11 20 371 https://staging.drfop.org/files/original/5482be4ae060a01e68f831179c03541a.pdf c4183c71a23a893c1ee48207ff643511 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_01_005.pdf Text Any textual data included in the document <h2>Editorial: Orthotics For Spinal Deformity - 1980 View</h2> <h5>Robert B. Winter, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Thirty-three years ago the Milwaukee brace made its first appearance, originally designed as a postoperative immobilizing and corrective device. Soon thereafter, it began to be used as a non-operative treatment method for both scoliosis and kyphosis. Between 1950 and 1970, the brace was gradually improved and the system of non-operative treatment became more refined, with more knowledge of the indications and contraindications.</p> <p>In Europe in the 1960's and in North America in the 1970's, a wave of new braces appeared, all attempting to control spinal curvatures without surgery. The corset Lyonnaise, the Riviera brace, the Pasadena brace, and finally the Boston brace and the Wilmington jacket were all basically "underarm" orthoses, although most could be extended up to a neck ring for special circumstances.</p> <p>The "underarm" orthoses were, of course, more aesthetically&nbsp;pleasing to the child, but there was considerable controversy as to whether they could achieve the same quality of curve control as was achieved by the Milwaukee brace.</p> <p>About this time, i.e. 1975, relatively long-term studies of the Milwaukee brace experience began to appear, not just what the curve was at the time of brace stoppage, but what was happening to those curves five and ten years later. It became increasingly apparent that there was a wide spectrum of brace results, even when ideal circumstances of brace manufacture, curve selection, and patient cooperation existed. The average result was a curve the same at the end as at the beginning.</p> <p>Why then use an orthosis if there is to be no correction? The answer is obvious: to prevent progression. We have learned through experience that orthoses are not designed to make large curves permanently into small curves. Orthoses <em>are</em> designed to keep small curves small.</p> <p>Should all small curves, therefore, be braced? The answer is "no," since many small curves are nonprogressive and do not need treatment of any kind. An 18° thoracic idiopathic scoliosis in a pre-menstrual 13 year-old girl has a 63 percent chance of being nonprogressive without treatment and a 4 percent chance of spontaneously improving without treatment. There is only a 33 percent chance of her curve progressing, and therefore she needs treatment only if progression is well-documented.</p> <p>What kind of a brace is best? It depends on multiple factors as to which brace is best for which patient. All too often, proponents of a particular design will claim that their design is best and will solve all problems. As in all phases of medicine, there is a spectrum of diseases and a spectrum of solutions. The pendulum of enthusiasm swings first one way (the Milwaukee brace only), and then the other (underarm orthoses only), and finally settles in the middle.</p> <p>The current "middle ground" of orthotic management is best expressed by that sophisticated program in which the orthotist and orthopaedic surgeon work together to design an orthosis for the specific child's curvature problem. For a lumbar or thoracolumbar curve, they will use an orthosis that exerts correctional and stabilizing forces on the curve, but does not extend up to the neck, i.e., some type of underarm orthosis. If there is a decompensation problem, a trochanteric extension will be employed.</p> <p>If the curvature is in the thoracic spine, i.e., the apex is at T7, an orthosis is needed which will give a maximal effect at that area. The best orthosis is still the Milwaukee brace, regardless of whether the curve problem is a kyphosis or a scoliosis.</p> <p>Why is a Milwaukee brace best for such thoracic curves? It is best because it is designed to apply its forces in that area without negative effects on other areas. Those who suggest that an underarm orthosis can achieve the same result are looking only at the roentgenogram, not at the patient. It is of no benefit to create a "good looking" roentgenogram, if at the same time the patient has decreased lung function, permanent alteration of rib cage dimensions, skin sores, digestion problems, or any of the other secondary effects which improper bracing can create.</p> <p>In summary, we have reached a point of professional advancement in which children with progressive curvatures are being detected early enough to permit non-operative control (not "correction") by orthoses. We are sophisticated enough not to overtreat small curves, nor to attempt to orthotically treat curves needing surgery. We now have a wide selection of orthotic devices from which to choose for the individual patient and her or his specific curve problem. We must stop looking just at an anteroposterior roentgenogram and begin to look at the patient as a three dimensional individual. Finally, we must recognize defeat - sometimes the orthosis just doesn't work and the patient needs surgery.</p> <em><strong><b>*Robert B. Winter, M.D. </b></strong>Professor of Orthopedic Surgery University of Minnesota</em><br /> <div style="width: 400px;"></div> Page Number(s) 5 - 5 Year 1981 Volume 5 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Orthotics For Spinal Deformity - 1980 View Creator An entity primarily responsible for making the resource Robert B. Winter, M.D. * https://staging.drfop.org/files/original/3737624fef3a56640de26ee5e3002198.pdf 15dcba40ce0ee64a88813bdb9436da11 https://staging.drfop.org/files/original/90b09bc05fe9f54eac7fb5d364a84b1c.jpeg bf517f01325ef5bfd382d9f9221d3ade https://staging.drfop.org/files/original/f21dd604b9586a00f2668ad4a7c12771.jpg 6fb57a7aca27799becfcbf804eeb70ed Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_01_006.pdf Text Any textual data included in the document <h2>Cross-Diagonal Closure Of Pelvic And Spinal Appliances</h2> <h5>Louis Ekus, CO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The pelvic region with its numerous bony prominences, subcutaneous structures, and varied contours, has long been a useful site for the stabilization of many different orthoses and prostheses. The Milwaukee orthosis, body jackets, prostheses for hemipelvectomy and hip disarticulation amputees, to name a few, often maintain high internal forces as components of complex three-point pressure systems. Due to the nature of these devices, the internal forces are often quite different on the patient's opposing sides. Most practitioners are already aware that when the differences in the forces from right to left sides becomes large enough, relative motion of the two sides of the appliance becomes a difficult problem. This motion, in the superior or inferior direction in the frontal plane, causes skin breakdown, irritations, torsional stress on the devices and, thus, provides less than optimal function. In hip disarticulation and hemipelvectomy prostheses, "pumping" can be attributed to a great extent to the lack of the closures to maintain effective apposition of the two sides of the socket. The cross-diagonal closure is one way of dealing with this undesirable movement effectively.</p> <p>When the attachment points of closure straps are placed horizontally across from one another, as in conventional practice, the long axis of the straps is perpendicular to the direction of the relative movement between the two sides. A large amount of this motion can then occur with little increase in the distance between these points. This fact, in addition to the high degree of compression and migration of the tissue in the pelvic region, contributes greatly to the problem. In this case, the unwanted action can take place due to a lack of increased tension on the closure straps at the onset of the motion. However, if the points are placed so that the long axis of the straps will <i>not</i> be perpendicular to the direction of movement, the distance change between these points per unit of motion is much greater.<a style="text-decoration: none;">*</a> This will cause a rapidly increasing tension on the straps, hence restricting additional movement.</p> <p>Each strap in the cross will restrict translation in one direction; motion in the other direction will bring the attachment points closer together, and the strap will loosen. Application of the cross introduces a strap for the limitation of motion in both directions (<a href="/files/original/90b09bc05fe9f54eac7fb5d364a84b1c.jpeg"><b>Fig. 1</b></a>).</p> <p>When applied to prostheses, a visible difference in the amount of relative motion possible could be noted between the conventional closure and the cross-diagonal closure (<a href="/files/original/f21dd604b9586a00f2668ad4a7c12771.jpg"><b>Fig. 2</b></a>). The appliances with the crossed type were no more difficult to don and doff than the corresponding conventional types. This closure is presented here because of the similarities in the pelvic sections of both prostheses and orthoses along with the similarities in the problems that accompany each. The cross-diagonal closure may be utilized as an important new method of optimizing increased effectiveness and patient comfort.</p> <b>Footnote</b> This physical phenomenon is explained trigonometrically by the fact that the difference in the sine functions of a one degree (1°) change (0° to 1°) near the horizontal is much larger than the difference in the sine function of a one degree (1°) change near the vertical (89° to 90°).<br /> <div style="width: 400px;"><br /><em><b>*Louis Ekus, CO </b> Currently medical student at the School of Medicine, Universidad del Noreste, Tampico, Mexico; formerly a staff orthotist, Institute of Rehabilitation Medicine, New York University Medical Center.</em></div> <div style="width: 400px;"><br /><br /></div> Page Number(s) 6 - 6 Year 1981 Volume 5 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1981_01_006/1981_01_006-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1981_01_006/1981_01_006-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Cross-Diagonal Closure Of Pelvic And Spinal Appliances Creator An entity primarily responsible for making the resource Louis Ekus, CO * https://staging.drfop.org/files/original/971d394bd3cab6b56131702cf9304cfc.pdf f2823830773aab477c31ef87b7ef4503 https://staging.drfop.org/files/original/19d63adbf4fba399327be2d43c975736.jpeg ddab110728e3ce26e0c64c15d5a8fee2 https://staging.drfop.org/files/original/5f71f091dd01239060dbc584eb8435a2.jpg 06f5cd1d15bf80197630f436ea40479a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_001.pdf Text Any textual data included in the document <h2>Prosthetic Sensory Feedback Lower Extremity</h2> <h5>Frank W. Clippinger, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />James H. McElhaney, Ph.D&nbsp;<a style="text-decoration: none;">*</a><br />Maret G. Maxwell, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />David W. Vaughn, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Grace Horton, R.P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Linda Bright, R.N.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This is a progress report of a Duke University research project involving sensory feedback from lower extremity amputation prostheses.</p> <p>It has been assumed for many years that replacement of sensory function in prosthetic limbs was a nearly impossible task. Developments in electronics have made possible small amplifier systems and usable transducers, but the basic difficulty remains that of getting the signals into the central nervous system in a fashion that is interpretable, comfortable, consistent, and convenient.</p> <p>The problem has not been ignored and the obvious routes-auditory signal, electrical stimulation of intact skin, mechanical stimulation, and developments leading to solving the skin barrier with compatible percutaneous materials have been explored.</p> <p>From 1969 to 1975, this laboratory developed the mechanism to produce sensation from upper limb prosthetic terminal devices. This system was built around the concept of proportional peripheral nerve stimulation by means of a surgically implanted, induction coupled radio receiver-pulse generator, driven by an external amplifier and transmitter that relayed frequency modulated signals, controlled by a strain gauge transducer in the terminal device.</p> <p>The conclusions from this study were:</p> <ol> <li> <p>The system is feasible and signals can be interpreted with reliability relative to the stimulating activity.</p> </li> <li> <p>The brain interprets the signal as coming from the normal peripheral distribution of the nerve stimulated.</p> </li> <li> <p>Signal threshold and nerve excitability does not deteriorate with time, at least in this application.</p> </li> <li> <p>The implanted device is reliable, and durable, there having been no implant failures in twelve years.</p> </li> </ol> <p>In 1975, a grant was received from the National Cancer Institute to apply this technique to the lower limb amputee. This study is to determine whether sensory feedback, in addition to that provided normally from the stump-socket interface and terminal knee impact, useful or advantageous.</p> <p>To date, 21 patients have been fitted with a lower extremity sensory feedback system, including below knee, above knee, and hip disarticulation amputees. The majority of these have been cancer patients.</p> <p>The new amputee from malignancy presents a special problem. It is difficult to subject a person recently amputated for cancer to another surgical procedure to insert a stimulator implant. In addition, the amputation is followed by months of chemotherapy during which time wound healing is compromised and the patient does not feel well. Emotional factors must be considered also.</p> <p>For this reason, it was necessary to develop a noninvasive system as well as the implanted nerve stimulator. After a brief unsuccessful trial with a skin vibrator, the auditory route was selected.</p> <p>The electronic systems of both the implanted and auditory devices are similar. The system consists of a set of strain gauges which measure anteroposterior and mediolateral bending moments incorporated into the below knee segment of the prosthesis utilizing an endoskeletal unit developed by the Department of Bioengineering at Duke, hybridized with Ottobock endoskeletal prosthetic components.</p> <p>In addition to the strain gauges, a pressure activated piezo-electric crystal is imbedded in the heel of a SACH foot. This is activated on heel strike.</p> <p>When the weight is balanced in mid stance or when the prosthesis is unloaded, as with the patient sitting, there is no signal produced by any of the transducers. The system is designed to provide proportional feedback as soon as weight is biased in any direction.<br /><br /><a href="/files/original/19d63adbf4fba399327be2d43c975736.jpeg"><strong>Figure</strong></a></p> <p>For the implant system, the signal to the nerve is frequency-modulated with the frequency of stimulus increasing from 0 to 90 Hertz proportionate to the load. With frequencies greater than 90 Hertz, a decrease in signal or complete loss of signal has been experienced routinely. Voltage is adjusted to a level that is comfortable for the patient. Threshold in these patients has varied between .5 and .9 volts.</p> <p>The implanted receiver is identical to that used in the upper limb project except that four electrodes are placed around the sciatic nerve in the buttock rather than the two that were used for the median nerve in the upper limb project. The receiver is placed subcutaneously in the lower abdominal wall and the antenna is taped to the overlying skin. Only two electrodes are stimulated and the pair which produces the best response is selected. Electrode orientation is important and this is a compromise. The alternative would be to do the surgery with the patient awake which has obvious disadvantages.</p> <p>In all patients, an interpretable signal was produced although the mental imaging, which was 90 percent correct in the upper limb, has been haphazard in the lower. No patient has reported that the stimulus or the mental image produced was uncomfortable, unpleasant, or confusing, however.</p> <p>The auditory system uses the same external transducer unit, but the signal is fed to a hearing aid earpiece placed behind the ear without blocking the external auditory canal.</p> <p>In that the end result of any sensory feedback is a subjective response, it is difficult to determine its effect in scientific terms.</p> <p>A gait laboratory has been developed to analyze walking with and without the sensory feedback system. This provides computer-assisted analysis of force plate and segmental accelerometer data. This facet of the study has just started and at the moment, insufficient data analysis is available to be meaningful.</p> <p>It is felt, however, that the subjective individual patient response will actually be more helpful in the long run. This is "quality of life" response and is voiced as statements like: "I can walk out in the driveway at night without worrying", "I feel better about going downstairs", "I can play basketball better with it turned on", "I can control the accelerator on my car far better".</p> <p>Not all the subjects have found the system useful. <b>Table I</b> outlines the patients who have had the sensory feedback systems and their outcome. Most of those who have abandoned it, however, have had the auditory unit.<br /><br /><strong>Table I</strong></p> <img src="/files/original/5f71f091dd01239060dbc584eb8435a2.jpg" h3="" />Conclusions <ol> <li> <p>Sensory feedback systems in lower extremity amputees appear to have advantages. How much better the amputees are is still under investigation and whether the system is cost effective is still not determined.</p> </li> <li> <p>The auditory system is somewhat confusing and cumbersome. It may end up being a good training apparatus but not appropriate for long term use.</p> </li> <li> <p>The electronics package in the below knee segment of the prosthesis presents some problems related to the cosmetic cover which has to allow frequent access for adjustment and battery changes. An attempt is underway at present to replace the instrumented pylon with an instrumented ankle bolt.</p> </li> <li> <p>Investigation is still needed to determine exactly what information is useful. Knee position, for instance, may be more useful information than the direction and magnitude of loading.</p> </li> </ol> <em><b>*Linda Bright, R.N. </b>Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><b><br /><em>*Grace Horton, R.P.T. </em></b><em> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*David W. Vaughn, C.P.O. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*Maret G. Maxwell, Ph.D. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*James H. McElhaney, Ph.D </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*Frank W. Clippinger, M.D. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em> Page Number(s) 1 - 3 Year 1981 Volume 5 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1981_03_001/1981_03_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1981_03_001/1981_03_001-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prosthetic Sensory Feedback Lower Extremity Creator An entity primarily responsible for making the resource Frank W. Clippinger, M.D. * James H. McElhaney, Ph.D * Maret G. Maxwell, Ph.D. * David W. Vaughn, C.P.O. * Grace Horton, R.P.T. * Linda Bright, R.N. * https://staging.drfop.org/files/original/fdb824053cd07dc56b8a0f9bb5710f77.pdf 040eee9523be02600597ae2e21998310 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_005.pdf Text Any textual data included in the document <h2>Editorial: Tightening The Loops On Sensory Feedback</h2> <h5>John Lyman, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Ma Bell's radio and TV ad theme, "reach out and touch someone", appeals to everyone. It represents contact with those sensitive, often sentimental, emotional connections we have with our environment and the people and things that we value. In real life, it is only one's voice and the feedback of the voices of our familiar compadres that makes situations comparable to the telephone company ad warm and real. We all know the experience. What makes it work?</p> <p>Many years of experience in the serious pursuit of possible answers to this question, and its broader implications concerning the role of sensory feedback in shaping human performance, have brought us only a few answers on which we can count. Mostly, we only know that the importance of sensory feedback varies greatly with specific situations, and that the role of the senses is very complex because of two-way filter interactions with the central nervous system. We do know quite a lot about the specifics of the sensory receptors themselves. It is, however, the manner in which the patterns of sensory stimuli provide information for processing by the spinal cord and higher levels that is clinically provocative.</p> <p>With specific reference to limb amputees, everyone agrees that to achieve functional unity with a prosthesis, there must be some form of awareness established by the wearer about the capabilities of the prosthesis. How reliably does it respond to the amputee's command? Does it react predictably to each familiar environmental situation so that the wearer has an accurate mental model of what to expect? Getting a wrong number does not reach out and touch the expected connection. After too many wrong numbers or too much noise in the connection, one tends to lose that warm feeling of predictable expectation. This appears to be the case in the matter of the state-of-the-art with sensory feedback in limb prosthetics.</p> <p>We have long known that the primary source of sensory feedback for limb prosthesis wearers was an "open loop" mental model of the space occupied by the prosthesis, its dynamic control features and pressure patterns on the stump-all modulated by visual, and sometimes auditory, information from both the prosthesis and its situational environment.</p> <p>To date, except for blind amputees where any feedback from the environment is helpful, we have not been able to definitively establish whether or not specialized sensors located on the prosthesis itself could effectively communicate signals to the wearer that would significantly enhance task performance. Experimental results have, for the most part, been marginal and frustrating, both scientifically and clinically.</p> <p>Despite many disappointments, especially in terms of immediately useable clinical benefits, our knowledge base has been substantially broadened, mostly concerning the scope and complexity of factors that realistically must be brought under control. For example, in the biological model of a limb, it is known that receptor density for cutaneous and kinesthetic senses (pressure, pain, thermal, etc.) may reach several hundred per square millimeter. These high receptor densities provide precise patterns of environmental information. They generate functionally important physiological and psychological adjustments of information flow rates. Refined movement may require highly defined sensory patterns to optimize the available muscle capability of the normal limb. The stability and continuity of these patterns is identified with the integrative function of the central nervous system. The distortion of the patterns by modification from disease, or by total physical destruction, requires laying down new cognitive adaptations. These adaptations can only reach a degree of approximation to the original system. The extent of the sensory side of the approximation is dependent on the capability for sensory input that remains or is replaced. Substitution of one pattern of signals for another depends on achieving a common coding scheme. Whatever scheme is achieved, it must be compatible at both the input and output sides of the person-prosthesis loop. Missing or distorted patterns are functionally reconstructed into new channels, both by means of the "software" of the brain, and substitution of sensors. When the sensations are natural, e.g., from the surface of a stump, the sensors available probably were not previously used for primary information about the location of and forces on the limb in space. New cognitive patterns must be brought into association. These new patterns may only provide part of the information previously presented, or the information provided may not be relevant. Thus, there may be a permanent substantial loss of skill.</p> <p>The original, natural, learning process in the intact person seems to make use of whatever sensory function is available to provide a pliable, plastic motor output capability. This is subject to refinement of precision according to criteria set genetically (e.g., walking), or learned according to environmental and personal, i.e., cognitive set standards for performance. "Normal" gait for a leg prosthesis wearer, "smooth," "coordinated" delivery of a fork full of food by an arm amputee, may have to come to mean something different, cognitively, than these actions for the non-amputee.</p> <p>For the amputee, complex situational vectors are set up by a combination of motor deficits and sensory deficits. This makes it especially difficult to independently assess the role of sensory feedback in task performance. For example, direct observations of the role of the senses is confounded by factors such as the transmission precision of the power train, by dynamic stability properties of the structural interface between the stump and the socket, and by task complexity, e.g., climbing stairs, rotating a door knob, etc. A simple analog would be to try to observe the role of sensory feedback in the performance of a non-amputee who was trying to write with a pencil that had the tip attached to a soft, compliant, rubber-like shaft. The capricious relationship between the tip of the pencil and the writer would make interpretation of the performance associate more closely with the hardware interface between the writer and his task than with the properties of the writer's sensory-motor system.</p> <p>To function with maximum effectiveness, the communications channels, as well as the energy (power) transfer channels, must be locked intimately and reliably together in both the relationship of time, e.g., minimum transmission time-lag, and geometric positions. It seems probable that sensory information, to be effective, must have a tight, reliable, one-to-one superposition with a tight, reliable motor output system.</p> <p>It is, thus, our view that perhaps a major reason for not being able to obtain clear-cut experimental results with artificial sensory feedback techniques for limb prostheses is that the linkages between the subsystem interfaces have usually been excessively "loose." The messages in both directions are garbled. As the requirement for task precision increases, the effects of loose communication links become increasingly evident. Softness of fit between the prosthesis and the flesh of the stump, for example, generates uncertain messages in both directions. The "reach out and touch" is a spongy approximation, a sensory haze at the cognitive level.</p> <p>The bad news is that in the prevailing situation, where direct bone attachments have not reached a level of development suitable for standard clinical practice, the tightening of sensory feedback loops and feed-forward loops seems to be inherently limited in promise. The good news is that with each year, the background research and technology is progressing to significantly more sophisticated levels, achieving denser, more accurate and less power-consuming transducer arrays for picking up the tactile features of the environment. As has often been the case before in the history of important prosthesis development, much of the technology for sensory augmentation is to be found in other applications, in this case, industrial automation and robotics. When, as will happen sooner or later, art and technology reach out and come together, the parts of the limb-prosthesis system will indeed, touch-with feeling.</p> <em><b>*John Lyman, Ph.D. </b> Professor and Chair, Engineering Systems Department Head, Biotechnology Laboratory, UCLA, Los Angeles, CA 90024</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 5 - 6 Year 1981 Volume 5 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Tightening The Loops On Sensory Feedback Creator An entity primarily responsible for making the resource John Lyman, Ph.D. * https://staging.drfop.org/files/original/eb7af921f4b32f8e97132e548f88898b.pdf b3171ca328eee50b5195df04b2d0c788 https://staging.drfop.org/files/original/8b668143ca8ff4ec00d38bdaca0e8295.jpeg 8099103e73990942586441d921a16c1c https://staging.drfop.org/files/original/3bb0ef66a8d97b487e2406e04dfe528a.jpg 657f28db4b18efbba8fdf19ced12aefc https://staging.drfop.org/files/original/c874cf9cf5f6cd93cbfd7caefebfdb17.jpg 3a422d3bde70187bd6eacbad0b5b61bd https://staging.drfop.org/files/original/8ae5ce0e382f544320be566569a2f206.jpg e3914b13228afa24f44648b12154099a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_007.pdf Text Any textual data included in the document <h2>Feedback For Electrically Powered Prostheses And Orthoses</h2> <h5>Warren Frisina, B.E. (in M.E.)&nbsp;<a style="text-decoration: none;">*</a><br />James A. Reeve, B.S. (in E.E.)&nbsp;<a style="text-decoration: none;">*</a></h5> <p style="font-size: 60%;"><i>All rights reserved © Warren Frisina 1981</i></p> <p><i>This research was supported by the National Institute of Handicapped Research under the designation of New York University Medical Center as a Research and Training Center.</i></p> <p>Basically, pressure feedback systems for upper limb electrically powered prostheses consist of sensors about the prehensile area, electronic processing circuits, and actuators that contact the body. Sensors require careful installation and tend to be vulnerable to damage. Processing circuits leave that much more delicate equipment to coordinate. Actuators sometimes unduly complicate construction and fitting.</p> <p>The system to be described here makes use of the characteristic current response of an electric motor encountering a load—current increases in proportion to the load. This response is directly employed as the combined feedback/actuating signal. It is sent to a miniature direct current electric motor⁴ (<a href="/files/original/8b668143ca8ff4ec00d38bdaca0e8295.jpeg"><b>Fig. 1</b></a>). The top of <b>Fig. 1</b> shows three Micromo motors and the bottom of the figure, the assembled unit. On the shaft of the motor an eccentric mass is mounted. (Several such masses are shown on the right of <b>Fig. 1</b>). This causes the motor to vibrate in proportion to the motor speed (motor speed is proportional to current). When this motor is rigidly mounted to virtually any portion of a prosthesis, the entire prosthesis will vibrate in turn (<a href="/files/original/3bb0ef66a8d97b487e2406e04dfe528a.jpg"><b>Fig. 2</b></a>). Thus, the entire surface of the skin in contact with the prosthesis receives feedback information. The units installed thus far in patients' below-elbow myoelectric prostheses have been fixed at the distal end of the socket with a hose clamp which has been laminated to the socket (<a href="/files/original/c874cf9cf5f6cd93cbfd7caefebfdb17.jpg"><b>Fig. 3</b></a>).</p> <p>The feedback motor can be installed in virtually any electrically powered prosthesis by putting it in series with the drive motor(s). So that most of the current flows to the drive motor(s) and to avoid overloading the small feedback motor, a resistor of approximately three ohms is placed in parallel with the feedback motor. In order to fine tune the system, it would be convenient to have this resistor be of the variable type.</p> <p>This system has been applied to myoelectric prostheses for seven patients at the Institute of Rehabilitation Medicine, New York University Medical Center. It is being applied explicitly for force feedback. But it appears to serve for position feedback as well, since the prosthetic hand unit and glove offer resistance to the drive motor as the hand opens, i.e., the greater the opening, the higher the vibration frequency. The hardness or, more importantly, brittleness, of objects could also possibly be determined by the sensing of rate of change of vibrations, i.e., vibration rate of change for a hard object like an egg is greater than that for a soft object like a paper cup. There have been no controlled studies as yet to verify these possible benefits.</p> <p>A variation of the principle has been applied in the laboratory to an electric arm orthosis tried by a C-4 lesion quadruplegic patient. The feedback motor is either clipped to the user's lapel (<a href="/files/original/8ae5ce0e382f544320be566569a2f206.jpg"><b>Fig. 4</b></a>) or to the back of his wheelchair.</p> <p>Another orthotic variation of the principle was tried in the laboratory by replacing the feedback motor with a flashlight-type light bulb to provide proportional visual feedback. Brightness of the bulb is proportional to pressure at the desensitized finger tips when used with an electrically-driven prehension orthosis.</p> <em><b>*James A. Reeve, B.S. (in E.E.) </b> Project Engineer, Orthotics &amp;Prosthetics, IRM, NYU Medical Center.</em><br /><br /><em><b>*Warren Frisina, B.E. (in M.E.) </b> Formerly Associate Research Scientist, Orthotics &amp;Prosthetics, Institute of Rehabilitation Medicine, NYU Medical Center</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 7 - 8 Year 1981 Volume 5 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-4.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 Feedback For Electrically Powered Prostheses And Orthoses Creator An entity primarily responsible for making the resource Warren Frisina, B.E. (in M.E.) * James A. Reeve, B.S. (in E.E.) * https://staging.drfop.org/files/original/9efbf424d1bfe2b5b84fe13f0d2fd516.pdf 0bcf1c41627ab178388a24b6e69db174 https://staging.drfop.org/files/original/9811319d59776c370a44ed906f991cfd.jpeg 00380d4a6a0059f69700b9ea0c517dc3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_04_001.pdf Text Any textual data included in the document <h2>Rehabilitation Engineering and Prosthetics/Orthotics</h2> <h5>Anthony Staros, MSME, PE&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The words "Rehabilitation Engineering" are now commonly used to mean a paramedical practice which in its job characteristics and their demands, in the basic technical background needed, in its high activity level, and in its human service slant, is an extrapolation of professional prosthetics and orthotics. Prosthetics and orthotics are in fact very significant components.</p> <p>Rehabilitation engineering is defined as that broad discipline having as its ultimate objective the <i>application</i> of technology to enhance life's quality for the disabled. It includes subsidiary goals in research, development and education. But one doesn't need to be an engineer to <i>practice</i> rehabilitation engineering!</p> <p>With the recent advances in technical aids, prosthetics and orthotics included, there has been increasing need for those who currently serve the disabled with technology to expand the range of their commitment requiring a persistent demand for more knowledge. At the same time, there are counterpressures:—the potentially harmful low rates of increase in the numbers of practitioners. Fewer people are trying to do more while also needing more information for what they do. The effects that Government budget restraints will produce in this situation are difficult to predict, but clearly seen is that the pressures will be greater, that there will be real need for increased efficiency in all parts of society and more so for us committed to the delivery of high quality service to the disabled: increased productivity and more knowledge are conjointly required.</p> <p>Much of what rehabilitation engineering means in real practice is the selection of devices, the making of special systems, or the design of environments, and then the delivery of these, customizing them even further when necessary, and applying them to assist the disabled. Demanded is the achievement of independence through function and/or access with both comfort and control maximized. Training of the client is essential. These efforts are effected in a precise and deliberate process with full understanding of the patterns of disability presented and a substantial awareness of the personal wishes of the disabled person being served (and his/her family).</p> <p>Rehabilitation engineering includes aids fitted directly to the client as in prosthetics and orthotics, tools such as communication devices, and adaptations to environment, to work sites, to the home, or to the vehicles used to reach one or the other or to those mobility devices operated within an environment. Some of the technical aids may be very simple in design; most of those which are custom-made require biomechanically sound, creative, and often inventive approaches. The simplest may require the most creativity.</p> <p>In the rehabilitation engineering applications process, in supporting the physician's role in prescription or in the selection of aids and then in their application, the knowledgeable and interested prosthetist, orthotist, and therapist (physical, occupational, speech) can play the key roles. Especially <i>productive</i> and <i>cost effective</i> is the involvement of the skilled technician, an essential member of the rehabilitation engineering team. The team concept is crucial in that the knowledge needed comes out of the sharing of training and experience—and the creativity sought can usually come from the synergism in the group, especially including the client. The actual "making" although involving all to various degrees becomes the special province of the technician, with the "fitting" itself being a product of the team. The required contribution to benefit the patient will be a scenario of analysis and synthesis, idea and response, search and research, give and take, and then plain work.</p> <p>That which is rehabilitation engineering has been performed for many years, before it became stylish to use this expression to represent a special technology. But there is now in place an acceleration in the development of new technology in products and processes, many so recent that they are not known to members of the rehabilitation team who received preparatory training or post-graduate courses years earlier. Even now the newer information needed is not obtained in structured formats. Pathways should be constructed for each member of the team to broaden his/her own discipline to include constantly updated knowledge about all technology necessary for his/her personal professional contribution to the rehabilitation engineering team. And not to be overlooked is that the payers for services need to be instructed on the cost benefits of rehabilitation engineering.</p> <p>We recommend that these professionals (the prosthetist, orthotist, and therapist) have their own societies' publications and conferences include the information about the advance in rehabilitation engineering. They should also participate in those societies which meld the team, the <i>Rehabilitation Engineering Society of North America</i> and the <i>International Society for Prosthetics and Orthotics</i>, thereby advancing the practice of rehabilitation engineering through contacts with the other team members. Special seminars need to be structured for the 3rd party payers.</p> <p>In the team, or even in the individual practices, the added knowledge about rehabilitation engineering aids can only benefit. If the prosthetist or orthotist fitting a patient with an <i>upper-limb</i> deficit relates his fitting in part to the vehicle controls the disabled person may need to use, shouldn't he or she be knowledgeable about such controls and their installation? Beyond that, shouldn't both (prosthesis or orthosis <i>and control</i>) be "installed" under such professional supervision? Yet still, in this decade of rapidly advancing technology and of certification of those who dispense it, ordinary automobile repair garages install hand controls for licensed vehicles for disabled drivers. Why not the orthotist or prosthetist overseeing his/her technician?</p> <p>There are often frustrating limits to the mobility which can be provided in lower limb orthotic or prosthetic care. Under what circumstances does one use a wheelchair as a supplement or as a last resort? How is it selected? In what way should it be modified if at all? What kind of buttock and trunk support are required? Here the prosthetist, the orthotist, and the therapist should be involved for aren't these the professionals who can be and should be closely associated with wheelchair prescription and modification? In a national workshop held in 1978, WHEELCHAIR I,<a style="text-decoration: none;">*</a> mention was repeatedly made about the need for a "wheelchairist", a person to be concerned exclusively with wheelchair prescription and fitting. If prosthetists, orthotists, and therapists are indeed responsible for other aids for mobility, why not then the wheelchair? Isn't a functioning rehabilitation engineering team the "wheelchairist" sought?</p> <p>From the clinic team setting or from the counselor's desk, the usual site for the final selection and customization of technical aids and then their application is not unlike a prosthetics/orthotics laboratory, there blessed with talented technician support. In a recent paper,<a style="text-decoration: none;">*</a> we recommended that the prosthetics/orthotics profession develop the practice of rehabilitation engineering:</p> <p>"Recommended is that prosthetics and orthotics, with their foundation in clinical technology, constitute the basis for the establishment and certification of a broadly based rehabilitation engineering capability in the United States. Indeed, it would be well for prosthetists and orthotists to start expanding their scope to include the other technical aids in rehabilitation engineering and in collaboration with other members of the rehabilitation team, especially the orthopedic surgeon, provide the means for a wider coverage in the delivery of technology to restore independence and function to many handicapped individuals who are not now receiving the full, broad spectrum services they deserve."</p> <p><a href="/files/original/9811319d59776c370a44ed906f991cfd.jpeg"><b>Figure 1</b></a></p> <p>Is there then really need for the engineer, the graduate of a formal engineering curriculum to be the <i>applier</i>, the "clinical" practitioner of rehabilitation engineering? The rehabilitation <i>engineer</i> has a role: in design, development, research, and perhaps in management. The prosthetist, orthotist and therapist especially with technician support, as a team and as individuals can and should respond to the total technical needs of the patients presented to them; rehabilitation engineers should identify with the other (consulting) members of the medical-technical professional structure in the overall rehabilitation effort. To be called on only in the case of <i>special</i>, more complex problems, the engineer should be mostly involved in leading generalized design and development efforts, these to include others of the team as well.</p> <p>Total need, as the prosthetist, orthotist, and therapist well know, includes "tender loving care," this in the past demonstrated by the experiences of these professionals in analyzing then defining the problems of the disabled. For patients with the severer disabilities, those requiring broader rehabilitation engineering efforts, good practice requires more of such empathic yet deliberate reasoning to seek solutions: devices which yield function in a real sense and are more than just tolerated, used for their novelty, or accepted to please someone else. Seating, wheelchair designs, licensed vehicle modifications, electrical stimulation for pain relief or function, and home and job modifications are all parts of an armamentarium which spans the spectrum from modifications to the shoe to those to the motorcar, for mobility; from a mouth stick to a robotic system, for independent "prehensile" function; from a simple word-display board to synthetic speech, for communciation.</p> <p>Then, do we really need to cultivate large numbers of graduate engineers for rehabilitation engineering practices (other than for the employment of some smaller number in research and development)? Yes, if the prosthetist/ orthotist does not accept the alternative recommended: proper management of his/her practice integrating it with those of other team members and with the very significant role of their skilled technicians who become key constituents in that practice.</p> <p>Apparently some prosthetists and orthotists see an expanding future. The excellent document describing the professions of prosthetics and orthotics and recently published by the American Academy of Orthotists and Prosthetists<a style="text-decoration: none;">*</a> refers to the directions being taken by its professions, based for now on "bionics" referring specifically to automatic control of knee function and myoelectric control of powered upper-limb prostheses. These are presented as steps toward encompassing more and more technology, components of a rehabilitation engineering commitment. In fact the logo of this publication (shown here) presents the transition from orthotics and prosthetics to rehabilitation engineering over a natural pathway (or track) for growth.</p> <p>The essential initiatives now have to come from the current practitioners. In fact they could also abdicate their "clinical" role to the rehabilitation engineering equipment dealers!</p> <b>Footnote</b>The Academy brochure can be ordered from the National Office for $1.25 each.<b><br /><br />Footnote</b> Staros, A. and G. Rubin, The Orthopedic Surgeon and Rehabilitation Engineering in Orthopedics, March/April 1978, Volume 1/Number 2, Charles B. Slack, Inc., Thorofare, N.J.<br /><br /><b>Footnote</b> Moss Rehabilitation Hospital (REC) Wheelchair I; Report of a Workshop sponsored by RSA and VAPC, Dec. 6-8, 1977, Philadelphia, Pa.<br /><br /><em><b>*Anthony Staros, MSME, PE </b> Director, VA Rehabilitation Engineering Center New York, N.Y.</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 1 - 3 Year 1981 Volume 5 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1981_04_001/1981_04_001-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Rehabilitation Engineering and Prosthetics/Orthotics Creator An entity primarily responsible for making the resource Anthony Staros, MSME, PE * https://staging.drfop.org/files/original/ae05e878bd64c3dbd3b2584c3a8af1c3.pdf 908af03ad8cb34c07750c64b92d97c44 https://staging.drfop.org/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg edfa643666b367de3ccf1505947074ee https://staging.drfop.org/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg 673473bd1e41e590c4e9c60e9599e2fc https://staging.drfop.org/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg 682e526dd8cd44af055581f51d3543b0 https://staging.drfop.org/files/original/29254ec4552c6b302e11d7249167147b.jpg 5872069631752d0d3d9eb1f39bd37b76 https://staging.drfop.org/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg fc1c45950fcf019e826c6035112ac38e https://staging.drfop.org/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg f72d46285c6e66bf702f8dc9c651e66b https://staging.drfop.org/files/original/51d4491374c4e678089f6cdf6c27afae.jpg f51626e0ef82b0a4dfb1ee8ab4693ced https://staging.drfop.org/files/original/822789265194f5be4e60727bb55d3108.jpg 4499acf3c75535c673217cfa36745c01 https://staging.drfop.org/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg e67daa763e1a8051b264102cc6bd4c8b https://staging.drfop.org/files/original/df0e494105bf2580379ea0532148fd6e.jpeg 821ac6be13efc72dd02bf99301f354ec https://staging.drfop.org/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg efa1d6a37f55c3e4ec5ba5c6f99c1555 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_04_005.pdf Text Any textual data included in the document <h2>Knee Orthoses: Biomechanics</h2> <h5>Charles H. Pritham, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>Derived from a lecture given at the ISPO Lower Limb Orthotics Course, Dallas, Texas, March 9-13, 1981.</i></p> <p>Irrespective of etiology, deformities of the knee can be divided into three broad categories: angular (genu valgum, genu varum, genu recurvatum), rotary (internal, external rotation of the tibia relative to the femur), translatory (anterior/posterior subluxation of the tibia relative to the femur). They can be further categorized as either flexible (secondary to flaccid musculature and/or ligamentous and capsular laxity) or fixed (secondary to spastic musculature and/or ligamentous and capsular tightness). For a variety of reasons orthotics has traditionally devoted the majority of its attention to cases of angular deformity and coped with instances of rotary or translatory deformity only secondarily as they arise as complications of angular deformity. For that reason, then, the majority of discussion will focus on this aspect of the situation.</p> <p>Viewed in the frontal plane (the case is the same in the sagittal plane) with the body aligned so that the weightbearing line coincides exactly with the mechanical axis of the leg (<a href="/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg"><b>Fig. 1</b></a>), there is no tendency for the knee to bend into either genu valgum or genu varum. If the weightbearing line deviates to one side, a bending moment or torque is created (<a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg"><b>Fig. 2</b></a>) that causes a change in angle (angle of deformity, 0) of the femur relative to the tibia. The bending moment can be quantified by multiplying the deforming force (body weight, W) times the perpendicular distance (x) from the line of action to the center of rotation. As body weight is essentially constant, any increase in angle of deformity will lead to an increase in distance x and an increase in the deforming moment. In real life this tends to create a vicious circle since the deformity is resisted by the capsular and ligamentous elements on the opposite side of the knee. The stress is greatest on those elements farthest away from the center of rotation, as they are best positioned by virtue of their longer lever arm to oppose the deforming force. When the stress becomes intolerable, they yield, and the load falls on elements less strategically placed. As the angle of deformity increases, distance x increases, the deforming moment increases, and a compromised knee is jeopardized further. To correct this situation and prevent further damage, it is necessary to introduce a corrective moment and reduce the angle of deformity.</p> <strong><a href="/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg">Fig. 1</a>. Lower limb positioned so that weightbearing axis falls through the mechanical axis of the limb.</strong><br /><br /><strong><a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg">Fig. 2</a>. As the weightbearing axis deviates to one side a bending moment or torque is created</strong><br /> <p>This corrective moment is created by a three-point pressure system (<a href="/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg"><b>Fig. 3</b></a>). For the laws of equilibrium to be satisfied, the forces acting on each side of the structure must be equal, and the clockwise moments acting about the center of rotation must be equal to the counterclockwise moments. The farther forces H and A are from the center of rotation, the smaller they can be, due to increased lengths of their lever arms a and b. Force K can seldom be applied directly at the center of rotation (<a href="/files/original/29254ec4552c6b302e11d7249167147b.jpg"><b>Fig. 4</b></a>), as the anatomical structures vary in their ability to tolerate the pressure. It may very well prove necessary to locate force K some distance from the knee and apply it as two sub-elements, S and I. K would be equal to the sum of the two and vary in point of application according to their relative strength. As K moves away from the center of rotation (<a href="/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg"><b>Fig. 5</b></a>), it increases the bending moment acting in one direction or another, and if the laws of equilibrium are to be satisfied, the opposing moment will have to increase in magnitude, leading to an increase in total force on the limb. <a href="/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg"><b>Fig. 6</b></a> summarizes the discussion thus far. It should be noted that any orthosis fabricated to satisfy these conditions must be strong enough to do so without yielding or bending as the old pattern of the vicious circle (<a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg"><b>Fig. 2</b></a>) will assert itself. Yet another factor to be taken into account is the familiar relationship of pressure, force, and area (<a href="/files/original/51d4491374c4e678089f6cdf6c27afae.jpg"><b>Fig. 7</b>)</a>. The need to satisfy these conditions and thus reduce the total force exerted must be, of course, balanced with the desire not to encumber adjacent joints, and to keep the orthosis as cool and light as possible.</p> <strong><a href="/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg">Fig. 3.</a> Three-point pressure system acting about the knee.</strong><br /><br /><strong><a href="/files/original/29254ec4552c6b302e11d7249167147b.jpg">Fig. 4</a>. Force K acting as two sub-forces, S and I.</strong><br /><br /><strong><a href="/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg">Fig. 5.</a> As force K moves away from the knee the total force on the limb increases.</strong><br /><br /><strong><a href="/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg">Fig. 6.</a> A summarization of criteria necessary to minimize the force on the limb.</strong><br /><br /><strong><a href="/files/original/51d4491374c4e678089f6cdf6c27afae.jpg">Fig. 7.</a> The relationship of pressure to force and area.</strong><br /> <p>Another way to tackle the problem is to use a weightbearing brim (<a href="/files/original/822789265194f5be4e60727bb55d3108.jpg"><b>Fig. 8</b></a>). This, of course, reduces the deforming force and thus the deforming moment. What is not so apparent is that it might very well change the length of the lever arm x and reduce the bending moment. If some of the body weight is borne medially on an ischial seat, it would tend to shift the line of action of the body weight medial to its usual course through the head of the femur. This phenomenon is at work when a KAFO with a quadrilateral brim is used in cases of gluteus medium lurch. It might very well have implications in cases of genu varum and genu valgum. In the sagittal plane (<a href="/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg"><b>Fig. 9</b></a>), a similar situation is identified in the UCLA Functional Long Leg Brace<a></a>. Moving the line of action of the weight line anterior by virtue of the load on the Scarpa's Triangle, a knee extension moment is generated. Knee extension is further aided by the intimate fit of the quadrilaterial brim and a firm fit of the foot in the shoe which produces a distractive effect on the leg, straightening it, as would pulling on opposite ends of a rope.</p> <strong><a href="/files/original/822789265194f5be4e60727bb55d3108.jpg">Fig. 8.</a> Use of a weightbearing brim creates a proximally acting force, R, that counteracts weight, W.</strong><br /><br /><strong><a href="/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg">Fig. 9.</a> Forces applied to the higher anterior wall of a quadrilateral brim tend to move the weightbearing axis anterior to the head of the femur, and the knee center.</strong><br /> <p>Subluxation of the tibia (such as might occur due to the pull of the quadriceps secondarily to ligamentous laxity in cases of genu valgum in arthritis, a situation described by Smith, et al.<a></a>), can be corn-batted by separate force couples acting on the femur and the tibia (<a href="/files/original/df0e494105bf2580379ea0532148fd6e.jpeg"><b>Fig. 10</b></a>). This is a feature of the University of Michigan Arthritic Knee Brace.</p> <strong><a href="/files/original/df0e494105bf2580379ea0532148fd6e.jpeg">Fig. 10.</a> Use of force couples acting on the femur and tibia to prevent anterior subluxation of the tibia relative to the femur. The force system would be reversed in an instance of posterior subluxation. A system of force couples is subject to the same sort of analysis and criteria as a three-point pressure system.</strong><br /> <p>In the absence of direct action on the skeleton, control of rotation is more problematical. As the proximal portion of the shin is triangular, considerable rotational control can be achieved as in the PTB prosthesis, the spiral ankle-foot orthosis (AFO), and the hemi-spiral AFO. Purchase about the condyles of the femur and the patella can be achieved, but is compromised by the necessity for unencumbered knee flexion. It is, of course, possible to use a quadrilateral brim to gain a purchase on the proximal structures, but any prosthetist will be glad to regale his orthotist companion with tales or rotary instability in above-knee prostheses. The last alternative is a frictional coupling between the soft tissue and broad elastic straps as in the Lenox Hill Derotation Orthosis (<a href="/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg"><b>Fig. 11</b></a>). As considerable slack must be taken up in the soft tissues, 20 degrees of motion at the surface may result in only 10 degrees of motion of the femur about its axis. Moreover, the efficacy of even the best such measures is called into question considering the magnitude of the bending moment generated by the action of the center of gravity about the long axis of the leg and comparing it with the moments that can be induced about the same axis by the maximum tolerable force acting at the surface of the leg.</p> <strong><a href="/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg">Fig. 11.</a> Schematic cross-section of a limb, on the left, with the skin (outer circle) connected to the bone (middle circle) by soft tissue (radiating rippling lines) and acting about the center of rotation (innermost circle). The broad vertical line is for reference. As rotary forces (arrows) are applied, on the right, the force is transmitted from the skin to the bone by the soft tissue. As slack in the soft tissue must be taken up it becomes apparent that the bone moves less than the skin.</strong><br /> <p>In conclusion, some of the biomechanical factors involved in the function of knee orthoses are reviewed. Due consideration of these factors, the anatomical structures involved, and the intended purpose of the orthosis at the time of prescription should inevitably lead to a more functional orthosis.</p> <p><b>References:</b></p> <ol> <li><em>Final Report, Functional Long Leg Brace Research</em>. University of California, Los Angeles. Prosthetics/Orthotics Education Program, March 30, 1971.</li> <li>Edwin M. Smith, M.D., Robert C. Juvinall, M.S.M.E., Edward B. Correll, M.S.M.E., and Victor J. Nyboer, M.D., "Bracing the Unstable Arthritic Knee," <em>Archives of Physical Medicine and Rehabilitation</em>, Vol. 51, No. 1, Jan. 1970, pp. 22-28, and 36.</li> </ol> <div style="width: 400px;"><em><br />*<b>Charles H. Pritham, C.P.O. </b> Formerly Director, Prosthetics and Orthotics Laboratory, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia. Presently Branch Manager, Snell's of Louisville.</em></div> <div style="width: 400px;"><br /><br /></div> Page Number(s) 5 - 7 Year 1981 Volume 5 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-07.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/1981_04_005/1981_04_005-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Knee Orthoses: Biomechanics Creator An entity primarily responsible for making the resource Charles H. Pritham, C.P.O. * https://staging.drfop.org/files/original/2004b9922067489189c4d3ae92485e41.pdf b5adf4cefb2c7793eaa0d0c236efe080 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_001.pdf Year 1954 Volume 1 Issue 2 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/1954_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Limbs in Limbo</h2> <h5>Herbert Elftman, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>To stand on his feet and to walk with his legs wherever his heart desires are natural rights guaranteed to man by his own constitution. Heads may plan and hands may build, but only where legs and feet have brought them. Loss of the lower limb is therefore a major catastrophe.</p> <p>When loss of leg occurs, replacement becomes the primary hope. Ages past, an unknown man hobbled forth from his cave in search of a willow; with one of its limbs adopted as his own, he walked back with majesty. Since then the stage of history has resounded with the staccato echo of countless amputees marching with peg-leg, grit, and gumption.</p> <p>Rapid perfection of limb construction was to be anticipated after these early ventures had focused human ingenuity upon the problem. To the superlative talent which mankind has shown in the production of machinery both intricate and sturdy, the building of a mechanical leg would appear to offer little difficulty. Why is it, then, that artificial limbs have so generally belonged to the limbo of things undeserving either of unstinted praise or of utter condemnation? Failure of artificial legs to satisfy our hopes results less from the imperfection of their mechanisms than from the extravagance of our expectations. People who do not expect a glass eye to see or a prosthetic hand to play the piccolo are disappointed when an artificial leg squeaks while dancing the polka. Man has never commanded clear appreciation of his means of locomotion. From time to time he has been ecstatic about the eye and the liver, the heart, the brain, the hand. Legs have been referred to most frequently as symbols of neighboring functions, so lightly have their own merits been regarded.</p> <p>Why is the performance of the lower extremity so much less spectacular than that of the upper? Independence of the upper limb from obligation to the rest of the body allows it to indulge in ornamentation of movement, so impressive to the eye. The lower limb, sandwiched between the ground and the torso, must ever be responsive to the needs of the body as a whole. It cannot choose to support some parts of the body and not others or to walk with the body through only portions of each step. The intricacy of function of knee and ankle does not exhibit itself in capricious movements but excels when it modulates countless disturbing factors so that no tremor mars the stark simplicity of normal locomotion.</p> <p>No one can rightly expect an artificial limb to take over completely the functions of its predecessor unless it is endowed with an equivalent of muscular and nervous control. Difficult as it is to provide substitutes for bones and joints, such provision is simplicity itself compared with the incorporation within the prosthesis of its own control. Although considerable progress has been made in the field of decelerating mechanisms for lower-extremity prostheses, the leg amputee must still use his own resources when he needs to supply energy or to exercise discretion.</p> <p>The contribution which the amputee makes to the over-all prosthetic result far exceeds that of acting as a model for exhibiting the achievements of inventors. It is he who must finish creation of the new locomotor mechanism by reshaping the pattern of his muscular activity and establishing alertness to new sensory cues. The success of the artificial leg depends on how thoroughly it becomes a part of the form and the function of the amputee after he has blended its metal, wood, and plastic with his muscle and perception. It is only appropriate that the new mechanism, having superseded the natural limb, should contribute to amputee gait that special accent which identifies the supernatural walk.</p> <p>The complexity of human motion makes it inevitable that fundamental improvement in leg prostheses must come slowly, since it is based on factors so numerous that no one individual can comprehend them all. In addition to the profession of engineering, there is needed the cooperation of the physician, the physicist, the physiologist, the physiotherapist, the prosthetist, and the psychologist-to list them in alphabetical order—so that the patient may get the total care he deserves.</p> <p>The problems which need attention are of different degrees of complexity and must be approached by different methods. Choice of materials, details of construction, and provisions for repair require less consideration of the over-all characteristics expected in the rehabilitated amputee than do problems of fit and socket shape. More general considerations must be weighed in projects concerned with alignment, basic design of mechanisms, and evaluation of performance. For these there should be a conscious choice of a realizable objective, the attainment of which requires integration of man and machine into a functional unit.</p> <p>All of these are practical problems amenable to increasingly useful solutions year by year, provided we do not surrender to the impatience of those who must have the answer to the question of the century today and of the millennium tomorrow. It is necessary to preserve clear vision of long-term objectives, although some members of every team find the environment more familiar when details arise.</p> <p>Had trial-and-error and serendipity been able to produce truly satisfactory lower limbs, we would not still be waiting for such. It was left for the National Academy of Sciences-National Research Council to initiate the development of artificial limbs on a modern basis by creating the Committee on Prosthetic Devices and, later, its successor, the Advisory Committee on Artificial Limbs. By carefully balancing the fundamental and the practical in their program, these Committees have laid a firm basis for some progress today, much more tomorrow.</p> <p>This is the key to the future in lower-extremity prosthetics. Used wisely, it will allow us eventually to rescue the limb problem from limbo and to provide the amputee of the future with a fitting legacy.</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>Herbert Elftman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Anatomy, College of Physicians and Surgeons, Columbia University; member, Lower-Extremity Technical Committee, ACAL, NRC.</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 Limbs in Limbo Creator An entity primarily responsible for making the resource Herbert Elftman, Ph.D. * https://staging.drfop.org/files/original/30b4b4710a8911bc0aea77a638feabd8.pdf d94353f2854ff602c0f9346f778e7e3d https://staging.drfop.org/files/original/ff9bbaad1957b97f9dbdb9a80193dba9.jpeg fafe36c6b4d258417e6f680dddb9b70e https://staging.drfop.org/files/original/571e595fe827f4f47a6bcb256a5c41d3.jpg 293e8f412cb4574591640035f63316e5 https://staging.drfop.org/files/original/6cf829e905f2e447ba594e3384850a62.jpg 4550835e4a6000c414e01462ccfa5217 https://staging.drfop.org/files/original/add90ab6d50a34714b20dca5c661b095.jpg f6b8c5082ce320e83340172ce97d6143 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/1979_01_001.pdf Text Any textual data included in the document <h2>Instep Strap</h2> <h5>Richard Rosenberger&nbsp;<a style="text-decoration: none;">*</a><br />Charles H. Pritham <a style="text-decoration: none;">*</a></h5> <p>Ankle-foot orthoses are prescribed for a variety of reasons, but chief among them is the control of undesirable positions of deformities, the most common being equino-varus. Gravity alone will cause the ankle-foot complex to adopt the equino varus position, but spasticity or contracture of the triceps surae can only complicate the situation.</p> <p>A conventional metal ankle-foot orthosis, with either a single or double uprights, can be effective in combating this deforming position, but success depends on proper construction and application of the orthosis. While in most instances the shoe is strong enough, in the presence of severe spasticity it is necessary to reinforce the shank of the shoe lest it break down at the anterior edge of the tongue and thus allow the shoe and foot to adopt a position of equinus. To properly control the foot the shoe should fit snugly when laced up. This latter point can be difficult to achieve and it is not uncommon to find that the heel has ridden up in the shoe. It may be necessary to prescribe a high-top surgical boot with undesirable economic and cosmetic side effects that weigh against use of the orthosis, as does the stipulation, when necessary, that the orthosis be worn at night. It is unconventional, uncomfortable, inconvenient, and unsanitary to wear shoes to bed.</p> <p>The situation with unmodified plastic ankle-foot orthoses is much the same, although it is somewhat easier to apply the orthosis properly than is the case with the shoe. For this reason it has proven popular to modify the basic orthosis by the addition of straps in various configurations. The attraction of this course of action should be obvious. First it makes it possible to don the orthosis and maintain the desired position without a shoe, and thus eliminates the need for expensive high-top surgical boots and it is practical to wear the orthosis in bed. The clear view afforded by these orthoses (as well as the translucency of polypropylene when used) and the strap makes it easy to secure the foot in the proper position before donning the shoe, which obscures the view. Moreover, the use of an instep strap makes the selection of a proper shoe even less critical than it is with the unmodified ankle-foot orthosis. While selection of proper heel height is unaffected, the instep strap allows the use of loose floppy shoes and slippers. This can be important for people who must get up at night or who desire to use the orthosis at poolside.</p> <p>In the hospital the use of an orthosis modified by an instep strap allows ambulation to proceed with an ordinary bedroom slipper while a proper shoe is being obtained. Frequently, delays can be encountered in obtaining shoes, with needless extension of the hospital stay.</p> <p>What is less clearly appreciated is the proper positioning of the strap. For our purposes in this instance the shin-foot complex can be considered as two arms, the tibia and the foot, set at right angles to each other and articulating at the ankle. In combating equinus the orthosis imposes two anteriorly directed forces, one at the top edge of the orthosis, and the other at the metatarsal heads. If unopposed by an anterior third point the leg will ride up in the orthosis, pivoting about these two points with the ankle moving forward. In effect, the leg bowstrings about the two most extreme points. To be maximally effective and comfortable the third force should be as far as possible from the two end points so as to develop the maximum resistance with the minimum force and thus minimum pressure under the strap. In the ordinary course of events this third force is provided by the lace closure of the shoe over the oblique instep of the foot. Since this surface is oblique the force provided normal to this surface can be resolved into two right-angle forces, each of which opposes one of the two anteriorly directed forces of the orthosis. If an accessory strap is added in this bony area it is likely to prove uncomfortable owing to the relatively small area underneath it and the fact that it is positioned too far distally to oppose the anterior motion of the tibia with minimum force. Moreover, if a shoe is worn over it the additional bulk in the shoe is likely to prove undesirable. Conversely, if the strap is added proximal to the malleoli it will be in good position to control the tibia but inadequate to affect the foot.</p> <p>Unless opposed by a second strap or the shoe, equinus is likely to occur and since anterior motion of the tibia is prevented all the motion is likely to occur in a proximal direction with the malleoli riding up and shear taking place under the strap.</p> <p>Following the foregoing analysis then, it seems logical to locate the strap at the deepest point of the radius connecting the oblique dorsal surface of the foot and the vertical tibia, roughly equidistant to the ankle mortice and the subtalar joint. In this position the instep strap is as far as possible from each of the two end points, well positioned to control motion in each segment, and free of the lace area of the standard low-quarter shoe. Instep straps have been used in this configuration a number of years now and, contrary to expectations, irritation under the strap in this relatively unpadded area has not been a problem. This can be attributed, in part, to the fact that the strap is well placed to develop maximum torque with minimum pressure. It is, of course, possible to pad the strap if so desired.</p> <h3>Method</h3> <p>Two methods of adding the strap have proven successful. In one the strap and a narrow loop are riveted to the orthosis on either side along the intended line of force. In the second two slots are cut in the material of the orthosis if the orthosis extends far enough anteriorly to permit it. One end of a Velcro strap is passed through one of the slots and sewn back on to itself. The free end of the strap can then be passed through the other slot and placed back on itself to secure the orthosis. In each case a flexible tape measure can be used to measure the proper length of strap and to plan the proper points of attachment (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, and <b>Fig. 4</b>). This procedure can be done either over the positive model or the involved extremity itself and a strap can be added at any time.<br /><br /><strong><a href="/files/original/ff9bbaad1957b97f9dbdb9a80193dba9.jpeg">Fig. 1</a>. A tape measure is used to locate the position of the rivet hole for attaching the Velcro strap. This can be done on the patient or around the positive model.</strong></p> <strong><a href="/files/original/571e595fe827f4f47a6bcb256a5c41d3.jpg">Fig. 2</a>. Similarly, a tape measure is used to plan the location of the slots to be cut in the orthosis.</strong><br /><br /><strong><a href="/files/original/6cf829e905f2e447ba594e3384850a62.jpg">Fig. 3</a>. Appearance of the Velcro strap and metal loop once they are riveted to the orthosis. Normally, of course, the patient would be wearing a stocking. The metal loop should be located further posterior so as not to impinge on flesh.<br /><br /><a href="/files/original/add90ab6d50a34714b20dca5c661b095.jpg">Fig. 4</a>. The Velcro strap attached to an orthosis through slots cut in the orthosis. Excess material has been cut away from around the slots to present a neat and finished trimline.<br /></strong><br /> <h3>Summary</h3> <p>A rationale for the use of an accessory strap to control equino-varus in an orthosis without the shoe is given. Some thoughts about its placement and descriptions of two methods of attachment are also given.<br /><em><b><br />Charles H. Pritham&nbsp;<br /></b></em><em>Director, Orthotics and Prosthetics Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, Pennsylvania<b><br /><br />Richard Rosenberger <br /></b>Director, Prosthetics and Orthotics Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia<b><br /></b><br /></em></p> Page Number(s) 1 - 3 Year 1979 Volume 3 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Instep Strap Creator An entity primarily responsible for making the resource Richard Rosenberger * Charles H. Pritham * https://staging.drfop.org/files/original/708fa372e3aa806c06ea2cec87c6d54d.pdf 9a1fac5f9d62e7f6b1c6180a01f964f8 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_001.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_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>Artificial Limbs-Today and Tomorrow</h2> <h5>F. S. Strong, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Ours is an age of scientific research and development in almost every field of human interest. Some work to make man live longer, to make him more comfortable, more mobile, more informed. Some devise ways to maim or destroy him. This report and others to follow will tell the story of those who strive to replace what war, accident, or disease have removed, or what nature simply failed to provide. This is concerned with what modern science and engineering skill can do today-and what may be expected in the future-for the person in need of a substitute for normally standard equipment-an artificial limb for a missing arm or leg.</p> <p>From the dawn of history men have contrived replacements for lost extremities, particularly the lower. The loss of an arm, while causing inconvenience, has not resulted generally in serious handicap. But without a leg, a man becomes immobilized. Thus, over the years there has come about a considerable development until today some of the better types of artificial legs afford reasonably satisfactory service, always provided they are well fitted and aligned by qualified prosthetists. The same has not been true of upper-extremity devices. And so when young men returned from World War II with missing limbs, while the lower-extremity amputee could expect a replacement of some merit, the man who needed an arm was definitely in trouble. As a matter of fact, the entire field of artificial limbs needed serious attention to bring amputee service more in line with the scientific and engineering progress which has become synonymous with America in the modern world.</p> <p>To meet this need, not only for the benefit of veteran amputees, but also to help all similarly handicapped individuals everywhere, a program was established at the end of the war under the sponsorship of the Armed Services and the Veterans Administration and was later implemented on a permanent basis by the Eightieth Congress through Public Law 729. This act authorizes the expenditure of $1,000,000 annually "to aid in the development of improved prosthetic appliances ..." and designates the Veterans Administration as the appropriate agency for the administration of the funds thus made available.</p> <p>The activities encompassed within the framework of these endeavors have come to be known as the Artificial Limb Program. And since the field, though serving less than a million persons, of whom only some 27,000 are veterans, involves the cooperation of several scientific disciplines as well as various organizations both civil and military, a special structure had to be contrived for successful operation. This was done through a contract between the Veterans Administration and the National Academy of Sciences, by means of which an Advisory Committee on Artificial Limbs of the National Research Council has been established for general supervision and coordination, and through other contracts between the Veterans Administration and various educational and industrial organizations for research and development. In addition the Surgeons-General of the Army, Navy, and Air Force, and the Chief Medical Director of the Veterans Administration, have made available the services of certain laboratories and personnel in further support of the over-all program. While in the early stages of this undertaking, it was necessary to proceed generally on a broad front in order to explore and define the complete problem so that at one time as many as sixteen contracts were in force, at present the number has been reduced to three only, and an operational structure has been evolved through which a long-range plan can be followed with reasonable hope of success</p> <p>The word "prosthetics" has been found a convenient term to define the general field of amputee service. Since the problems of replacement in the lower extremity are quite different from those in the upper, the field is divided into two parts. Lower-extremity research and development are centered at the University of California, Berkeley Campus, while upper-extremity studies are similarly covered at the University of California at Los Angeles, all under a contract between the Veterans Administration and the University. Assisting in lower extremities is the Oakland Naval Hospital Artificial Limb Department while the Army Prosthetics Research Laboratory at Walter Reed Army Medical Center cooperates in the development of artificial arms and terminal devices Finally, through a contract with New York University, and with the cooperation of the VA Prosthetic Testing and Development Laboratory in New York well-defined methods of testing and field application assure that devices and techniques developed under the program are, before acceptance, in fact useful improvements in amputee rehabilitation.</p> <p>For general technical guidance in these two branches, standing committees, in lower- and upper-extremity prosthetics respectively, have been constituted, each composed of specialists in the fields of medicine, engineering, prosthetics, and the like, and each under the chairmanship of the leader of the appropriate University of California research project. These groups meet annually, or more frequently if necessary, to review progress, define requirements, and recommend action to the Advisory Committee on Artificial Limbs, to the artificial-limb industry, or to others interested in amputee rehabilitation problems. In addition smaller research and development panels have been appointed from these technical committees to supervise current activities between meetings of the larger groups. In this work, definite transition procedures have been adopted for orderly progress from the inception of ideas for improved devices and techniques to their final application in the limbshop or rehabilitation clinic.</p> <p>By these methods the results of some eight years of research and development are now being channeled as directly as practicable to the service of amputees, rather than indirectly merely through the issuance of reports or through publication in scientific journals. In order that physicians, prosthetists, rehabilitation specialists, insurance carriers, and other interested individuals and organizations may be informed of advances in this field as promptly as possible, this series of reports is being undertaken. While the Advisory Committee on Artificial Limbs has previously issued monthly progress reports on a limited basis to those immediately concerned, and although the various contractors and governmental laboratories associated with the program have contributed reports and other data on specific subjects, this will be the first organized attempt to disseminate timely information to a broad list of individuals and institutions interested in the rehabilitation of the amputee. This is being done in furtherance of the intent of the Congress which, in Public Law 729, authorizes the Administrator of Veterans' Affairs "to make available the results of his investigations to private or public institutions or agencies and to individuals in order that the unique investigative materials and research data in the possession of the Government may result in improved prosthetic appliances for all disabled persons."</p> <p>In offering these reports to the reader who has not been in a position to follow recent progress in this field as unfolded through the Artificial Limb Program it can be stated that the views and information to be set forth in this and Subsequent issues are the result of long and objective study by specialists in the various branches of science and engineering involved. These findings, therefore, can be accepted with considerable confidence as indications not only of the present state of the art but also as to future trends And where these findings may appear at variance with previous traditional concepts or the writings of earlier authorities, it can be said simply that the field of prosthetics is even today largely uncharted and untraversed-that it is a field where the marvels of modern science and engineering have yet to leave their mark.</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>F. S. Strong, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Advisory Committee on Artificial Limbs, National Research Council.</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 Artificial Limbs-Today and Tomorrow Creator An entity primarily responsible for making the resource F. S. Strong, Jr. * https://staging.drfop.org/files/original/75dc06cd0cb2f16f20c55049bd0bdbc7.pdf f76171ab4432c6a50cf6f259be7af891 https://staging.drfop.org/files/original/d81d51673f68ef5fe93f7930d455e5f8.jpg 7008a305e99a0abc591c52fc2411bb17 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_004.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 4 - 7 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Objectives of the Lower-Extremity Prosthetics Program</h2> <h5>Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>Man depends upon his legs to support the body and to move it from place to place as occasion warrants. Since mobility is nearly indispensable to most human activities, the loss of part or all of a leg—through accident, war, or disease—imposes serious limitations and has always made a replacement of some sort more or less of a necessity. Accordingly, artificial legs of one kind or another have been made and used since the most ancient times. As a result of the long-continued effort, leg prostheses have undergone progressive, if slow, development through the centuries, so that many lower-extremity amputees have in the past been successfully restored to something resembling a normal life. With the advent of industrial development, and of improved tools and materials with which to work, the nineteenth century marked the appearance of many new lower-extremity devices and of new techniques in the medical treatment of amputations.</p> <p>Impetus provided by World Wars I and II gave rise to rapid advancement in all branches of technology and thus made possible a concerted attack on the problem of supplying the best possible artificial limbs. The term "lower-extremity prosthetics" has now come to mean the practice of rehabilitation of the leg amputee by providing him with an artificial limb that will restore lost functions to the greatest possible degree. But more than just the artificial leg is involved. The amputee himself is a most important part of the end-product, and amputees, like other people, are individuals with widely differing characteristics and abilities. Of course surgical procedures should be designed to secure a painless stump and to retain maximum function, and it would seem that the artificial leg, when properly fitted, should duplicate as closely as possible the normal activity of the lost part. Moreover, physical conditioning and gait training are both important phases of the whole rehabilitation process.</p> <p>This concept of lower-extremity prosthetics has developed during the years since the start in 1945 of the program of the Advisory Committee on Artificial Limbs, National Research Council. Initially, the primary objective was to develop improved devices, it being considered as obvious that, if a better prosthetic knee or ankle or foot could be devised, the amputee would benefit. Attempts to produce such items, however, made necessary the determination of functional requirements and thus immediately revealed the lack of necessary fundamental information. Basic research into the complicated phenomenon we call "locomotion" was therefore carried on simultaneously with the development of devices.<a style="text-decoration:none;">*</a> These investigations indicated a need for the application of basic mechanical principles to fitting and alignment of artificial legs. A three-pronged approach, all parts of which are complex and interrelated in various ways, has thus evolved. Basically, the three objectives are:</p> <ol> <li>To extend knowledge of the amputee, of lost and remaining functions affecting locomotion, and to collect information on the best possible medical treatment.</li><li>To improve fitting techniques and practices, including training, so that existing devices might be used with greater comfort and function.</li><li>To develop improved lower-extremity devices.</li></ol> <p>Relative emphasis on these three phases is shown in <b>Fig. 1</b>. Implied in such a program is the dissemination of information and techniques to those who serve the amputee. Many of the accomplishments to date are recorded, and fully documented with the report literature, in Klopsteg and Wilson's <i>Human Limbs and Their Substitutes </i>(McGraw-Hill, in press). In addition, various seminars and short courses for surgeons and prosthetists have been conducted throughout the program.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the lower-extremity prosthetics program, 1945-54, projected through 1956 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fundamental Studies</h3> <p>Detailed and comprehensive study of normal human locomotion is the basic key to improvement in all phases of the lower-extremity problem. Walking is to all appearances so natural and simple a process that it is difficult to conceive of its complexity. A knowledge of the behavior and the contribution of each anatomical part in providing the many services required of legs in normal use is essential to determine the functions that have been lost through amputation and the functions that still remain. The surgeon needs such information in order to provide the best amputation stump with maximum remaining function. The prosthetist must understand the limitations and potentialities of the amputee-prosthesis combination for optimum fitting, alignment, and adjustment. The designer needs detailed information on angles, displacements, velocities, accelerations, forces, energy requirements, and functions in order to improve existing devices and to develop new ones. And finally, the amputee himself has problems that require a fundamental approach. Causes and treatment of phantom or other pain, circulatory difficulties resulting from amputation, skin tolerance to pressure in areas never intended for such use, as well as the better understanding of the psychological problems of the amputee are examples of important areas of investigation.</p> <p>The objectives of the program of fundamental studies of the lower extremity may be summarized as:</p> <ol> <li>To study the phenomenon of locomotion in a sample of normal individuals and to analyze the results for use by the surgeon, the designer, and the prosthetist.</li><li>To develop design criteria for new or improved devices and as a basis for evaluating existing devices.</li><li>To develop an understanding of the compensatory mechanism of the human body and its ability to adapt itself to overcome functional deficiencies of its parts.</li><li>To provide a frame of reference for evaluating the degree of success obtained in replacing lost functions by means of an artificial leg.</li><li>To obtain information on the cause and possible treatment of phantom pain and other medical problems of the amputee.<a style="text-decoration:none;">*</a></li></ol> <h3>Development of Techniques of Fitting and Alignment</h3> <p>It appears obvious that, no matter to what degree an artificial leg is perfected mechanically, its effectiveness will depend upon the comfort afforded the wearer. Comfort is a function of the fit and alignment of the prosthesis.</p> <p>Although the artificial-limb industry has, through the years, developed reasonably successful techniques for fitting and aligning artificial legs, the results have been obtained mostly by trial-and-error methods; seldom have basic mechanical and anatomical principles been employed. It was found, for instance, that even among the most successful prosthetists there existed little agreement as to what constituted a satisfactory fit. For these reasons it appeared necessary to include in the lower-extremity program a project to develop fitting and alignment techniques based on sound scientific principles and to include, if necessary, the development of auxiliary tools and a study of materials and of methods of suspension.</p> <p>The study was launched with the following objectives in mind:</p> <ol> <li>To learn from the artificial-limb industry the procedures used in fitting and alignment of artificial legs.</li><li>To work with the industry in applying fundamental principles to the problem of fit and alignment and to formulate the guiding principles involved.</li><li>To develop mechanical aids to improve fit and alignment and to serve as tools to simplify shop operations.</li><li>To investigate and evaluate types of suspension as well as materials and methods used in socket fabrication.</li><li>To develop simplified methods of evaluating the amputee-limb combination-to be used as a check by the prosthetist, the surgeon, and the physiotherapist.</li><li>To improve methods of training the lower-extremity amputee in order to get better functional and more effective use of his prosthesis.</li></ol> <p>Out of this study have come such developments as the introduction of the above-knee suction socket and the University of California adjustable legs and alignment duplication jig. The study of fitting and alignment continues at the University of California, Berkeley Campus.</p> <h3>Development of Prosthetic Devices</h3> <p>New and improved devices have always been a major objective of the ACAL program. Great effort has been expended in this direction, often without the necessary or valid criteria. Although engineering designs can be made to accomplish nearly any specified function, the end result of any given design may be unsatisfactory if the specifications were unrealistic. The device may be too complicated, too heavy, uneconomical for the improvements obtained—or it may actually interfere with some service functions though improving others. Since the beginning of the ACAL research program, a number of outstanding industrial firms have engaged in development of devices. As a result of these activities, a great deal has been learned about what is possible—and about what <i>not </i>to do. Together with the fundamental studies, a body of knowledge has been developed to provide a realistic approach to design criteria. A number of devices based on this information are now in the development stage; they show promise for the future.</p> <p>Criteria for improved knee joints for above-knee amputees have undergone great changes as fundamental knowledge of locomotion has increased and as various knees, alleged to be improved ones, have been tested on amputees. Similarly, dependence of knee performance on ankle function, fit and alignment, training, and total coordination is becoming better understood. In the light of present knowledge, it seems clear that "super-devices" are not apt to be the solution to improved artificial legs and that considerations of natural appearance, minimum energy consumption, and simplicity of mechanism for maintenance and economy will in the end be the controlling factors. Of course no device should be made available for general distribution until it has been checked thoroughly for function, strength, maintenance requirements, life expectancy, and adaptability to different types of amputees. A complete testing program has there- fore been established under the direction of New York University to ensure the adequacy of each device approved under the program.</p> <p>Present objectives for the development of prosthetic devices may be stated as:</p> <ol> <li>To invent new mechanisms, improve and adapt existing mechanisms, and apply new materials so as to add functions, or to improve presently provided functions of prostheses, seeking in the end to provide better devices to meet the needs of every amputee type.</li><li>To perfect those functions involved in level walking, with the best possible solution for oilier services such as sitting down, walking on slopes and stairs, etc.</li><li>To adapt devices that take advantage of remaining functions in the amputee's stump.</li><li>To increase stability during the weight-bearing phase but to reduce the energy requirement during transition as well as during the entire cycle of walking.</li></ol> <h3>Clinical Study</h3> <p>Throughout the program, amputees have been fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. Techniques and practices involved in fitting amputees are so varied, however, that some orderly means of investigating these areas became necessary. Accordingly, in 1952 a program of clinical studies was established under the project at the University of California, Berkeley, in space at the Artificial Limb Shop of the U. S. Naval Hospital at Oakland, California. Here an orderly approach can be made to a review and formulation of best practice in lower-extremity prescription, fabrication, fitting and alignment, and training in the use of the prosthesis. Complete documentation of each step in the process, as applied to a variety of amputee types, under the supervision of an advisory panel and with the cooperation of members of the limb industry in the San Francisco Bay-Area, will serve to close the gap between fundamental work in the laboratory and practice in the field. Besides this, it will serve to supply source material for the information of the various professions involved in physical rehabilitation of the amputee as well as to define areas where more information or new devices are required.</p> <p>In addition to establishing what is the best prosthetic practice, the objective of the clinical study is to develop, for distribution to each member of the rehabilitation team, including the amputee, information such as:</p> <ol> <li>Medical data for use by the surgeon in connection with amputee problems.</li><li>Criteria for use in proper prescription of a prosthesis.</li><li>Principles and practices of fabrication, fitting, and alignment of a prosthesis.</li><li>Suggested means of evaluating prosthesis and amputee, Including gait analysis, performance checks, and achievement tests for use by the prosthetist, the surgeon, and the physical therapist.</li><li>Suggested curriculum for training the amputee in the use of his prosthesis.</li><li>A comprehensive list of specific prosthetic appliances and devices, with descriptions of their individual characteristics and functions, for use in preparing prescriptions.</li><li>Suggested curriculum for training the prosthetist, the surgeon, and other members of the clinic team in lower-extremity prosthetics.</li><li>Data useful to the research and development laboratories in continuing their studies.</li></ol> <h3>Future Program</h3> <p>The investigation and development involved in a lower-extremity prosthetics program are complicated and time-consuming. And since it appears impossible to reach the ultimate goal of replacement of all functions that have been lost, the task must be considered as never-ending. For the immediate future it is contemplated that development of devices, the clinical study, fitting and alignment studies, and fundamental research will continue. The relative emphasis on each phase is projected on <b>Fig. 1</b> through 1956.</p> <p>As progress is reflected in the results of the clinical study, some means must be developed for effectively transmitting this information to orthopedic clinic teams throughout the nation. Whether this is to be accomplished periodically at a central location, or whether through field teams on a continuing basis, will depend to a large extent upon the results obtained in the clinical study during the coming year. Whatever method evolves, every effort will be made to ensure that any useful information is disseminated to the field as quickly and efficiently as possible.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be noted that the work on phantom pain is applicable to both upper- and lower-extremity amputations.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A more logical and systematic approach, had there been sufficient time, might have been to postpone device development until the results of the basic work became available. But the urgency of amputee demands at the end of World War II made such an approach less desirable than the one adopted.</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>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_004/May-1954OCRBatch1-1.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 Objectives of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Howard D. Eberhart, M.S. * https://staging.drfop.org/files/original/1bfbe5548da1f1f787c5f9b69ac77ae4.pdf 11ca54b65800177402546316e1352c8c https://staging.drfop.org/files/original/802ddce4e368ab0f321e2bdc98173842.jpeg 69d07f495f9362b3076d7c0c53fec5da https://staging.drfop.org/files/original/d017fceacd06924dce3634293e3e615b.jpg 97c81669de828d6ffc77b59c510d05c2 https://staging.drfop.org/files/original/f23d96f97d854059d735a6faad5512bf.jpg c266c715736592a367b2d55d47b3a24d https://staging.drfop.org/files/original/96f6e7ec405077c1caca5aedbaa75f75.jpg 3f17afffe7cbfb411e498760677497e4 https://staging.drfop.org/files/original/a98c8f64d3c51b152bb32d0b1711eb89.jpg 867a3d79bedf809260590f74ce87e77e https://staging.drfop.org/files/original/116b9b3e583ae10ac88748d7f2091f23.jpg b664cf731070925b4db7aecacdf2b205 https://staging.drfop.org/files/original/8ce37ee8d1e152a826a64cddbff91402.jpg 13d16f86a53a7698aab3c0bf5c088144 https://staging.drfop.org/files/original/7f4d31c4953101fb3dac69063e9fd876.jpg d103dfa8fc9520418b1e36fdf51a7b1d 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/1979_01_004.pdf Text Any textual data included in the document <h2>Prosthetic principles in bilateral shoulder disarticulation or bilateral amelia</h2> <h5>G. Neff&nbsp;<a style="text-decoration: none;">*</a></h5> <blockquote> <p><i>The following article by Dr. Neff originally appeared in German in the November 1978 issue of Orthopaedie Technik. At the suggestion of Siegfried Paul we had the article translated for publication of the Newsletter because it seems to supplement the material on external power included in earlier issues of the Newsletters. As we were about to begin editing the rather literal translation provided by the commercial service, Volume 2, Number 3, of "Prosthetics and Orthotics International" arrived and we were pleased to see that it included an excellent English version of Dr. Neff's article. Accordingly with permission from the editors of both journals we are pleased to provide the readers of Newsletter the English version developed by the International Society for Prosthetics and Orthotics.</i></p> <p><i>This article is presented not with the idea that the hardware shown is available for use, but rather to provide the readers of this publication with the findings of a very experienced clinical team as given in the discussion.</i></p> <p><i>A. Bennett Wilson, Jr.</i></p> </blockquote> <p><i>Based on a paper presented at the Second World Congress, ISPO, New York, 1977.</i></p> <h3>Abstract</h3> <p>Following a brief survey of the historic development of pneumatic prostheses the actual principles of prosthetic management in bilateral shoulder disarticulation or bilateral amelia are explained.</p> <p>The active functions are restricted to active pronation and supination, active gripping of the terminal device "hook" or "hand", combined with pneumatic locking of free swinging shoulder and elbow joints in one artificial arm; the cosmetic arm provides only space for the power package in the resin socket of the upper arm. Both arms are suspended on a Simpson frame.</p> <p>Thus optical control is concentrated on the movements of the functional arm. The reduction of valve control makes prosthetic training and use easier.</p> <p>Recently hybrid systems came into use because electric power proved superior to pneumatic power for pronation and supination and gripping, whereas CO₂ is still necessary for locking the elbow and the shoulder joint. The accumulator can be recharged daily at a plug socket, the CO₂ container need only be refilled after one or two weeks ensuring more independence for the disabled. The advantage of such a prosthesis is the better appearance in public combined with a certain functional use.</p> <p>However only intensive foot training without prostheses provides independence in daily activities, because even sophisticated prosthetic systems cannot make up completely for body loss.</p> <h3>Introduction</h3> <p>Whereas an amputee with shoulder disarticulation and one healthy upper limb generally finds a cosmetic prosthesis without active functions adequate, there is an obvious problem in the fitting of cases of bilateral disarticulation or congenital absence of both upper extremities with functionally satisfactory prostheses. No unexplored possibilities remain for the body powered positioning of artificial arms and for opening and closing the terminal device "hook" or "active hand"; so external power for a functional prosthesis becomes indispensable.</p> <p>In 1948 the first experiments with CO₂ driven pneumatic prostheses were undertaken by Hafner and Weil; CO₂ was used as a safe, easily controllable, easily applied and at the same time cheap propellant. In 1957 Marquardt and Hafner first fitted a child with bilateral amelia of the upper limbs with pneumatic prostheses.</p> <p>The initial aim of the most extensive motorisation possible of both prostheses rapidly proved itself inexpedient. The absence of suitable body parts for operating the control valves and the limited capacity of coordination, even in the most intelligent patients, was opposed to the increasing number of necessary control signals. The insufficient sensory "feedback" necessitated an exclusively optical control over the actions of the terminal devices. The independent use of each prosthesis at the same time beyond a small, optically controllable area was bound to fail for this very reason. The heavy weight and increasing energy consumption required finally led to reflection on the practicability of such "fully motorised" prosthetic systems. As a consequence there was a step by step reduction to the necessary functions and the improvement or new development of better suitable fittings.</p> <h3>Present practice</h3> <p>Partly manufactured by the industry and partly handmade in our own workshops the following pneumatically driven modular parts are available today:</p> <ul> <li> <p>a hook for children,</p> </li> <li> <p>a hook for teenagers,</p> </li> <li> <p>the pneumatic Otto-Bock-system hand,</p> </li> <li> <p>joints for pronation and supination,</p> </li> <li> <p>an active pneumatic elbow joint with lock,</p> </li> <li> <p>a free mobile elbow joint with pneumatic lock,</p> </li> <li> <p>for children, a free swinging shoulder joint manufactured from a standard modular elbow joint with pneumatic lock and extremely small CO₂ consumption combined with a friction joint for abduction,</p> </li> <li> <p>for older children and teenagers a free swinging shoulder joint with pneumatically lock-able forearm linkage.</p> </li> </ul> <p>The philosophy of prosthetic fitting of such seriously disabled patients, as described by Marquardt, is based on the idea that the prosthesis is only to be prépositioned, that is, a rough adjustment is obtained and held. Fine coordination is achieved by body movements, for example by bringing the mouth to the cup or to the spoon, which is already prepositioned with the prosthesis within the range of the body movements (<b>Fig. 1</b>).</p> <strong><a href="/files/original/802ddce4e368ab0f321e2bdc98173842.jpeg">Fig. 1.</a> Prepositioned prosthesis permits the patient to bring the mouth to the spoon.</strong><br /> <p>Connected with this is the reduction of prosthetic technique to the minimal yet indispensable functions. The dominant side is provided with a functional arm for active use. The opposite side is fitted with a cosmetic arm without active functions; in the moulded resin socket of its upper arm the CO₂ storage cylinder is accommodated. The functional arm has at its disposal:</p> <ul> <li> <p>a free swinging, pneumatically lockable shoulder joint,</p> </li> <li> <p>either a free or pneumatically movable elbow joint, in both cases pneumatically lockable,</p> </li> <li> <p>a pneumatic joint for active pronation and supination,</p> </li> <li> <p>a pneumatic "hook" or a pneumatic "system hand" (if possible interchangeable) for active gripping.</p> </li> </ul> <p>The cosmetic arm of the opposite side has only a free swinging shoulder joint and a passively adjustable elbow friction joint. Occasionally the hand of the cosmetic arm may be additionally pneumatically activated to allow a certain amount of hand to hand coordination. Both artificial arms are suspended on a Simpson frame (<b>Fig. 2</b>), which has replaced our former frame constructions (<b>Fig. 3</b>) due to its reduced weight and superior confort in wearing.<br /><br /><strong><a href="/files/original/d017fceacd06924dce3634293e3e615b.jpg">Fig. 2</a>. Prosthetic system with active arm on the right side with pneumatically lockable shoulder and elbow joint, pneumatic pronation and supination and pneumatic hand; on the left side, a free swinging shoulder and elbow friction joint, and built-in CO₂ storage cylinder in the upper arm. Both arms are suspended on a Simpson frame.</strong></p> <strong><a href="/files/original/f23d96f97d854059d735a6faad5512bf.jpg">Fig. 3</a>. Former frame construction for pneumatic prostheses for a child with phocomelic upper limbs.</strong><br /> <p>The individual functions are controlled by means of valves. For locking or unlocking of the free swinging shoulder and the elbow joints, flip-flop valves have proved successful since in these the pressure points are clearly defined. The pronation and supination of the forearm is controlled by means of a doublepoint pressure valve, situated above the acromion, or by a doublepoint traction valve, operated by a shoulder strap while lifting the shoulder (<b>Fig. 4</b>). The opening and closing of the gripping device is effected by activation of a flip-flop valve in front of the shoulder.</p> <strong><a href="/files/original/96f6e7ec405077c1caca5aedbaa75f75.jpg">Fig. 4</a>. Detail of doublepoint pressure valve in front of the shoulder and doublepoint traction value fitted to the Simpson frame.</strong><br /> <p>The few active functions can be easily controlled and, in general, learning problems in prosthetic training do not occur. The optical control is directed exclusively towards the activity of the functional arm. Energy consumption is limited, the contents of a CO₂ container, corresponding to about 500 actions, is sufficient for a normal day's use, as shown by experience. The weight of such a complete prosthetic system for a 10 year old child is about 1750 g with a pneumatic hook and about 1950 g with an Otto-Bock-system hand.</p> <p>One thing which remains unsatisfactory, is the dependence on refilling the CO₂ storage container carried in the prosthesis from a stationary CO₂ pressure cylinder by means of a reduction valve and a special adaptor. With regard to this inconvenience electrical power from batteries or from rechargeable accumulators has proved superior to CO₂ pneumatics.</p> <p>On this account we changed over to electromechanical prostheses. The first patients were children with phocomelic upper limbs; their forearmlike prostheses were attached to a modified "Ring-bandage" instead of the uncomfortable stiff frame, permitting maximum freedom of movement (<b>Fig. 5</b>). The phocomelic limbs were fitted into the moulded resin sockets in such a way as to give the impression of an actively movable elbow joint and to enable the fingers to operate microswitches which in turn controlled the electromechanically driven hands (<b>Fig. 6</b>). The result was an improvement upon wearing comfort, cosmetic appearance and function.</p> <strong><a href="/files/original/a98c8f64d3c51b152bb32d0b1711eb89.jpg">Fig. 5</a>. Recent prosthetic fitting of a phocomelic girl with electromechanical prostheses and suspension on a modified "Ringband-age"; Hosmer outside locking for elbow joints. Extreme right, cosmetic result.</strong><br /><br /><strong><a href="/files/original/116b9b3e583ae10ac88748d7f2091f23.jpg">Fig. 6</a>. Microswitch which is operated by the movements of the one finger phocomelia.</strong><br /> <p>For the reasons mentioned above it seemed sensible to convert also the prostheses for patients without arms to electrical power. So far, however, no comparably efficient electromechanically lockable shoulder and elbow joints have been developed. Thus in the meantime, we are developing hybrid systems which exploit the advantages of the pneumatic as well as of the electrical external power (<b>Fig. 7</b>).</p> <strong><a href="/files/original/8ce37ee8d1e152a826a64cddbff91402.jpg">Fig. 7.</a> Hybrid prosthesis in bilateral amelia with pneumatically lockable shoulder joint (controlled by valves in the left side) and pressure and traction microswitches for gripping and forearm rotation. Built-in accumulators fitted to the frame of the right upper arm.</strong><br /> <p>The shoulder and elbow joint of the functional arm is pneumatically lockable as before. The CO₂ consumption for these actions is extremely small; the volume of the container carried in the prosthesis is now sufficient for one or two weeks, according to the amount of use, assuring greater independence from the stationary energy reservoir at home. The energy consuming functions, such as pronation and supination and gripping movements, are electrically driven. The accumulator can be recharged at the nearest, most convenient plug socket or, with little interruption in prosthetic use, it can be exchanged for a charged second accumulator. In our experience this hybrid system can be most recommended.</p> <h3>Discussion</h3> <p>In spite of these improvement excessive enthusiasm concerning the extent of functional use of such prostheses in daily life is out of place. Their actual value lies in the indisputable "normalization" of the patient's appearance in public (one should perhaps say: <i>for</i> the public), combined with an optimizing of the functional possibilities of such prostheses by exploiting the technical knowledge available today. Therefore an intensive training in daily activities without prostheses is also essential. Besides simple technical aids, as for example, an eating aid attached to and moved by the leg, foot training is of the utmost importance, especially for overcoming daily recurring problems not only in toilet use, dressing and undressing, washing (<b>Fig. 8</b>), combing hair, teeth cleaning, but also in eating, drinking and in writing (with or without typewriter). Not only can many things be <i>handled</i> better with the feet but functional independence of (meaning freedom <i>from</i>) the prosthesis-at least at home in privacy-releases the patient from the unpleasant feeling to be capable of living only as a "perfect operator of a sophisticated prosthetic robot". This consideration should be uppermost in the mind while prescribing such a costly AID: it protects against the over-evaluation of technology and the concomitant under-evaluation of the individual, whom the technology should serve.</p> <strong><a href="/files/original/7f4d31c4953101fb3dac69063e9fd876.jpg">Fig. 8.</a> Result of self-care foot training, independence from prostheses in daily activities at hom</strong>e.<br /> <p><em>*Developed by H. Kramer, Research Lab. of the Dept. for Dysmelia and Technical Orthopaedics, Heidelberg University</em>.</p> <p><b>References:</b></p> <ol> <li>Marquardt, E. and Hafner, O. (1956). Technische Bewahrung und prakhische. Anwendung der Heidelberger pneumatische Prosthese. <em>Archiv fur Orthopadische und Unfallchirurgie</em> 48,115-135.</li> <li>Marquardt, E. (1957). Muskelsteuerung von pneumatischen Unter-und Oberarmprothesen. <em>Archiv fur Orthopadische und Unfallchirurgie</em>, 49,419-426.</li> <li>Marquardt, E. (1965). Erfahrungen mit pneumatischen Prothesen. <em>Verh. Dtsch. Orthop. Ges.</em>, 52, 346-352.</li> <li>Marquardt, E. (1974). Pneumatische Prothesen, Eigenkraftprothesen und technische Hilfen fur schwere Armfehlbildungen in:¹⁰<em>Jahre Entwicklung und Erprobung von Hilfen und Hilfmitteln fur behinderte Kinder</em>. Hrsg.: AG Technische Orthopadie und Rehabilitation, R. Schunk Verlag, Konigshofen.</li> <li>Neff, G. Marquardt, E. (1977). Stand der Versorgung mit pneumatischen Prothesen in: <em>Amputation und Prothesenversorgung bein King</em>. Ed.: R. Baumgartner, F. Enke Verlag, Stuttgart.</li> <li>Neff, G. (1978). <em>Prinzipien der prothetischen Versorgung nach beidseitiger Schulterexartikulation oder bei beidseitiger Amelie Orthopadie-Technik</em>, (In press.).</li> <li>Simpson, D.C. and Kenworthy, G. (1973). Entwurf eines voll-stangigen Amersatzes (Teil 2) <em>Orthopadie-Technik</em>, Feb. 41-44.</li> </ol> <em><b>G. Neff<br /></b>Orthopädische Universitätsklinik, Tubingen</em><br /> <div style="width: 400px;"></div> Page Number(s) 4 - 7 Year 1979 Volume 3 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-7.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/1979_01_004/1979_01_004-8.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 Prosthetic principles in bilateral shoulder disarticulation or bilateral amelia Creator An entity primarily responsible for making the resource G. Neff * https://staging.drfop.org/files/original/b76e176eea5ade74fc19b1a4179ee035.pdf 70fa24e8024de93a3dac3ead7a24a4c3 https://staging.drfop.org/files/original/8d4e4395448b88c9f47146d10e2bd761.jpg e7aecd53a8fb74f0db642462ee9eacbc DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_004.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 4 - 8 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Objectives of the Upper-Extremity Prosthetics Program</h2> <h5>Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The upper-extremity prosthetics program, under the sponsorship of the Advisory Committee on Artificial Limbs, National Research Council, has been a growing and evolving program from its inception in 1945. Its initial objectives were limited to time and motion study of amputees and to device invention and development. But from the vantage point of 1954 we may list many additional objectives that have been assumed according to the necessities of a national program dedicated to the welfare of the amputee. As new activities have been added, none of the original have been abandoned, although certain of the original ones have been reduced in relative emphasis and expenditure.</p> <p><b>Fig. 1</b> illustrates in schematic form the major phases of the upper-extremity program as they have waxed and waned over the years from 1946 to 1953. The scope and magnitude of these activities represent a program with few parallels in our peacetime economy. As is evident in <b>Fig. 1</b>, not all the activities were started (or even conceived) at the outset. But, as has been pointed out by Strong,<a style="text-decoration:none;">*</a> no one could predict at the outset the ramifications of a program dedicated to the tangible goal of putting new and improved prostheses on amputees. The appropriateness of this program under the auspices of the National Research Council was underscored by President Bronk, who praised the ACAL program as a fitting example of the service to the public welfare for which NRC was founded.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the upper-extremity prosthetics program, 1945-53. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fundamental Studies</h4> <p>The study of normal and amputee biomechanics underlies all improvement in prosthetic replacement. A continuous program of inquiry in this field is therefore essential. Although much of such research is undertaken without immediate practical goal, free inquiry brings to light ideas which find widespread application, as has already been demonstrated time and again. The continuous observation of arm motions and of prosthetic motions provides a nourishing bed of interest and information from which the application phases draw strength and purpose.</p> <p>The program of fundamental studies has featured research on normal motions, analyzed in terms of physical mechanics and in terms of industrial time and motion concepts. These investigations have built up a body of information on the patterns of motion, speeds, forces, and skills that is invaluable in conceiving, planning, and predicting the results of new developments. A special phase of this program has had to do with cineplasty, where the direct utilization of muscle force has remarkable potentialities for prosthetic replacement but where intimate knowledge of the mechanics of the muscle is required in order to obtain successful operation of the prosthesis. Knowledge of stump shrinkage, of finger forces, of external power controls, of accessory body mechanics, of mechanical stresses in the prosthesis during use—all these are fundamental to the proper assessment of normal and of amputee biomechanics.</p> <p>The objectives of the program of fundamental studies in the upper extremity may be summarized as:</p> <ol> <li>To study the performance of manipulative activities in normal individuals and to analyze the activities in terms of biomechanics and of time and motion criteria.</li><li>To compare the motions of amputees with pros-theses with similar motions of normals in order to define the erns of altered and substitute motions peculiar amputees.</li><li>To measure the forces and displacements of muscles and muscle groups in relation to cineplasty, harness controls, and external power controls.</li><li>To define the alterations in general body mechanics in amputees as a result of the asymmetrical loss body weight.</li></ol> <h4>Development of Prosthetic Devices</h4> <p>The "bread and butter" of the ACAL program is the development of improved prosthetic devices, and a major emphasis has always been placed upon this phase of the program. Development of each device originates in the need shown by fundamental studies or by experience with amputees. design, experimental fabrication, amputee test, and field evaluation are the successive steps through which each device must pass. The past and present development laboratories include Northrop Aircraft, Inc., the Army Prosthetics Research Laboratory, and the University of California at Los Angeles, but other agencies, such as New York University and many cooperating industry limbshops, function in the final evaluation phases.</p> <p>ACAL developments in prosthetic devices include new inventions and many adaptations of mechanisms and materials from other technical fields. Engineers have delved deep into the rich heritage of American technology to find applications of plastics, lightweight metals, and mechanisms that have immensely improved the structural and functional characteristics of upper-extremity prostheses. In short, the development objectives are:</p> <ol> <li>To invent, adapt, and apply new materials and mechanisms so as to add new functions, or to improve old functions of prostheses, seeking in the end to provide an armamentarium of devices to meet the needs of every amputee type.</li><li>To design and redesign prosthetic components for simplicity and ease of manufacture, and for durability, without loss of essential function.</li><li>To create a system of interchangeable components which may be singly prescribed for the individual amputee case, but which can be combined into a functionally integrated and an esthetically compatible prosthesis.</li><li>To incorporate cosmetic and anthropomorphic principles into basic design so that prostheses are not abnormally conspicuous and are pleasing from the standpoint of color, texture, and form.</li></ol> <h4>Industry Advisory Participation</h4> <p>From earliest days, ACAL has recognized the benefit that would accrue to its activities if the experienced "know-how" of the industry could be utilized in an effective way. To attain this goal, it was considered necessary to bring into the planning meetings of the ACAL group the counsel of leading prosthetists and limb manufacturers. Accordingly, three members of the limb industry were made members of the Upper-Extremity Technical Committee to serve at the national level, while in Los Angeles a local Industry Advisory Committee was set up to advise and aid the UCLA project. These cooperative ventures have proved to be of great mutual benefit, the objectives being briefly as follows:</p> <ol> <li>To learn from the industry the needs for device development, for advancement in prosthetics technology, and for improvement of amputee services.</li><li>To utilize the experience and judgment of members of the limb industry in determining policy and in planning cooperative ventures involving field application studies.</li></ol> <h4>Contributions to Prosthetics Technology</h4> <p>With the wealth of World War II technological development to draw upon, the ACAL program rapidly adopted new materials and practices, not only in the design and development of new prostheses but also in shop fitting and fabrication practices. Most outstanding of these innovations is the incorporation of plastics for prosthetic use. The principal laboratories under the program, APRL, Northrop Aircraft, Inc., and UCLA, have exemplified these uses, and their reports have been a source of information to the industry.</p> <p>The objectives are:</p> <ol> <li>To adapt new and different materials for use in fitting and fabrication.</li><li>To introduce into prosthetics practice methods of measurement and fabrication tending to improve quality of service and economic efficiency.</li></ol> <h4>Amputee Case Study</h4> <p>In the early stages, the ACAL program emphasized research and development on devices, and amputees necessarily were fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. It soon became apparent, however, that established practices in prescription, fitting, and training of amputees were highly variable and that, to round out consideration of all factors bearing on amputee rehabilitation, these practices themselves should become the subject of investigation. This objective was strengthened by the knowledge that no single design of prosthesis is superior for all amputees but rather that, of many types of equipment, the most suitable selection for a given amputee depends upon his individual personal, social, and occupational needs and desires. Accordingly, the Case Study Program was initiated at UCLA in 1950 and continued until 1952. The large amount of information on the 70 amputees in this study is being reduced for publication; much of it has been directly transferred into the Educational Program (see below).</p> <p>The case study of cineplastic amputees at APRL has followed in its major outline the procedures at UCLA, and much valuable information is being gathered on this important class of amputee.</p> <p>These programs serve an especially important role in bridging the gap between fundamental work in the laboratory and practice in the field. Prosthetics involves, in unique degree, a combination of science and technology with the practical arts. Every amputee is to some extent a special case. It has therefore been . necessary to incorporate the case-study phase in order to ensure the applicability of technical improvements.</p> <p>In concise form, the objectives of the Case Study Program may be stated as follows:</p> <ol> <li>To investigate the application of prostheses to a wide range of amputee types so that a rational procedure for prescription for the needs of the amputee can be formulated.</li><li>To test and develop the elements of physical and occupational therapy that apply to amputee rehabilitation and prosthetic use.</li><li>To discover the effect of occupation, education, recreational interest, and other personal factors of the amputee upon his prescription, fitting, and training.</li><li>To determine effective methods for evaluation of amputee service, not only pertaining to the quality of mechanical equipment but also to the results of training, to the end that the amputee obtains a truly functional prosthesis.</li></ol> <h4>Prosthetics Education</h4> <p>It has been a cardinal principle of the ACAL group that the products of its research, investigation, and development should be speedily disseminated to all technical and professional groups interested in applying such knowledge for the welfare of the amputee. The scope of these activities has steadily in-creased. Early discoveries were conveyed by means of technical reports which were primarily useful to the other member laboratories and to manufacturers within the industry. Later, as case study and other application phases of the program developed, the broader responsibility was assumed of supplying educational materials dealing with many aspects of technical and professional prosthetics service. Two volumes have been prepared. <i>Human Limbs and Their Substitutes</i> (McCraw-Hill, in press) supplies an authoritative reference on prosthetics, while the Manual of Upper-Extremity Prosthetics (University of California at Los Angeles, 1952) has been issued to serve as a shop guide for the practicing prosthetist.</p> <p>Valuable as the printed material has proved to be, it was found that the needs of the prosthetist for advanced training could not be met with sufficient rapidity and thoroughness. These craftsmen, lacking formal institutional training in their specialty, and with the highly variable backgrounds of apprentice training, displayed great need for direct instruction to bring "them up to the standard required by the new technology. Two other professional groups most concerned in amputee service, physical and occupational therapists and physicians and surgeons, were no less in need of learning the newer knowledge of prosthetics. This condition made it imperative to offer an accelerated advanced training in the theory and practical arts concerned in prosthetics.</p> <p>Accordingly, the Prosthetics Training Program was instituted at UCLA with the following objectives:</p> <ol> <li>To give for selected groups of prosthetists advanced training in the skills and knowledge needed to make and fit upper-extremity prostheses using many of the most recent refinements arising from research.</li><li>To give for selected groups of physical therapists and occupational therapists advanced training in the skills and knowledge needed to assist amputees in adjusting themselves physically, mentally, and vocationally to the use of the newer developments in upper-extremity prostheses.</li><li>To enable physicians and surgeons to expand their understanding of the possibilities and limitations of the more recent developments in prostheses and of some effective procedures for taking advantage of these developments.</li><li>To encourage the acceptance and practice of the "team approach" to the problem of prosthetic prescription, in which the physician or surgeon, as captain of the team, is assisted by professionally qualified physical therapists, occupational therapists, and prosthetists.</li></ol> <h4>Field Research Studies</h4> <p>To test the usefulness of the knowledge gathered during the ACAL research program, a field research project was instituted in Chicago during 1952. The intent was to determine whether the local rehabilitation people concerned with the problems of prosthetics-the physician, the therapist, and the prosthetist-would benefit from the new knowledge. Accordingly, a group of Chicago physicians, therapists, and prosthetists were invited to attend a "pilot" course in upper-extremity prosthetics at UCLA, the content of the course being based almost exclusively upon the research performed under the ACAL program.</p> <p>Upon completion of the training, a clinic-was established in Chicago, where a group of 50 amputees was processed in accordance with the information taught at UCLA. The status of each amputee was carefully evaluated both before and after clinic treatment. Results showed a dramatic and clear-cut improvement in the functional and psychological attributes of this group of amputees. Thus, initial field evaluation clearly demonstrated the practical usefulness of the research results when applied to amputees in the local situation.</p> <p>Upon completion of the Chicago study, and in close coordination with the educational program already described, nationwide field studies were instituted under the supervision of the Prosthetic Devices Study, New York University. The purposes of these studies, which are presently going on, are as follows:</p> <ol> <li>To ensure the proper application of the research findings to upper-extremity amputee cases throughout the country.</li><li>To provide the local clinics throughout the country with administrative and technical consultation so that assistance may be provided in the resolution of difficult problems.</li><li>To evaluate the effectiveness of these procedures when applied to amputees, in order to determine where problem areas still exist and thus to direct future research toward the resolution of these difficulties.</li></ol> <p>It is anticipated that, upon conclusion of the present field research program, studies will have been conducted in conjunction with clinics operating in some 40 of our largest communities.</p> <h4>Conclusion</h4> <p>As a result of the upper-extremity prosthetics program, arm amputees can now be provided with reasonably comfortable, functional prostheses. Studies indicate that between 80 and 90 percent of the arm amputees fitted during the UCLA Case Study Program and the Chicago Project continue to wear and use their prostheses. When this is compared with the 10-percent figure estimated for arm amputees throughout the country who wear prostheses, it appears that some measure of success has been achieved. But it is apparent to workers in this field that the progress made to date is merely a step in the proper direction and that we can expect continued improvement in all aspects of upper-extremity rehabilitation.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Bronk, D.W., President, National Academy of Sciences. Address to the Advisory Committee on Artificial Limbs, Annual Meeting, Washington, May 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Strong, F. S., Jr., The Artificial Limb Program: Five Years of Progress. Advisory Committee on Artificial Limbs, NRC, Washington, November 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering and Biophysics, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_004/January-1954-1.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 Objectives of the Upper-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph.D. * https://staging.drfop.org/files/original/892fdbb362b8e10138add9644e5ab5c1.pdf bea506cbf5df4cebb34bc4911c8becb0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_001.pdf Year 1954 Volume 1 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/1954_03_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_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>Bioengineering- Blueprint for Progress</h2> <h5>Augustus Thorndike M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The limbs of man move in space and time, in response to systems of internal and external forces, and in accordance with the laws of mechanics. To restore to any satisfactory extent the functions lost through amputation of an extremity therefore requires intimate knowledge not only of the structure, form, and behavior of the normal limb but also of the techniques available for producing complex motions in substitute devices activated by residual sources of body power. Since adequate replacement of a natural limb with an artificial one requires successful integration of the human mechanism with a toollike device, the biomechanical features of the stump and the physical characteristics of the prosthesis must be wedded as nearly as possible into a single, functional entity.</p> <p>Two-sided as this problem would now obviously appear, it is only in comparatively recent years that the medical sciences of surgery, anatomy, and physiology and the physical one of engineering have been brought together in a unified attack upon the whole problem of amputee rehabilitation. Until recently, surgeons, with few exceptions, had little or no understanding of engineering problems. And heretofore the design and construction of artificial limbs has been conducted mostly by artisans who, however ingenious they may have proved to be, were mostly without formal education in engineering or anatomy. Besides this, except in isolated instances the two worked separately and alone. All of which no doubt accounts for the fact that, as late as World War II, the available artificial limbs fell far short of the standards of accomplishment attained in other fields of research and invention.</p> <p>In the research program coordinated by the Advisory Committee on Artificial Limbs, National Research Council, there have been brought together in harmonious working relationship the individual skills of surgeon and engineer in a sort of mutual bioengineering to produce truly functional artificial limbs. As a result, there has been in the field of prosthetics perhaps more progress during the past decade than in all the preceding 2000 years of limb-making.</p> <p>Because the lower limb is more essential to human activity than is the arm, and also doubtless because the basic functions of the leg are easier to replace than are those of the arm, progress in artificial arms and hands has from the earliest times always lagged far behind developments in artificial legs. This circumstance was reflected in the fact that, when the Artificial Limb Program was established in 1945, much more had already been accomplished in replacements for the lower extremity than in those for the upper. And consequently developments in the ACAL program to date have been most noticeable in upper-extremity prosthetics, despite extensive engineering studies of normal and amputee locomotion and refinements in the techniques of lower-extremity fit and alignment.</p> <p>In any case, the development of prosthetics had necessarily to follow the pattern of developments in surgery, and conversely the surgeon's philosophy with regard to "sites of election" and other matters was necessarily dictated by the character and availability of such prostheses as there were. Since the science of amputation surgery and the art of limbmaking proceed as one, the standards and practices in one field dictate standards and practices in the other, and vice versa. That each of these has now been brought to understand more fully the problems of the other may be looked upon as a major achievement in the art of prosthetics.</p> <p>In the following pages of this issue of Artificial Limbs is to be found substantial evidence that the engineering profession, working with the amputation surgeon, has provided new thoughts, new ideas, and new approaches to the problem of providing adequate functional replacements for the limbless. In the whole Artificial Limb Program there exists no better example of cooperation toward progress than is demonstrated here. In the first of two articles, a surgeon and an engineer collaborate in describing the latest devices and techniques arising from systematic research and the influence which these developments ought rightly to exert upon the philosophy of modern amputation surgery. In the second, an engineer outlines the methodology required in investigation of the normal limbs and in the design of useful replacements. Only through such teamwork in biomechanics can truly great advances in the field of prosthetics be expected. The development of the thirty Veterans Administration and other civilian orthopedic and prosthetic appliance clinic teams has resulted in the better distribution of new knowledge toward improved fitting and alignment of artificial legs and in the design and construction of improved artificial arms.</p> <p>The program of research coordinated by the Advisory Committee on Artificial Limbs involves the participation of government, university, and industrial laboratories. The Veterans Administration, the Army, and the Navy provide the necessary funds for the operation of their own establishments, while the VA provides the contractual authority with the funds necessary for work in the universities and in industrial laboratories. Out of this cooperative effort there have come within recent years improved functional prostheses for almost every level of amputation, particularly for those special amputee cases heretofore considered unsuited for an artificial limb. With the mutual cooperation of surgeon and engineer, there has resulted a cross-fertilization of ideas and a new set of modalities in the rehabilitation of amputees.</p> <p> Nevertheless, the presently available devices, though anthropomorphoid in form, are far from anthropomorphoid in function. Unfortunately, no artificial limb, however elaborate, can ever serve as an ideal substitute for a natural member unless it incorporates some of the features of sensory and muscular control characteristic of the limb it replaces. Therein lies the challenge of the future- to devise mechanisms which not only simulate the motions and the functions of normal limbs but which also provide appropriate feedback of information such as occurs in natural arms and legs. In our present state of knowledge, the ultimate goal of the limb designer is still a long way off. Further progress depends largely upon the continued cooperation of surgeon and engineer, of prosthetist and therapist, and of the amputee himself.</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>Augustus Thorndike M.D. </b></td></tr><tr><td class="clsTextSmall">Acting Director, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, Washington 25, D.C.</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 Bioengineering- Blueprint for Progress Creator An entity primarily responsible for making the resource Augustus Thorndike M.D. * https://staging.drfop.org/files/original/5a4fc207f88a465ad37dcf6b41150096.pdf 479c711e6dc5b0867b71528e3903ffe9 https://staging.drfop.org/files/original/d9ff1b62874d00a6e00a0d672fb43173.jpg 0e51c21a9139763ce305a13968b0cec8 https://staging.drfop.org/files/original/470d0172053dbf6511badf4a238ae5be.jpg 15352b6afae30f74a1a8e9f9ad3f67b6 https://staging.drfop.org/files/original/407855162477bbeecc14efd62661a52c.jpg 724072469eb262d7f443f6bfd29433f7 https://staging.drfop.org/files/original/ea665054cf74df0afd40296eaa419d88.jpg 18d5adb11fc47556e504851627efe5d5 https://staging.drfop.org/files/original/115a307852ee295ff5a6479530d3b830.jpg 57a34343d50ccf4fd7303046f6a9bdcc https://staging.drfop.org/files/original/e9eb5b5f48d616e1dd25a731a081527f.jpg f8fd1d577ec78d9e1f12a765caf2a199 https://staging.drfop.org/files/original/f751c384bf9fac833690768a5251a514.jpg 0f1756a2ea50caf1741b0411c7bdf878 https://staging.drfop.org/files/original/00a80e563c204095cf4122ec59ed733c.jpg 129961f2dc91933885eded5d7c503983 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_008.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 8 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_008.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_008.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>Contributions of the Lower-Extremity Prosthetics Program</h2> <h5>Edmond M. Wagner, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>When, in 1945, the National Research Council launched its program for improvement of artificial legs, the original concept was that the major portion of the work would in all probability consist simply of devising mechanically improved artificial knees, ankles, and feet and of applying new materials to existing designs. But it soon became apparent that, if any appreciable success were to be had, the scope of the work would have to be broadened considerably. For new items that were designed failed Lo satisfy the amputee, and there were insufficient fundamental data on which to base improvements. Such information as was available on the mechanics of the lower extremity was either incomplete or else not presented in such form as to be useful to designers.</p> <p>The character of the fit was shortly found to be a matter of paramount importance in determining the success or failure of a given device. But fitting itself was based largely on the personal experience of individual fitters, and there were in existence no formalized standards or rules for guidance in obtaining proper fit. Moreover, the results of testing of devices were too often based on the impressions of only a few amputees and casual observers, either or both generally not qualified to express a competent opinion. There was not even general agreement on some of the principles involved in the surgery of amputations. Before any real progress could be made, information had to be secured in all these fields and coordinated with data from others.</p> <p>The task of obtaining the required information was assigned by the National Academy of Sciences to a number of subcontractors. At the outset, basic research on problems concerned in lower extremities, including studies on surgery, pain,<a></a> and fitting,<a></a> was placed with the University of California at Berkeley.<a></a> To assist designers and fitters, and to provide a record of the devices and techniques being used in the limb industry, a review of prior art was carried out at Northwestern University,<a></a> and the Surgeon General of the Army sent to Europe a commission<a></a> to study and report on the prosthetics art as practiced in various other countries. Solutions attempted in the past for many problems in leg design are cataloged and described in the Northwestern report<a></a> and in the report of the European commission .<a></a> Development of devices was undertaken by Goodyear Tire and Rubber Company;<a></a> Vickers, Inc.,<a></a> Detroit; C. C. Bradley and Son;<a></a> Catranis, Inc.;<a></a> Adel Precision Products;<a></a> A. J. Hosmer Corporation;<a></a> Northrop Aircraft;<a></a> the U.S. Naval Hospital at Oakland, California;<a></a> National Research and Manufacturing Company;<a></a> the Aero-Medical Laboratory of the U.S. Air Force, Wright-Patterson Air Force Base; the Army Prosthetics Research Laboratory, Walter Reed Army Medical Center; and the University of California at Berkeley . <a></a> Later in the program, the Denver Research Institute<a></a> of the University of Denver carried out an investigation of below-knee prostheses, some additional basic data have been supplied by New York University<a></a> and by the Prosthetic Testing and Development Laboratory of the Veterans Administration in New York City, and another commission<a></a> was sent to Europe to observe progress abroad after 1945. Testing and evaluation of devices has been developed and carried out at New York University,<a></a> and the Orthopedic Appliance and Limb Manufacturers Association has cooperated in general program guidance.</p> <h3>Development of Basic Data</h3> <p>Because prior to 1945 little study had been conducted on the characterislics of human locomotion, because of the complexity of the problem, and because of its highly specialized nature, it was necessary first to devise special equipment for collecting information which, ultimately, would lead to determination of the mechanical and physiological changes occurring during various activities of the lower extremity. A number of pieces of unusual apparatus, such as force plates, a glass walkway (<b>Fig. 1</b> and <b>Fig. 2</b>), and special photographic equipment were designed,<a></a> and from the data collected using this equipment it was possible to determine such factors as the forces and moments in human and artificial legs and the roles played by major muscle groups under a series of conditions. From such findings it has been possible to describe fully the phenomenon of human locomotion and thus to establish a set of realistic criteria for the design and evaluation of artificial-leg components. Aside from applicability to the field of prosthetics, the data collected are useful also to designers of leg braces and to the medical profession in the treatment of pathological gait.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The University of California glass walkway. With this device, motion pictures taken from a single camera yield sufficient information to determine relative motions of various segments of the body during level walking. Subject shown here is wearing an above-knee experimental leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Normal subject prepared for participation in studies using the University of California glass walkway. Some targets are mounted on levers to amplify motions otherwise of small magnitude. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major portion of this work was performed at the University of California, Berkeley, and many of the results have been documented in reports and in the journal literature. Of the many reports issued, most, such as those of Cunningham<a></a>, of Bresler and Berry<a></a> and of Radcliffe,<a></a> generally cover a single phase of the subject.</p> <h3>Creation of Design Objectives</h3> <p>From study of the basic data, and from careful review of current practices, it has been possible to set up a listing of design objectives for leg prostheses, it being understood that above all the prosthesis must satisfy the amputee. Arranged in generally decreasing order of importance, these requirements are as follows:</p> <ol> <li>Security from fall.</li><li>Minimum consumption of energy in normal walking</li><li>Appearance of the walking pattern to compare favorably with that of a normal person.<br /> a. Smooth swing phase, including deceleration of the prosthesis at the end of extension, control of heel rise at the end of flexion, and deceleration of the prosthesis just prior to heel contact.<br /> b. Smooth stancephase, includingattainmentof full extension without final snapping action.<br /> c. Ability to change gait to maintain smooth, normal-appearing gait.</li><li>Ability to extend the leg under load at any time.</li><li>Proper phasing of the locking action, if used, with all portions of the stance and swing phases.</li><li>Performance of incidental operations—such as going up and down stairs and ramps, turning, and sitting down—with reasonable ease and smoothness.</li></ol> <p>A listing of the features desired of leg prostheses at three functional levels (<b>Table 1</b>) has finally evolved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Improvement of Fitting and Alignment</h3> <p>As a result of the early attempts to improve existing knee-brake devices, it was found that fitting and alignment were together often more of a determining factor in amputee acceptance than was the performance of the device itself. In the two trips to Europe,<a></a> various techniques and several mechanical aids for obtaining greater uniformity in fitting were observed. These techniques and devices have been analyzed, and from the resulting knowledge, together with information from the basic studies, improved methods of fitting and aligning above- and below-knee legs have been formulated. All of these observations have been published in a report of the University of California at Berkeley .<a></a></p> <p>In order to make these principles of fitting and alignment easier to apply, an adjustable leg (page 23) for above- and below-knee prostheses, with provisions for individual adjustment of major elements, was designed by the project at Berkeley and turned over to the limb industry. This leg, once adjusted, can be worn by an amputee for periods of a few days to determine if the fitting is satisfactory. To transfer to the permanent prosthesis the measurements thus determined by the adjustable leg, there has been designed a fixture which holds the elements of the prosthesis in position while they are being assembled with the predetermined alignment. With these two devices, which are now available commercially, fittings become quite exact. The ease with which minor adjustments can be made in the adjustable leg makes it possible to try variations in fitting which, previously, were avoided because of the time and expense involved. Moreover, the adjust- able leg has the psychological advantage of demonstrating to the amputee that the fit of the device he is obtaining is the optimum for him.</p> <h3>Methods Of Suspension</h3> <p>A major factor involved in fitting of both above- and below-knee legs is the socket. On the first trip to Europe,<a></a> a number of exceptionally well-fitted suction sockets (page 29) were observed in Germany. This type of suspension had been tried previously in the United States<a></a> and in England with poor results. The successful cases seen in Germany in 1946, however, prompted another trial of the technique in the United States. A thorough study of the shape of the socket and other features involved in fitting of suction sockets was undertaken at the University of California at Berkeley.<a></a> As a result of the successful conclusion of this work, the suction socket has since been widely applied by the United States limb industry and has been accepted by the Veterans Administration as an improved method of fitting prostheses for above-knee amputees where there are no contraindications. The knowledge gained in perfecting the technique of suction-socket fitting and in determining the optimum shape of the suction socket has contributed to improvement in the fitting of other sockets. Development work is now proceeding on suction sockets for below-knee amputees.</p> <p>In addition to the work on suction sockets, a "soft" socket for below-knee amputees, consisting of a thin, resilient pad under a conventional leather or plastic socket lining in a plastic or wooden socket, has reached the testing stage at New York University.</p> <h3>Schools for Prosthetists and Surgeons</h3> <p>Since the suction socket was as much a technique as a device, it was determined that, if the suction socket was to be as successful in general practice as it had been in the development period under the supervision of the University of California, the technique had to be taught to limbfitters throughout the United States. Accordingly, plans were laid for a series of schools to be held in various cities in the United States. A course of instruction was laid out, and under the auspices of the Veterans Administration, with the assistance of the Orthopedic Appliance and Limb Manufacturers Association, a series of schools was held throughout the country. The Veterans Administration, by requiring that fitters and surgeons have certificates from one of these schools before suction sockets could be provided beneficiaries, ensured that the best practices were provided. Establishment of these schools was an important advance, for it provided a mechanism for bringing to the commercial limb industry and medical pro- fession the new techniques and ideas developed. Their success has led to expansion of the principles of the clinic-team approach for handling both upper- and lower-extremity cases.</p> <p>In connection with the suction-socket schools, manuals were issued on how to fit suction sockets. They constituted the first attempt to present, in a manner that would be useful to the limbfitter, data developed in the program. Their success has led to the issuance of manuals on other subjects.</p> <h3>Amputation Surgery</h3> <p>In the early investigations, it became apparent that relative difficulty of fitting rather than surgical considerations often dictated the site of amputation. This circumstance led to a study of the sites of election and to a consideration of whether some changes might not be advisable. Studies have since clearly shown that the longer the stump the more function and control can be obtained-a matter that has not always been fully appreciated. In the above-knee amputee, the increased length of stump is particularly important, since it is one of the governing factors in obtaining stability of the prosthesis in abduction. In the above-knee amputation, it has also been found advantageous to tie the muscles together across the bottom of the stump or otherwise to attach muscles to the bone to aid in obtaining stability in abduction. These new concepts are leading to a revision of amputation practices. There will, no doubt, be other such advances in amputation surgery as more is learned about body mechanics.</p> <h3>Pain Studies</h3> <p>Pain, both phantom and real, has always been a troublesome problem in amputee management. In order to obtain a clearer understanding of and possible solutions to the pain syndrome, a project was instituted at the University of California. Although practical applications of methods to alleviate pain and eliminate phantom pain have been meager to date, the mechanism of pain radiation has been elucidated, and the results<a></a> form the basis for future work in this field.</p> <h3>New Devices</h3> <p>One of the most important parts of the lower-extremity program is the development of new devices. Consequently, device development has been one of the major efforts. In the early stages of the program especially, there was an urgent demand from new Service-connected amputees for improved devices. At the time, the data from the basic studies at the University of California were not available. But because of the urgent demand, a program for invention and development of devices was undertaken simultaneously with the program for developing basic data. While most of these devices were unsuccessful, the time, money, and effort expended developing them were not entirely wasted. For in trying these devices, much needed information was developed, and the need for long-range research on several items of a basic nature was pointed out. As the data were collected at the University of California, devices were pro- duced incorporating features which seemed desirable.</p> <p>A great deal of effort was expended in attempting to perfect a knee lock for above-knee amputees. But most of these designs were abandoned for one reason or another after a few models had been made and tried on amputees. The particular difficulty in obtaining smooth and reliable action in a knee lock was found to reside in the method of control. In addition to knee locks, considerable effort has been expended on coordinated motion between the knee and ankle, toe pickup, transverse rotation in the leg, and control of the swing phase. Numerous devices incorporating such features have been made. Both mechanical and hydraulic devices, with varying degrees of complexity, have been tried.</p> <p>Of all the knee locks tried to date, only two, the Stewart-Vickers (<b>Fig. 3</b>) and the Henschke-Mauch (<b>Fig. 4</b>), appear to have reached the point of having commercial possibilities. More recently, however, there have been indications that proper swing-phase control, coupled with alignment stability or limited stability over the first few degrees of flexion, are all that the average above-knee amputee may need. The more or less elaborate knee locks might therefore be indicated for special cases, for older persons, or for those who prefer "the best" and can afford it. Both Stewart and Henschke-Mauch have swing-phase control devices incorporated in their designs, and both have under test legs in which only the swing phase is controlled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Schematic diagram of the Stewart-Vickers hydraulic leg incorporating knee lock, swing-phase control, and coordinated motion between ankle, shank, and thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Schematic diagram of the Henschke-Mauch hydraulic leg incorporating knee lock and swing-phase control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another lower-extremity device now under test is the University of California four-bar-linkage or polycentric knee (<b>Fig. 5</b>). The four-bar-linkage knee is not a new idea, but the UC version has been so designed that the toggle action existing in prior designs to provide extreme stability as the knee approaches full extension has been eliminated. Instead, it depends for its stability on alignment in fitting. It has the advantage, like many other four-bar linkages, of providing at the start of flexion a pivot point about 6 in. above the actual knee joint-a feature which provides a very favorable mechanical advantage for the amputee to start the leg to flex.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Schematic diagram of the University of California four-bar-linkage (polycentric) knee showing change in center of rotation of shank as knee is flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the UC leg the swing phase is controlled by a radial-vane type of damping device in which hydraulic fluid passes from one side of the vane to the other through suitable needle valves. Hence this device is responsive to gait change and limits excessive heel rise as cadence is increased.</p> <p>The limbshop at the U.S. Naval Hospital, Oakland, California, has developed and had accepted by ACAL a complete above-knee leg featuring a very simple mechanical device for controlling the swing phase in connection with a more or less conventional knee bolt (<b>Fig. 6</b>). This type of swing-phase control is not nearly so responsive to gait change as are the hydraulic units, but it marks a definite advance in the design of artificial knees. Also featured in the Navy leg are a plastic shank and the so-called "Navy functional ankle." The latter (<b>Fig. 7</b>) uses a rubber block with different degrees of hardness at front and rear to provide for plantar flexion and dorsiflexion and at the same time to permit some rotation about the vertical axis of the leg. It is anticipated that the Navy above-knee leg will be available commercially early this summer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. U.S. Navy variable-friction knee. As flexion takes place, projection <i>A </i>of the knee block rotates until it contacts lever arm C, which induces additional friction about the knee bolt to limit heel rise. As extension occurs, projection <i>B' </i>rotates to contact lever arm <i>D, </i>which induces additional friction to decelerate the shank (terminal deceleration). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. U.S. Navy functional ankle. Single cable extends through rubber block of different degrees of stiffness at front and back. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To summarize the work done on new devices for lower extremities, there is now available a large store of information on devices which have been tried and found lacking in one respect or another. With what is now known about performance desired in above-and below-knee legs, it is possible that a review of past developments, coupled with some changes based on present knowledge, may lead to the development of more acceptable leg prostheses. At this time, however, only the Navy functional ankle and the swing-phase control have been accepted as completed devices. Others appear very close to acceptance.</p> <h3>Testing and Evaluation</h3> <p>Throughout the early stages, the development of new devices in the lower-extremity program was retarded by the lack of techniques and organization for objective testing and evaluation. Until the data on the mechanics of walking had been developed, it was almost impossible to set up means for objective evaluation because no satisfactory standards of comparison were available. In addition to this lack of standards, it became apparent early in the program that some means had to be established for testing, under a controlled set of conditions, the devices which appeared ready for production. A testing laboratory at New York University was therefore set up. With its entry into the program, there was obtained a much better evaluation of the desirability of the devices proposed and a much better idea of their mechanical performance . <a></a> It was soon found that most of the devices submitted had minor mechanical shortcomings, and as a result many devices which two or three years ago appeared almost ready for release are only now approaching that point. The field-testing procedure has avoided premature release of several supposedly completed items and has indicated the need for more information on several basic points. It has thus proven to be a very valuable step in the development program, and the information gained in the field tests has fully justified the time and cost of field-testing.</p> <h3>Clinical Program</h3> <p>When the program for development of new devices had reached a certain stage, it became apparent that, if there could be instituted a clinical program to try devices on various amputees under as nearly identical conditions as possible, progress would be much more rapid. Information was also needed to confirm conclusions about the suitability of certain devices for various sites of amputations and for various physical and mental characteristics of the amputee and to determine new types of devices which might be needed under certain sets of conditions. Among others, such questions as the need for, or suitability of, a knee lock, or whether limited stability coupled with swing-phase control would be better, needed investigation and decision.</p> <p>A clinical study was therefore set up under the direction of the University of California at the U.S. Naval Hospital, Oakland, with certain facilities provided by the Surgeon General of the Navy. It is expected that, by providing a complete staff of surgeons, prosthetists, physiotherapists, engineers, and research workers, with the opportunity for controlled fitting and follow-up of patients, rapid progress will be made in improving fitting and alignment techniques, in surgical procedures, and in the development of improved devices.</p> <h3>Development Program</h3> <p>Since the establishment of the lower-extremity clinic, a development group, staffed with people skilled in lower-extremity prosthetic art, including representatives from the industry, has been established. This group has headquarters at the U.S. Naval Hospital at Oakland, California, in close proximity to the clinic. It is expected that they will complete the development of some of the devices partially completed in the past and develop new devices, possibly combining or utilizing some of the ideas and data resulting from development work on these new devices. It is expected that this group will bring the program for new devices somewhere near its required level within the next two years.</p> <h3>Conclusion</h3> <p>Because the improvement of leg prostheses has required research and investigation in many fields, and because of the broad scope of much of the work, its full usefulness will not be realized until some time in the future. Time and study are required to analyze the data and to apply the results of such analyses. Nevertheless, the basic data developed under the ACAL program have already been useful, not only in the design of above- and below-knee prostheses but also in the design of leg braces, and they have proved extremely helpful in the diagnosis of pathological gait. Among the developments of more or less immediate practical applicability are the new techniques introduced for fitting and aligning above- and below-knee prostheses. Devices to facilitate adjustments in fitting so that optimum results can be attained quickly have been developed and introduced to the industry, as has also the equipment for transferring the dimensions determined for the prosthesis.</p> <p>As a result of efforts of ACAL, the suction socket for the above-knee amputee has come into general use in the United States. In addition, the principles developed in the suction-socket program have helped to improve techniques used with other types of sockets, thus contributing generally to the well-being of the leg amputee. Experience gained in the suction-socket program has led either directly or indirectly to the development of the clinic-team concept which is proving so useful in the management of amputees of all types.</p> <p>Certain changes in the surgical procedures of amputation have been suggested, especially in regard to the so-called "sites of election" and to stabilization of the above-knee stump in adduction. Study of the nature and propagation of pain in stumps has yielded results which should be the basis for future advances in treatment and prevention of pain arising from amputation.</p> <p>Outgrowths of the lower-extremity clinical study may be expected to confirm, apply, and develop further the principles of fitting and alignment, to advance further the use of the suction socket, to improve the fitting of conventional above- and below-knee sockets and the "soft" socket for below-knee amputations, and to develop prostheses for other types of amputations. With the above-knee clinic established, the work in surgery, prescription, fitting, and training of the amputee is likely to advance even more rapidly than has been the case in the past.</p> <p>The development of devices with increased function, reliable enough and with benefit enough to the amputee to justify the increased complexity and cost, has proven difficult.</p> <p>Many devices have been built, tested, and found wanting in one detail or another mechanically or else have proven too costly to be practical at the present time. Although thus far only two devices, the Navy variable-friction knee and the Navy functional ankle, have been accepted by ACAL and made ready for distribution, several experimental ones appear to be almost ready for general use. The groundwork in the field of lower-extremity prosthetics has been laid. By 1956 we should see the appearance of many more, and more practical, accomplishments resulting from the preceding eight years of pioneering work.</p> <p><b>References:</b></p> <ol> <li>Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>The development of a hydraulically operated artificial leg for above knee amputations, </i>1947.</li> <li>Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, </i>1947.</li> <li>Bresler, B., and F. R. Berry, <i>Energy characteristicsof normal and prosthetic ankle joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 1954.</li> <li>Cunningham, D. M., <i>Components of floor reactionsduring walking, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950.</li> <li>Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, </i>August 1953.</li> <li>Eberhart, Howard D., Verne T. Inman, and Borisresler, <i>The principal elements in human locomotion, </i>Chapter 15 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-sockei suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, </i>1947.</li> <li>Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., </i>1947.</li> <li>National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, </i>1947.</li> <li>New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, </i>March 1953.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A report on prosthesis development, </i>1947.</li> <li>Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947.</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</li> <li>Radcliffe, C. W., <i>Information useful in the design ofdamping mechanisms for artificial knee joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Radcliffe, C. W., <i>Use of the adjustable knee and align-ment jig for the alignment of above-knee prostheses, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</li> <li>Saunders, J. B., V. T. Inman, and H. D. Eberhart, <i>The major determinants in normal and pathological gait, </i>J. Bone and JointSurg., <b>36A </b>(3):543 (1953).</li> <li>Stewart, John H. F., U. S. Patent 2,478,721, August 9, 1949.</li> <li>United States Naval Hospital (Amputation Cen-er), Oakland, Calif., <i>Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, </i>printer's date 9-29-53.</li> <li>University of California (Berkeley), Prostheticevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>University of California (Berkeley), Prosthetic</li> <li>Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Summary of European observa-tions, summer, 1949 </i>[by H. D. Eberhart <i>el al.], </i>October 1949.</li> <li>University of California (Berkeley), Prostheticevices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>3rd edition, April 1949.</li> <li>University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee, </i>June 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-sockei suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design ofdamping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 1949.</td></tr><tr><td class="clsTextSmall"><b> 26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and align-ment jig for the alignment of above-knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bresler, B., and F. R. Berry, Energy characteristicsof normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components of floor reactionsduring walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Stewart, John H. F., U. S. Patent 2,478,721, August 9, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Borisresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">United States Naval Hospital (Amputation Cen-er), Oakland, Calif., Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, printer's date 9-29-53.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edmond M. Wagner, M.E. </b></td></tr><tr><td class="clsTextSmall">Consulting engineer, 930 Rosalind Road, San Marino, California; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-4.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-5.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-6.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-7.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-8.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Contributions of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Edmond M. Wagner, M.E. * 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 Review Status Status of review after import from old O&P Library into Omeka platform. Not Performed https://staging.drfop.org/files/original/bfcefefb32a201912fdc868f0f0cc04e.pdf 0148ecdd9b99d82897c6b1c95fb4d6cd 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/1979_03_001.pdf Text Any textual data included in the document <h2>To Check Out Or Not To? That Is The Question</h2> <h5>Kurt Marschall, CP&nbsp;</h5> <p>It is now over twenty-five years since the introduction of intensive short-term courses in prosthetics and orthotics at New York University, Northwestern, and the University of California at Los Angeles. These condensed courses have benefitted every practitioner, not only in his practical approach to patient management, but also in his inter-relationship with his peers through a unified and common language that we call "nomenclature." In countless cases, these formal educational courses have served as a springboard to successful completion of the certification examination.</p> <p>It was the Veterans Administration which at that time took the primary responsibility of disseminating and funding prosthetic research programs. Their Clinic Team approach became very popular, leading to the simultaneous education of physicians, therapists and prosthetists/orthotists. Undoubtedly, this close relationship of the three disciplines, working together for one common goal, namely, the rehabilitation of the disabled, has narrowed a gap that formerly was all too visible. I feel it has also helped to lift the field of prosthetics and orthotics out of the dark age, out of its sole "craftsmanship concept" into the more comprehensive classification of "professionalism"—all in all, an appropriate tribute that was long overdue.</p> <p>Every prosthetist/orthotist, having successfully completed these short-term courses, came out a better person, a better clinician. The physician and therapist, by the same token, gained insight into our field as never before. Now all three disciplines in their deliberations at clinic meetings spoke at the same level through a unified language, and intelligent solutions were arrived at by understanding the underlying problems.</p> <p>A by-product of this progressive and noteworthy approach was the respect the prosthetic/orthotic practitioner gained from the medical and paramedical professions, once his continued striving for excellence in performance and elevation of standards was realized by them. This respect, however, was not attained very easily. In our quest for sharing the knowledge and insight into our field with the physician and therapist, we also committed a monumental mistake—making them experts in the fitting, alignment and fabrication of every prosthetic/orthotic device there is. Without realizing it at the time, we gave into their hands a powerful tool, even further, a most powerful weapon —<em>the check-out sheet!!!</em></p> <p>There, in black and white, we developed a questionnaire telling them exactly how to pick a device apart, piece by piece, making them the sole, omnipotent judge of whether to pass or fail it. By setting up this systematic method of examining our devices we have admitted that one cannot trust our professional judgment or technical expertise. I know of no other group in the health care profession that has so mindlessly relinquished its professional prerogatives and intricate understanding of a subject to another discipline, with certainly less knowledge of the particular subject, for its scrutiny. Even today, after 25 years of continuous upgrading, we sheepishly subject ourselves to this procedure. This permits even a therapist fresh out of school, but equipped with a check-out sheet, to suddenly become powerful and to be feared for his or her "judgment" when check-out day rolls around. Countless man-hours and precious components and materials have been wasted when physician and therapist could not see eye-to-eye with the prosthetist/orthotist on alignment, fitting and finishing procedures. A device often had to be altered, sometimes even done over entirely, for rather trivial reasons, not to mention the immense damage inflicted on the patient-prosthetist/orthotist relationship when these so-called "problems" were hashed out in the open, for everyone to hear, rather than in a more private setting.</p> <p>There is no doubt in my mind that the level of education and the competence of every prosthetist/orthotist has risen tremendously in the last two and one-half decades, especially for one who takes advantage of the continued education process. He is a better person than he was 25 years ago, and his knowledge of the subject, "Prosthetics and Orthotics," is vastly greater than that of a physician or therapist. He is a professional who will, without complaint, work his way around a poorly-amputated limb that may not be to his liking for fitting purposes and come up with a functional prosthetic device without asking the surgeon for a revision. He will produce an adequate prosthetic device despite flexion contractures and edema, due to insufficient exercise and lack of proper stump-wrapping.</p> <p>Nobody denies the need for a check-out after a prosthetic/orthotic device has been completed. But yesterday's check-out sheet should be scrapped in its entirety —the sooner the better—and replaced with one consisting of only three questions:</p> <ol> <li>Is the prosthesis/orthosis as prescribed?</li> <li>Is the patient comfortable?</li> <li>Is the prosthesis/orthosis functional?</li> </ol> <p>The above criteria should more than satisfy any physician or therapist.</p> <p>The decision as to pleasing cosmetic appearance, insofar as possible, should be left to the patient.</p> <p>The decision on whether or not accepted standards and principles have been met in the fitting, alignment and fabrication of the device, should be entirely that of the prosthetist/orthotist.</p> <p>The field of prosthetics and orthotics has come of age; so have its practitioners. The check-out sheet has not kept pace with changing times and should be abolished in its present form.</p> Page Number(s) 1 - 2 Year 1979 Volume 3 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 To Check Out Or Not To? That Is The Question Creator An entity primarily responsible for making the resource Kurt Marschall, CP  https://staging.drfop.org/files/original/54dae95f148a182054379dab02968d3b.pdf 8910c8603388bad0090b5916a7fc8ef7 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/1979_03_002.pdf Text Any textual data included in the document <h2>Guest Editorial: Thoughts On The Amputee Clinic Team</h2> <h5>Newton C. McCollough, III, M.D.&nbsp;</h5> <p>The Amputee Clinic team as we know it today, evolved during World War II when the Surgeon General of the Army established a number of Amputee Centers within Army Hospitals to upgrade the management of these patients. Impetus to this multidisciplinary approach was given by the Veterans Administration in 1948 when suction suspension was introduced for the above knee amputee and a protocol was developed establishing the Amputee Clinic Team which initially comprised the physician, the prosthetist and the therapist.</p> <p>Since that time as a more holistic approach to disability developed the team has been enlarged in most clinics to include the occupational therapist, social worker and vocational specialists among other disciplines.</p> <p>The clinic team approach is comprehensive and unquestionably has resulted in superior management of patients with limb loss over the past thirty years. However, recently questions have been raised regarding the efficiency of such a clinic and whether or not a more streamlined approach is desirable from the standpoint of the logistical management of relatively large numbers of patients. The impersonal nature of such a clinic has also been impugned in recent years, and some have felt that the patient may actually be intimidated by such a host of professional personnel.</p> <p>Several years ago, at the University of Miami, a compromise approach to amputee management was undertaken. All new patients and patients with identifiable medical problems (including skin breakdown) were seen in the traditional setting with the physician as the amputee team leader in clinic. Routine follow-up visits and problems which were purely prosthetic in nature were seen in "prosthetic clinic" by the prosthetist and therapist with a prosthetist as the team leader or clinic chief. Other clinic personnel including physicians were available for these clinics but were not necessarily in attendance. This approach was far more efficient in terms of man hours and in many ways more practical than imposing the traditional approach upon all patients at every clinic visit.</p> <p>Two major drawbacks to this system of care slowly became apparent and currently we have resumed the traditional approach to all patients. The first difficulty encountered was that many routine prosthetic visits were also accompanied by concurrent medical problems which could not be identified before the patient was actually seen. Of course, the patient could be referred to the next "full team clinic" but this resulted in undue delay of treatment. Psychological or vocational problems though less frequent were also concurrent in some patients. Secondly, in a major teaching hospital, the education of residents, interns and students suffered from this approach. The critical analysis of prosthetic problems in relation to alignment, gait, suspension, etc. was lost upon students in the absence of interchange between prosthetist, physician and therapist. Additionally, innovative techniques in prosthetic management not infrequently result from discussions involving the prosthetist and physician and the presence of all team members in clinic greatly enhances this aspect of the amputee program.</p> <p>In conclusion, I now feel that the multidisciplinary clinic team approach is sound and has no equal in the educational sphere. Spinoffs from the dialogue created may enhance prosthetic research and thus ultimately patient care. Efficiency in this sytem is less than ideal, but the benefits are greater in the long run. Suitable precautions must be taken to avoid "depersonalization" of the amputee in the multi-disciplinary environment and it is encumbent upon each team member to insure that the clinic experience is a rewarding one for the patient.</p> Page Number(s) 2 - 3 Year 1979 Volume 3 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 Guest Editorial: Thoughts On The Amputee Clinic Team Creator An entity primarily responsible for making the resource Newton C. McCollough, III, M.D.  https://staging.drfop.org/files/original/affc6aca870d2691c532bcb1de52320b.pdf 6da74b52fefbfd84763702e128d153bc https://staging.drfop.org/files/original/4855abea0e973f4417c0b317f993c386.jpg ef252a1fdf4eaa98400bc4eafd5598f5 https://staging.drfop.org/files/original/5f532646ed4a4826e06c36271fd690b0.jpg 86bd762152af57f1311a4b7bda41f25e https://staging.drfop.org/files/original/f10066429e8178e00674e849efd5ad63.jpg 035865f6b9ab5f776a3d2d22e9eaef11 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_009.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 9 - 14 Text Any textual data included in the document The Prosthetics Clinic Team <h5>Charles O. Bechtol, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>With the increasing complexity of medicine and its related sciences, the day is past when a single man can cope successfully with all the specialized problems in the treatment of injury and disease. The "horse-and-buggy" doctor did an excellent job considering the limited number of drugs and facilities avail-able to him. His results, however, can in no way compare with those obtained at a well-conducted, modern clinic, where a team of physicians as well as representatives of all the allied medical specialties are available. A comparable situation now prevails in the field of artificial limbs.</p> <p>The basic Prosthetics Clinic Team is composed of a physician, a therapist, and a prothetist. Workers in other fields, say a psychiatrist or psychologist, a social worker, a vocational counselor, or an engineer, should be available for consultation when the basic team considers that such services are required.</p> <p>Each member of the team has been trained to perform one particular job well, and, despite the considerable education and experience of each of these team members, no one man could be expected to carry out the entire procedure beginning with surgery and ending with the fitting and training of the patient. Although it is not generally stated, the patient himself is also a member of the team, since during the period of fitting and training he must cooperate by carrying out the instructions of the various team members and at the same time make and convey his own observations on the good and bad qualities of the prosthesis.<br /><br /></p> <h3>Function of Each Team Member</h3> <h4>The Physician</h4> <p>The physician acts as the chief of the clinic team. His particular training has prepared him to coordinate various ancillary services in the solution of all types of medical and surgical problems and to follow the progress of the patient until the difficulty for which medical care was sought has been corrected. In the past, this has been known as the "end result idea," more recently as <i>Rehabilitation</i>. The physician, in addition to his specific duties, is able to act in this same supervisory capacity in the prosthetics clinic team.</p> <p>First, the physician can evaluate the general medical status of the patient and either carry out any necessary surgery or, if he is not a surgeon, refer the patient to a properly qualified one. Immediate postoperative care in the hospital is under his direction. Then the prescription for physical therapy, whether preoperative or postoperative, is in his hands, and he is also the person who assumes ultimate responsibility for prescribing the prosthesis.<a style="text-decoration: none;">*</a> Moreover, the physician supervises evaluation of the prosthesis and renders final approval. And lastly, it is his responsibility to ensure that adequate training in use of the prosthesis is provided, to the end that the amputee may be able to gain the full functional advantages offered by a properly constructed, modern prosthesis.</p> <h4>The Therapist</h4> <p>The particular field of the physical and occupational therapists lies in preoperative and postoperative training and physical conditioning. The therapist is almost solely responsible for training in use of the prosthesis and usually for details of the checkout and evaluation procedures. These functions, however, are no more important than are those of physical conditioning and training in use of the prosthesis. And hence the therapist is a most necessary consultant in decisions relating to time of fitting, type of prosthesis, and type of post prosthetic training.</p> <h4>The Prosthetist</h4> <p>The special problem of the prosthetist, of course, is the actual fabrication and fitting of the artificial limb. Thus he is an indispensable member of the team. His consultation is particularly valuable at the time of prescription of the prosthesis. Using the medical data supplied him by the physician and the therapist, he can give excellent advice as to the relative degree of function that can be offered by different artificial-limb components. With cooperation in this respect, later changes in the prosthesis can be held to a minimum and possibly avoided entirely.</p> <h4>Other Consultants</h4> <p>In complex cases, the team will often feel a need for the services of others. It may be necessary to call upon a psychiatrist or psychologist to determine whether the mental attitude of the patient is such that a prosthesis can be used. Or a design engineer may be able to devise a mechanism or component that will be useful in special cases. Finally, the services of a vocational counselor or social worker may be needed in determining some of the future requirements of the amputee.</p> <h4>Administrative Personnel</h4> <p>In addition to the professional services involved, it is mandatory that someone assume the usual administrative responsibilities. An orderly clinic cannot be conducted without someone to schedule the patients' visits, to maintain individual records, and to carry out other administrative functions. This is of course true of any type of clinic operation, but it is perhaps even more important here because of the many factors involved and the numerous disciplines required.</p> <h4>Procedures in the Clinic</h4> <p>An amputee appears before the team a minimum of three times, as shown graphically in <b>Fig. 1</b>. The first visit is for the purpose of preparing the prosthetics prescription, the second to evaluate the amputee and his prosthesis before training, the third to evaluate the amputee and his prosthesis after training.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 1. Steps in the clinic--Team procedure.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 1</h4> <p>If, in the opinion of the team, the amputee is ready for fitting, a prescription is prepared. If for some reason—medical or otherwise—he is not ready, appropriate therapeutic measures are recommended.</p> <p>On hand is a preprescription form (<b>Fig. 2</b>) on which have been recorded such data as the cause of amputation, the patient's background, his physical limitations, and his desires for the future. Before attempting to prepare a prescription, each team member should be thoroughly familiar with the information given in the preprescription form. Unless the therapist is familiar with the case, it is desirable to check any existing physical limitations.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 2. Typical preprescription information form for upper-extremity amputation.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>The prescription is prepared through the cooperative effort of the team and is signed by the physician. Fitting is then carried out by the prosthetist in accordance with the prescription. A prescription form for upper-extremity amputees is shown in <b>Fig. 3</b>.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Typical prescription form for upper-extremity prostheses.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 2</h4> <p>Upon completion of the prosthesis, but before training, the amputee is brought before the clinic team a second time. Here emphasis is placed on "before training." Taken literally, this may mean that the amputee will have no conception of even the simpler control movements. In the final stages of fitting the upper-extremity amputee, however, it is necessary that the prosthetist instruct the amputee in basic control motions in order to ensure that the prosthesis is capable of function as fitted. Accordingly, the prosthetist must be thoroughly familiar with initial training procedures lest unnatural motions have to be unlearned.</p> <p>The primary purpose of the second clinic visit is to ensure that the amputee is ready for training. Included is an evaluation of his physical and mental condition as well as of the degree of comfort and function provided by the prosthesis. A simple but comprehensive series of tests has been developed to aid in evaluating functional aspects in upper-extremity cases, and a description of these appears elsewhere in this issue.</p> <p>When the team is satisfied that training is in order, the patient is referred to the therapist for this phase of the rehabilitation procedure. Although a patient and his prosthesis may meet all the criteria of the checkout procedures during the clinic session, quite often use of the prosthesis or changes of the stump during training make modifications necessary. Hence, the more familiar the therapist is with the functional aspects of the various components of the prosthesis the more quickly can he call such deficiencies to the attention of the team. Not only is time saved, but factors which tend to discourage many amputees are eliminated. The over-all result is added confidence in the prosthetics team.</p> <h4>Visit No. 3</h4> <p>Upon completion of training, the amputee is once more brought before the clinic team for a final evaluation of his ability to resume an active role in society. The patient should be encouraged to request the services of the team whenever required and also to report for follow-up examinations at regular intervals. The length of time between visits depends, of course, upon the peculiarities of each case, but as a rule it is best that the patient be examined at least once a year.</p> <h4>Conclusion</h4> <p>The concept of the Prosthetics Clinic Team is not a mere theory. Under the direction of Dr. Augustus Thorndike, the Prosthetic and Sensory Aids Service of the Veterans Administration has established 30 such teams since 1949. Others are in operation in private clinics and within the Armed Services. The initial success of these teams, often under very difficult operating conditions, has led the Advisory Committee on Artificial Limbs to stimulate development of evaluation techniques that can be used under clinical conditions and to encourage the use of the clinic-team approach for amputee rehabilitation generally.</p> <br /> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Footnote</b></td> </tr> <tr> <td class="clsTextSmall">It must be emphasized that these prescriptions, even though they be signed by the physician, should correctly be the product of consultation by the entire team. It is perhaps in the preparation of these prescriptions that the knowledge of each team member is utilized to the fullest.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Charles O. Bechtol, M.D. </b></td> </tr> <tr> <td class="clsTextSmall">Assistant Clinical Professor of Orthopedic Surgery, University of California; Western Area Consultant for Prosthetic and Orthopedic Clinics, Veterans Administration; member of the Upper- and Lower-Extremity Technical Committees of ACAL.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_009/January-1954-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig3.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 Prosthetics Clinic Team Creator An entity primarily responsible for making the resource Charles O. Bechtol, M.D. * https://staging.drfop.org/files/original/8bb8e9e8755bb707d94843a7f67c3c83.pdf 2d1e1c9eb5739153c629b229aba1573c https://staging.drfop.org/files/original/0aa3c65a77880b3f215c6a379f41ebdf.jpeg 4e53ce2cb0da74c0306d918dbcbf3600 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/1979_03_003.pdf Text Any textual data included in the document <h2>Comment</h2> <h5>Lawrence W. Friedman, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><b></b><strong><a href="/files/original/0aa3c65a77880b3f215c6a379f41ebdf.jpeg">Photo</a>: Lawrence W. Friedmann, M.D.</strong></p> <p>Dear Sir:</p> <p>I have just been reading <a href="https://staging.drfop.org/items/show/179433">Volume II, Number 4, 1978</a> of the NEWSLETTER. While I have a lot to say on immediate postsurgical fittings, whose major problem I fear is the inaccurate name since very few people really fit a prosthesis immediately post-surgically, I think that the part of the NEWSLETTER that deserves the most comment is the reprint of the article "<a href="https://staging.drfop.org/items/show/179433">Prostheses, Pain and Sequelae of Amputation as Seen by the Amputee</a>" from Prosthetics and Orthotics International.</p> <p>There appears to me to be little doubt that the complaints of the amputees are accurate. There is not only poor fitting and poor fabrication, but a tremendous absence of knowledge on what is correct on the part of the medical profession, the amputees, and, unfortunately, sometimes even the prosthetists. We must recognize the fact that many doctors "prescribe" an artificial limb with instructions to the prosthetist to "give the patient a prosthesis" or, if they want to be very accurate, "give the patient an above-knee prosthesis". This leaves the entire prescription, fabrication and sometimes training of the amputee on the prosthesis to the prosthetist, who does the best he can, but is not adequately trained to take over the entire responsibility for the care of the patient. It is the exact equivalent of a doctor "prescribing" a medication for a patient and saying "give heart medicine".</p> <p>Most of the doctors doing amputation have little or no interest in the aftercare of the amputee once the wound is healed. For that reason, the amputee is required to be responsible for his own care and must seek out amputee clinics in which adequate prescription, checkout and training can be given to assure that adequate prosthetic fabrication has been achieved. The average general or vascular surgeon cannot be assumed to have been able to keep up with the latest in prosthetic components, fitting and training. While research is important, we are not, at the present, delivering the standard of care which we could have delivered twenty-five years ago had every amputee the access to an amputee clinic team.</p> <p>It is obvious that the amputees questioned are suggesting checkout procedures, such as x-rays, to measure the accuracy of prosthetic fit which have been available to us and have been used for decades. Unfortunately, it is the "consumer" who determines what is produced in the market place. In my view, the amputees must band together and insist on getting adequate service. When they do so, the competitive market place will give them what they need.</p> <p>In some areas, there is a problem because there are very few prosthetists and the amputee is, to some extent, at the mercy at that individual. With modern transportation however, any dissatisfied amputee should be able to get to a knowledgeable amputee team for adequate care. I know that there are many problems. In a neighboring state I know that the orthopedic surgeons have inhibited any competitor from coming into the state to challenge what everyone admits is an inadequate prosthetist-orthotist because they like that individual as a person, even though they know that the devices produced are grossly inadequate. While this is beneficial to the individual prosthetist-orthotist, it is to the detriment of his patients.</p> <p>Part of the problem is that each amputee is concerned with his own welfare, and when his needs are satisfied to a tolerable level, he tends not to band together with his fellows for their common good. This decreases their effectiveness in demanding optimal care. Rehabilitation is a process in which a patient is made responsible for his own well-being. In this regard, we may have made amputees feel so independent that they have lost sight of the power of communal action.</p> <p>Perhaps the NEWSLETTER format should be duplicated for the amputees as well as for those of us serving the amputees, so that the amputee himself could know what is going on and what devices and techniques are available to him should he need them. Certainly a list of the formal clinics and services would be of help.</p> <p>While there is much discussion of the advantages and disadvantages of different socket designs and other prosthetic components, it appears to me that these are, to some extent, academic discussions, since even the plug fit socket can be made comfortable for the majority of above-knee amputees, provided it is properly fabricated for the individual. What is needed is to improve the state of prosthetic delivery, even more than the state of the prosthetic art. The situation in prosthetics is the same as the situaiton in general medicine, in which in many places in this country what has been known in the medical literature is not getting to the individual patient.</p> <p>As far as upper extremity amputees go, the professor is much more satisfied with the appearance of the cosmetic hand cover than are the amputees themselves. I believe that I have the opportunity in this region to see." some of the most cosmetic hand covers available. They are, despite all our efforts, still inadequate and rejected by the great majority of amputees. As far as myo-electric hands are concerned, all of my patients want them. Most of them use them for a period of a few months and then discard them, except for rare use as a cosmetic hand, since they are so poorly functional as well as delicate. I believe it is important to prescribe one, if the patient demands a myo-electric hand, because he will never be satisfied of its mediocre function, until he has the opportunity to try it. I think the professor needs to be aware of many of its limitations. We, perhaps, get carried away too often by our favoritism for our own development.</p> <p>I believe further discussion on this point would be of help to the amputee community and also to the medical community in its broader sense, to give us a proper perspective of where our problems are.</p> <p>Best wishes for a happy and productive year.</p> <p style="margin-left: 50%;"><i>Lawrence W. Friedmann, M.D.</i></p> <br /> <div style="width: 400px;"></div> <em><b>Lawrence W. Friedman, M.D.<br /></b>Chairman of the Department of Rehabilitation Medicine at the Nassau County , Medical Center in East Meadow, New York.<br /></em><b><br /></b> Page Number(s) 3 - 4 Year 1979 Volume 3 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete. Figure 1 http://www.oandplibrary.org/cpo/images/1979_03_003/1979_03_003-1.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 Comment Creator An entity primarily responsible for making the resource Lawrence W. Friedman, M.D. *