping the pressure off the involved area with a metatarsal support proximal to the metatarsal heads and eliminating snug, high heeled shoes can be helpful in decreasing the pain.</p> <p><i>Rheumatoid Arthritis</i></p> <p>The typical advanced deformities of rheumatoid arthritis causing metatarsalgia are hallux valgus with lateral deviation and dorsal dislocation of the lesser metatarsophalangeal joints. This results in the distal displacement of the plantar fat pad, thus leaving the metatarsal heads displaced plantarly with insufficient fat pad coverage (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg"><b>Fig. 3c</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg"><b>Fig. 3d</b></a>). Broad, soft soled shoes with an adequate height of the toe box to accommodate the deformities are necessary. Providing a soft, total contact insert with metatarsal padding proximal to the prominent metatarsal heads is helpful in decreasing the weight born by the metatarsal heads and more evenly distributing the weight across the sole of the foot.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg"><strong>Figure 3C. Typical forefoot deformities of rheumatoid arthritis-hallux valgus and dorsal dislocation of metatarsalphalangeal joints (plantar view).</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg"><strong>Figure 3D. Typical forefoot deformities of rheumatoid arthritis-hallux valgus and dorsal dislocation of metatarsalphalangeal joints (lateral view).</strong></a><br /> <p><i>Pes Cavus</i></p> <p>A common complaint of the person with pes cavus, or a high arch, foot deformity is metatarsalgia. The elevated arch results in greater weight being borne on the metatarsal heads. The cavus foot is more rigid and, thus, has less shock attentuation capability than the normal, more supple foot. Metatarsalgia can be worsened in the presence of clawing of the toes, which involves hyperextension of the metatarsophalangeal joints, thus making the metatarsal heads even more prominent plantarly.</p> <p>The deformity can best be appreciated on physical exam by watching the patient in a standing position. In addition to the elevated longitudinal arch, heel varus may be noted. Plantar flexion of the first ray may be present and can be seen by viewing the foot anteriorly with the patient seated. Stabilize the calcaneus in alignment with the tibia and note the level of the plantar aspect of the first metatarsal head relative to the others. The patient with metatarsalgia secondary to pes cavus may benefit from a soft arch support to increase the weight bearing surface of the foot and to improve shock attenuation.</p> <h3>Ankle Instability</h3> <p>Ankle instability may be the result of lateral ligamentous laxity, a varus heel, or a varus an-gulated tibia.<a></a> A patient with lateral ligamentous laxity of the ankle may give a history of having initially sustained an ankle sprain secondary to significant ankle trauma followed by recurrent sprains with minimal or no trauma. The wearing of high heeled shoes worsens the tendency of recurrent ankle sprains as this further throws the foot into supination.</p> <p>Ligamentous laxity causing ankle instability can usually be demonstrated by the "lateral talar tilt" test. The ankle is stress tested both in dorsiflexion, to test the calcaneofibular ligament, and in plantarflexion, to test the anterior talofibular ligament. The tibia is held stationary as the examiner applies pressure on the lateral aspect of the hindfoot in a medial direction (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg"><b>Fig. 4</b></a>). The ankle, which lacks adequate ligamentous support, will tilt medially indicating instability.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg"><strong>Figure 4. "Lateral talar tilt" test for ankle instability.</strong></a><br /> <p>The presence of heel varus can be appreciated by viewing the patient from behind as he stands with shoes removed. It will be noted that the calcaneous is medial to the longitudinal axis of the tibia. Upon manipulation of subtalar joint motion, there may be decreased eversion of the calcaneous relative to inversion.</p> <p>A person who had a varus angulated tibia, either from a congenital deformity or secondary to a tibia fracture which has united in varus, may also experience ankle instability. With such malalignment, the biomechanical forces pass lateral to the center of the calcaneous. Observing the standing patient from the front, the examiner will note that an imaginary plumb line dropped from the center of the patella will fall lateral to the center of the ankle on the affected side.</p> <p>A lateral heel and sole wedge tilts the hind-foot into slight valgus to help prevent recurrent ankle instability.</p> <h3>Summary</h3> <p>The principles of clinical assessment of four common clinical problems for which orthotic treatments are prescribed have been discussed. The information gained from the medical history and physical examination used in clinical assessment of foot problems can aid the ortho-tist in improving his or her effectiveness as a vital member of the foot care team.</p> <p><b>References:</b></p> <ol> <li>Baxter, Donald E., "The Evaluation and Treatment of Forefoot Problems in the Athlete" (Unpublished manuscript).</li> <li>Baxter, Donald E. and C. Mark Thigpen, "Heel Pain-Operative Results," Foot &amp; Ankle, 5:1, 1984, pp. 16-25.</li> <li>Johnson, Kenneth, "Tibialis Posterior Tendon Rupture," <i>Clinical Orthopaedics &amp; Related Research</i>, 166, 1983, pp. 143-150.</li> <li>Mann, Roger A., "Biomechanical Approach to the Treatment of Foot Problems," <i>Foot &amp; Ankle</i>, 2:4, 1982, pp. 205-212.</li> <li>Mann, Roger A., "Metatarsalgia," <i>Postgraduate Medicine</i>, 75:5, 1984, pp. 150-167.</li> <li>Mann, Roger A. <i>Surgery of the Foot</i>, The C.V. Mosby Co., 1986.</li> </ol> <p><em><b>*Karen S. Seale, M.D. </b> Karen S. Seale, M.D. is assistant professor in the Department of Orthopedics, University of Arkansas Medical School Center<br /><br /><br /></em></p> Page Number(s) 44 - 50 Year 1988 Volume 12 Issue 2 Figure 1 FIGURE 1A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg FIGURE 1B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg Figure 2 FIGURE 2A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg FIGURE 2B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg Figure 3 FIGURE 3A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg FIGURE 3B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-6.jpg FIGURE 3C http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg FIGURE 3D http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Analysis of Foot Problems Creator An entity primarily responsible for making the resource Karen S. Seale, 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.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>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.</p> <h3>Theories of Psychological Adjustment</h3> <p>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.</p> <p>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.</p> <p>The third model, the "individual differences" theory, proposes that adjustment is primarily related to individual differences in patients' premorbid personalities.</p> <p>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.</p> <h3>Psychological Responses of Staff</h3> <p>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.</p> <h3>Head Injury in SCI</h3> <p>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></p> <p>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.</p> <h3>Psychological Treatment Approaches in the Rehabilitation Setting</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <h3>Psychological Response to Orthotic Devices</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>There are numerous reasons why SCI patients may resist orthotic devices, or are unsuccessful with them, including the following:</p> <p><i>Body image</i></p> <p>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.</p> <p><i>Independence-Dependence Conflicts</i></p> <p>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.</p> <p><i>Self-Concept</i></p> <p>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.</p> <p><i>Denial</i></p> <p>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.</p> <p><i>Premorbid Personality</i></p> <p>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.</p> <h3>Summary</h3> <p>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.</p> <p><b>References:</b></p> <ol> <li>Bond, M.R., "Neurobehavioral Sequelae of Closed Head Injury," in I. Grant and K.M. Adams (Eds.), <i>Neuropsychological Assessment of Neuropsychiatric Disorders</i>, 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," <i>Archives of Physical Medicine and Rehabilitation</i>, 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., <i>Insight and Responsibility</i>, 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, <i>On Death and Dying</i>, New York: MacMillan Publishing Company, Inc., 1969.</li> <li>Lindenmann, Erick, "Symptomatology and Management of Acute Grief," <i>American Journal of Psychiatry</i>, 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," <i>Journal of Head Trauma Rehabilitation</i>, 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," <i>Archives of Physical Medicine and Rehabilitation</i>, 61, 1980, pp. 225-229.</li> <li>Taylor, G.P., and R.W. Persons, "Behavior Modification Techniques in a Physical Medicine and Rehabilitation Center," <i>The Journal of Psychology</i>, 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," <i>Archives of Physical Medicine and Rehabilitation</i>, 66, 1985, pp. 227-231.</li> </ol> <em><b>*Katharine S. Westie, Ph.D. </b> 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.<br /><br /><br /></em> 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/3736a23e738166381c6803e355cc30aa.pdf cb532dab7ed020184153028bdd91a2d2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_02_003.pdf Text Any textual data included in the document <h2>The Role of Orthoses in the Care of Knee Ligament Injuries</h2> <h5>Kenneth E. DeHaven, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The role of braces in the management of knee ligament injuries, particularly in high risk athletics, continues to receive a great deal of attention. There are a multitude of braces currently being manufactured and marketed with various claims relating to the effectiveness, comfort, durability, and cost.</p> <p>Two key questions remain for most clinicians: (1) Should knee braces be used at all?, and (2) If so, what type of brace should be used and under what circumstances? At present there is a paucity of scientific data available to answer either of these questions with certainty, but there are encouraging signs that this essential information will be forthcoming from current and future research. Until an adequate scientific basis has been established it is necessary to develop a philosophy about bracing in athletics that is consistent with the data that is available and our clinical observations.</p> <h3>Should braces be used at all?</h3> <p>There is frequently an ego problem for both the athlete (who views a brace as a sign of weakness) and the physician (concern that a brace reflects less than optimal results) who delight in the statement "Doc, I don't need that brace—I can run and cut without it." Definitive treatment, whether rehabilitation or surgery followed by rehabilitation, must provide the functional stability, and it is rare in my experience that an unstable knee is made stable simply by applying a brace. However, no matter how good it might feel to the athlete, a knee that has previously sustained major ligament injury is not normal, and in fact has suffered ligament disruption at a time when it was normal. The role of bracing, therefore, is not to provide stability but to help prevent reinjury by keeping the knee from going into extreme positions when subjected to sudden stress. When presented in this light, the concept of protective bracing after major ligament injury to the knee is more reasonable and more acceptable to both the athlete and the physician.</p> <h3>What type of brace should be used and under what circumstances?</h3> <p>While not definitively established, it appears that the beneficial effects of knee orthoses are related not only to their mechanical strength but also to providing increased proprioceptive input from the knee area (which can explain how some patients feel more stable in braces that provide little or no mechanical support). Optimal support is provided by braces that protect against varus/valgus and hyperextension stresses and are utilized routinely in our Center following ligament repair or reconstruction of collateral and/or cruciate ligaments. The brace is initially worn for ambulation in the early postoperative period (two or four months) and later for agility, contact, or other types of "high risk" sports. Less sophisticated braces that provide just varus/valgus support usually are sufficient for athletes returning to similar sports in the same season following Grade II collateral ligament sprains. The practicality, efficacy, and cost effectiveness of prophylactic bracing to prevent injury in contact sports such as football is also a topic of great interest but remains unresolved at present.</p> <p>It is important to emphasize that this represents personal philosophy and recommendations based upon the information available at this time. It is recognized that while these concepts appear to be reasonable they are largely unproven, and there continues to be great need for more biomechanical and clinical research to firmly establish a scientific basis for knee bracing in athletics.</p> <em><b>*Kenneth E. DeHaven, M.D. </b> Professor of Orthopaedics, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, New York 14642.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1984 Volume 8 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Role of Orthoses in the Care of Knee Ligament Injuries Creator An entity primarily responsible for making the resource Kenneth E. DeHaven, M.D. * https://staging.drfop.org/files/original/0fd16e6b909f7130aea2a750ca50a40a.pdf 853cb1beca60fbae264611089e78bb36 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_005.pdf Text Any textual data included in the document <h2>A Need for Information</h2> <h5>Kent Smith&nbsp;</h5> <p>April 6, 1971. My wife and I were eagerly anticipating the birth of our second child. I accompanied her to the hospital in suburban Chicago. It had been a normal pregnancy, much like the pregnancy two years earlier when our daughter was born. Shortly after midnight the joyous moment arrived. The doctor came to the father's waiting room; he was not smiling. Our son was born with a birth defect known as spina bifida. As we look back on that moment, we've realized how much the birth of our son Stephen has affected our lives.</p> <p>As a news writer/producer for a major television station in Chicago, I had access to a great deal of information. I had been trained to ask the right question, investigate the story thoroughly, and report both sides equally.</p> <p>My wife had received her education in library science and enjoyed the research involved in establishing a library and developing good reference systems. Nowhere in our professional experience had either of us come across information on the birth defect spina bifida, nor were we to realize how difficult it would be to get the information that should be so readily available to new parents of a spina bifida child.</p> <p>Parents find themselves very vulnerable after having given birth to a child with spina bifida. The hospital and medical staff appeared intimidating. We knew little about birth defects in general and nothing about our own child's specific needs. We looked to the "experts" whom we hoped would help.</p> <p>Our first attempt to get information was through the local chapter of the March of Dimes. Their personnel were courteous, sympathetic to our needs, but could not answer specific questions on how other families were coping with a child with spina bifida. We tried to gain understanding on a variety of terms. How did it affect our Stephen? Were we unique with this problem? What was the outlook for our son's future? Those questions went unanswered, although we did receive some pages copied directly from a well-known book on birth defects.</p> <p>Good friends stood by us trying to provide a sympathetic ear. They couldn't answer questions, but wanted to do the best for our family, even encouraging us to look at places where our child could be placed and be raised in a loving atmosphere; then we could go on with our own lives. This only frustrated us, for we wanted to help our son, who—by some quirk of fate—had problems that we knew were serious but we didn't understand. He was part of our family and we wanted to provide him with the best medical care available.</p> <p>As parents, we had to depend on others for guidance. The most obvious person to turn to is the family physician. Clearly, new parents of a disabled child need information on the disability and its treatment, as well as the names of agencies and support groups available to assist the family unit. Other parents who have faced the same situation can share their knowledge and give comfort and assistance.</p> <p>My wife and I were steered to a support group of parents and adults with spina bifida. This group met every month at the hospital. Our physician had been working with this parent group. Although he could not share the parental experience of raising a handicapped child, he respected the support that was freely given by parents "sharing their experiences." From our point of view, it was the best medicine that he could provide. It gave us hope that our son might make advances similar to other children.</p> <p>Information is the key to knowledgeable parents raising their children with spina bifida. My wife and I became active in this parent support group to learn more about the birth defect. From those adults with spina bifida we learned some problems they had faced and how we could help our son.</p> <p>Our involvement with a national organization wasn't something we planned, it evolved. In 1979, I was asked to establish a central office to provide information to new parents and be a resource to chapters consisting of parents, adults, and professionals in many cities. Under a letter of agreement with my employer, the American Broadcasting Company, I took a year's leave of absence to establish the office. I've never gone back to ABC.</p> <p>The leadership of Spina Bifida Association of America (SBAA) comes from the active participation of adults with spina bifida and parents working together. When SBAA was formed as a volunteer group in 1972, the greatest need was to provide printed information written in lay language. Today, the Association has 11 booklets directed to educators, new parents, adults with spina bifida, and to children. As a journalist, I was able to work with the writers in developing a distribution system that now has over 50,000 pieces of literature circulated each year.</p> <p>One concern we have is the misinformation that others continue to tell new parents regarding the current treatment or the lack of potential of people born with the birth defect today. In 1979, the SBAA established a policy that encourages early evaluation and medical/surgical treatment of every infant with spina bifida, and recommends that the evaluation be performed by professionals experienced in that care and treatment.</p> <p>Improved medical treatment within the last 25 years minimizes the disabling effects of spina bifida. Recent statistics from major treatment centers in New York, Pittsburgh, Chicago, Seattle, and elsewhere indicate that approximately 90 percent of those infants born today with spina bifida can lead a competitive life with some adjustments for physical disabilities.</p> <p>The majority of infants who receive aggressive treatment early do not suffer mental retardation. Lack of bowel and bladder control can be dealt with and should not take the "opportunity for life" away from the child. Some amount of paralysis often occurs, but the degree of involvement varies widely and cannot be determined at birth.</p> <p>The SBAA also sponsors an Adoption Referral program which offers a viable alternative to parents who feel unprepared to raise a child with a disability. The program has placed 70 babies in loving homes and has a waiting list of parents willing to take infants with spina bifida.</p> <p>During these last five years I have met hundreds of parents with similar stories, all with a commitment to provide information to a new parent who, like each of us, needed someone or some group to answer questions. The adults with spina bifida hold challenging jobs, and in general make worthwhile contributions to society. They have devised innovative ways in which to overcome their disabilities. Each represents a realistic goal which our child born with this birth defect can hope to achieve.</p> <p>If you would like further information on Spina Bifida and our Association, please call 1-800-621-3141.</p> Page Number(s) 5 - 6 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Need for Information Creator An entity primarily responsible for making the resource Kent Smith  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.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>This paper was presented for the American Academy of Orthotists and Prosthetists Annual Meeting and Scientific Seminar, San Francisco, January 30-February 1, 1985.</i></p> <h3>Swedish Cat/Cam History</h3> <p>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.</p> <p>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.</p> <h3>The Ispo World Congress In London</h3> <p>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.</p> <h3>Swedish Attempts</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p><b><a href="/files/original/3035cab4876d5e39dab2d7edc8f4280b.jpg">Fig. 1</a>: College of Health and Care Jönköping, Sweden</b></p> <p><b><a href="/files/original/317321434223dd65228f625d548145c2.jpg">Fig. 2</a>: Relevant Laboratory Resources for CAD/CAM<br /><br /></b><b><a href="/files/original/0d927e9043f66bd3e3af11041dbd3773.jpg">Fig. 3</a>: Criteria on CAD/CAM in Prosthetics and Orthotics<br /></b></p> <h3>Competence And Educational Considerations</h3> <p>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.</p> <p>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.</p> <p>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.</p> <h3>Cad/Cam Philosophy Of The Biomechanics Laboratory</h3> <p>The philosophy of CAD/CAM in prosthetics and orthotics at the college and at the Biomechanics Laboratory can be expressed by the following criteria:</p> <strong><a href="/files/original/0aec22109bbbab540a2b674c0f7b5c6d.jpg">Fig. 4:</a> The Principal Parts of the CAPOD System</strong><br /><br /><strong><a href="/files/original/c4eabe665ad4dd8ea652e3ce8c3d13c2.jpg">Fig. 5:</a> Specification of the Measuring Equipment</strong><br /><br /><strong><a href="/files/original/ecbbc4f77a47d1d78ba3db33d9c2c0bd.jpg">Fig 6:</a> Computer</strong><br /> <ol> <li> <p><i>The complete system should be available for each prosthetic and orthotic service shop.</i></p> <p>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.</p> </li> <li> <p><i>The system should require moderate investment.</i></p> <p>This criterion is only a consequence of the first criterion.</p> </li> <li> <p><i>Equipment of a very high specification (able to work to extremely close tolerances) should be avoided.</i></p> <p>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.</p> </li> <li> <p><i>Individual 3-D shape sensing should be the basis for control of the numerically controlled (NC) milling machine.</i></p> <p>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.</p> </li> </ol> <h3>Objectives Of The Capod System</h3> <p>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:</p> <ul> <li> <p>To develop a CAD/CAM-system for prosthetics and orthotics as one complete unit based on a micro computer.</p> </li> <li> <p>The cost of the system should remain within the range of US$30-40,000.</p> </li> <li> <p>To allow commercially available video image processing equipment to be adapted for 3-D shape sensing.</p> </li> <li> <p>To encourage the development of a specially designed NC milling machine, costing less than US$12,000.</p> </li> </ul> <p><b><a href="/files/original/a0c06126276a088136acdb56cfd72933.jpg">Fig. 7:</a> NC-Milling machine for CAPOD System<br /><br /></b><b><a href="/files/original/9b71e91d2b0275c07dda585373e86535.jpg">Fig. 8:</a> Principal Parts and Cost of the NC Milling Machine</b></p> <h3>Technical Specifications And Project Status</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <em><b>*Kurt E.T. Oberg, M.D. </b> Dr. Oberg is Director of the Biomechanics Laboratory Jönköping City Council, Munksjöskolan, Box 1030-S-551, Jönköping, Sweden.<br /><br /><br /></em> Page Number(s) 19 - 23 Year 1985 Volume 9 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-8.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Swedish Attempts in Using CAD/CAM Principles for Prosthetics and Orthotics Creator An entity primarily responsible for making the resource Kurt E.T. Oberg, M.D. *