12 20 371 https://staging.drfop.org/files/original/3f041b7c947e529153fa28232c237ff9.pdf d1f852ea47d629b46c047b9ae3e541ec https://staging.drfop.org/files/original/730b7c386610ac5066f7d34810d6e1cb.jpg 5d4cfcb9a11c6bdca221c13237a938da https://staging.drfop.org/files/original/7833aeed5e0f5b304177a2c2f4041545.jpg 8933a2daac139a455663a0839530e760 https://staging.drfop.org/files/original/3b3ef544eebe463014069b1f9f559617.jpg 49669d1ea09bc77fd63e098e093c5229 https://staging.drfop.org/files/original/1f0783dbf17ee81abcf3918ec110bc1a.jpg 3e6547ec9784789f1cd9426bc2316851 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_169.pdf Text Any textual data included in the document <h2>The O.K.C. Above-Knee Running System</h2> <h5>John Sabolich, B.S., C.P.O. <a style="text-decoration: none;">*</a></h5> For many years, above-knee amputees have been trying to run step over step rather than using the hop and skip running gait typified by Terry Fox in his run across Canada. This type of locomotion is still biomechanically defined as walking since it still contains a double support phase when both feet are touching the ground simultaneously. True running has no period of double support. One reason that above-knee amputees have had to run in this manner is that the lower shank does not accelerate forward fast enough for true running due to inertia. While the thigh segment quickly flexes about the hip, the foot tends to stay in place, causing the knee to flex beyond a desirable position and resulting in what is commonly referred to as "excessive heel rise." This excessive heel rise causes a delay in getting the foot-shank complex to move into extension which complicates the amputee's basic problem of not having active control of the knee. It seems that the harder the amputee tries to flex his hip, the worse the heel rise becomes. The O.K.C. system strives to solve these problems. It consists of a cable-housing arrangement (similar to that on a below-elbow prosthesis) that travels behind the hip joint and anterior to the knee axis (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg">Fig. 1</a>). The proximal end of the cable is attached to a belt similar to a Silesian bandage by a short piece of elastic webbing and Dacron tape which is adjustable via a 4-bar buckle. The distal end of the cable is fixed to the proximal anterior shank section of the prosthesis. <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg">Figure 1. Lateral views of prosthesis showing path and attachment points of the OKC running cable.</a> When the hip joint starts to flex, just at the moment of "running toe off," tension in the cable causes a dynamic extension moment at the knee. In other words, power is being transferred to the knee joint directly from the action of hip flexion. When the thigh is fully flexed, the tension in the system is at its maximum. This turns out to be very desirable biomechanically, since the knee needs to be fully extended at heel strike. The O.K.C. system therefore supplies a dynamic force to the shank, much as the quadriceps does in the normal human leg during running (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg">Figure 2. Running sequence showing action of the cable system.</a> It has been our experience that it is easier to start using this system on children running on grass and advance to adults later for two reasons. First, children are not afraid to try to run, especially when the practitioner tells them they are now capable of it. Second, due to lower stresses in the system, the prosthetist can use conventional upper extremity cable and housing components that are readily available rather than specially made cable and hardware which are needed for adults. It has been noted that some children are able to remove the cable after a few months, (much as training wheels on a bicycle) and still do a fair job of running step over step. They gain confidence from the system and use it to fine tune their running capabilities. However, it has been our experience that when truly fast running is required as in competitive events, the patient prefers the O.K.C. System. Parents report that their children like to keep the system in place at all times since it gives them a natural dynamic quadriceps effect. However, some adults prefer to remove the O.K.C. System for normal locomotion. For adult running, we have found that special aircraft grade cable and terminal ends are required due to the increased stresses in the system. It has also been discovered that monofilament fishing line (300-500lb. test line) works quite nicely as the coefficient of friction between the cable and housing is reduced. A plastic housing such as polypropylene tubing (commonly used in air conditioner drains) works best with this monofilament. An extension aid of surgical tubing or elastic webbing augments the O.K.C. System and provides another method of fine tuning the system. Some competitive runners also like to use a flexion limiter with the system. This consists of a 3/4" thick piece of PE-LITE® at the back of the knee joint which does not allow the knee to flex completely. This flexion limiter acts as a compressive stop which tends to bounce the knee into extension and swings out of the way during normal walking. A variety of other methods of limiting flexion can be used. To our knowledge, the first above-knee amputee to ever run step over step on an above-knee prosthesis was in March, 1982 utilizing an O.K.C. System. Since that day, many adults who enjoy competitive running or just sports in general have been fit. The shortest residual limb fit successfully with the O.K.C. System was on a 17 year old above-knee male with a 2 7/8" femur. The longest have been knee disarticulation amputees. <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-3.jpg">Figure 3. Series of photographs taken from video screen.</a> It is easier to implement this system if the patient is using an exoskeletal prosthesis, since the cable and housing have a natural surface to ride and sit on. However, we have placed several on endoskeletal systems with a little creative rigging (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg">Fig. 4</a>). It is also possible to laminate a track directly into the thigh portion of the prosthesis which eliminates the need for housing. However, this sometimes causes excessive breakage unless a section of housing is extended distally to reduce the bending radius distally about the knee. <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg">Figure 4. OKC running cable on an endoskeletal prosthesis. Aircraft cable and terminal ends were used in fabrication.</a> Sitting can be a problem unless the cable or monofilament is placed in such a way as to allow the cable and housing to move posterior to the knee during sitting. This prevents the creation of a knee extension moment, which could be bothersome during sitting. Last, we have found it most helpful that the heel portion of the prosthetic foot be soft enough to provide very easy planer-flexion so as to lessen the tendency for the knee to be forced into flexion by the ground reaction force at heel strike. *John Sabolich, B.S., C.P.O. John Sabolich, B.S., C.P.O, is president of Sabolich Orthotic Prosthetic Center, 1017 N.W. 10th Street, Oklahoma City, Oklahoma 73106. Page Number(s) 169 - 172 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_154.pdf Text Any textual data included in the document <h2>Energy Storing Feet: A Clinical Comparison</h2> <h5>John Michael, M.Ed., C.P.O. <a style="text-decoration: none;">*</a></h5> The human foot is an exceedingly complex structure. The pair contain 52 separate bones, dozens of intrinsic muscles, and scores of extrinsic ones. The feet are composed of multiple layers of ligaments, fascia, and muscle, and contain numerous interrelated articulations. In combination with the ankle complex, the foot provides the dual functions of support and propulsion. Paradoxically, this is accomplished by combining the diametrically opposite characteristics of flexibility and rigidity as the foot adapts to the gait cycle.<a></a> Despite hundreds of historical attempts to imitate this remarkable structure, very few designs have ever achieved widespread acceptance. Within the last three years, however, four new foot components have become commercially available—all in the previously unheard of class called "energy storing" designs. These intriguing new developments will be discussed in chronological order, summarizing our experience at Duke. <h3>Seattle Foot™</h3> In 1978, Bernice Kegal of the Prosthetics Research Study in Seattle published a paper entitled "Functional Capabilities of Lower Extremity Amputees,"<a></a> and noted that a major prosthetic limitation in sports activities was the inability to run. The vigorous amputee athlete was competing despite the components rather than because of them. The Prosthetics Research Study, in cooperation with engineers from Boeing aircraft, began developing a prosthetic foot specifically designed to store energy and release it at push off: the Seattle Foot™. First introduced in 1981 at a course in modern prosthetic rehabilitation presented by the American Academy of Orthopedic Surgeons, the Seattle Foot™ was later field tested by hundreds of Veterans Administration clients. Today, it should be widely acknowledged as the stimulus for the current explosion of new concepts in this area. The design specifics have varied over the past few years as the concept was refined. Originally, the keel was a fiberglas multi-leaf design, somewhat similar to an automobile suspension spring. The key concept was that as the patient increased his cadence, stiffer portions of the spring came into play. Various exotic materials were considered, including titanium, but were clinically impractical.<a></a> The commercial version first became available in October, 1985 and consisted of a Delrin bolt block and integral keel, with Kevlar® toe pad (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg">Fig. 1</a>). The entire structure is contained in a lifelike injection-molded polyurethane shape. To date, over 8,000 Seattle™ feet have been used in the United States.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg">Figure 1. Seattle Foot™ note cantilevered plastic spring keel to store energy (Courtesy MIND).</a> Although patient acceptance has generally been good, several technical difficulties have been noted with this design. During the VA field-testing, catastrophic failure of the plastic keel occurred in some cases. This has been greatly reduced in the commercial version, provided the proper keel configuration is selected using the manufacturer's guidelines. Because of ongoing problems with failure of the flexible rubber toes at the keel tip, the polyurethane composition has recently been reformulated for more tear resistance.<a></a> About one third of our feet at Duke have failed in the forefoot, although all were replaced under manufacturer's warranty. We have experienced no catastrophic failures whatsoever in our series. The "Life-Molds," although very natural in appearance, have presented some difficulties. The first is that the forefoot is fairly wide and often difficult to fit into dress shoes, particularly narrow widths. In addition, there is no uniformity in dimensions from size to size, or even between left and right in the same size. For example, if a patient returns requesting a foot one size smaller since purchasing tighter shoes, and a 26cm foot is substituted for a 27cm foot, the prosthesis has been inadvertently shortened by 5mm (1/4"). Also, the stark contours of the original "Life-Molds" can be difficult to blend into the prosthetic ankle at the retromalleolar area, and are too muscular for some patients. The recently available "Ladies Molds" have effectively addressed the problems noted above. Redesign of the male version is underway, and is expected to achieve similar results. The Delrin keel has also been a source of problems. Because it is very slippery, inadvertent rotation and loss of toe out has occurred. Since drilling and pinning the bolt block would significantly increase the risk of breakage, the manufacturer recommends bonding the foot to the ankle block or endoskeletal adapter with hot-melt glue. This has eliminated problems with loss of toe out in our series at Duke, although we still experienced occasional problems with the keel "slipping" completely out of the polyurethane shell for active walkers. Problems have also been reported with occasional bolt breakage, and speculation regarding cold creep of the plastic has been voiced. The manufacturer supplies special bolts, locktite, and torque specifications to address this issue. We have experienced no bolt problems at Duke. Finally, this is the heaviest solid ankle design commercially available. Although most patients have no apparent difficulties, some find the weight objectionable. One volleyball player, in particular, rejected the foot for jumping activities, even though she found it excellent for jogging and similar sports. Despite the technical difficulties noted, our experience at Duke has generally been favorable. Patients often comment on the "lively" step permitted by the cantilevered spring design. We particularly favor this component in the smaller sizes (26cm and below), as the incidence of breakage seems reduced. One unilateral hip disarticulation amputee commented that the more active push off "lets me pass someone in a crowd for the first time since I became an amputee."<a></a> <h3>Flex-Foot™</h3> At the same time the Seattle Foot™ was being developed, an independent collaboration between a plastics engineer and a young research prosthetist-amputee resulted in creation of the Flex-Foot™. This lightweight graphite composite structure offers a radically different approach. All are hand made from a computer-generated design specific to each individual patient. Data such as weight, activity level, and residual limb characteristics determine the specific orientation and thickness of reinforcement fibers. Ultra high pressure, high temperature molding insures the greatest possible strength to weight ratio, but requires several weeks for fabrication. Although this is a very costly approach, it does permit fitting the widest range of individuals. The chief restriction is that a minimum of five inches is required from the end of the residual limb to the floor, and seven inches or greater is preferred. Thus, the Flex-Foot™ is not suitable for small children, Symes and similar amputations, and very long below-knee residual limbs.<a></a> Unlike any other component currently available, Flex-Foot™ utilizes the entire distance distal to the socket for function. Since it stores energy throughout its entire length rather than just within a four inch keel, this results in a very responsive and resilient component. It also significantly improves the mass distribution of the prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg">Figure 2. Flex-Foot™, showing full-length composite strut for energy return (Photo courtesy Flex-Foot, Inc.).</a> Most multi-functional feet bolt onto the prosthesis at the ankle block, and are heavier than a conventional SACH foot. With the weight concentrated at the distal end, the limb swings as if it were a sledgehammer. Overcoming the inertia of this mass in order to propel it through space consumes energy, and the patient perceives it as "heavy." The Flex-Foot™, however, is more akin to an inverted sledgehammer. The bulk of the weight is in the socket and attachment cone, with the rest uniformly distributed in the pylon. This is analogous to holding the head of the sledge and swinging the handle through space. Even if the Flex-Foot™ prosthesis weighs nearly as much as the conventional limb, the patient finds it much easier to propel, and perceives it as "light." Actual weight savings of 10-15 percent are common, but patients typically perceive that the Flex-Foot™ weighs "half as much." Another advantage unique to the Flex-Foot™ is the ability to independently adjust the anterior and posterior lever arms. Overall stiffness is fabricated in at the factory, but tilting the pylon increases the anterior flexibility. Varying the length of the heel pylon independently controls its resistance. Conventional AP linear slide adjustments affect the resistances in the conventional manner: sliding the foot forward decreases posterior leverage while increasing the anterior resistance. Due to the complexity and magnitude of the inter-related alignment changes possible with the Flex-Foot™, we advocate use of a prototype prosthesis, at least initially. By dynamically aligning the new socket on a conventional foot using a conventional alignment fixture, mediolateral alignment and the quality of socket fitting can be easily evaluated and refined. Once these are satisfactory, the vertical transfer fixture can be used to permit substitution of the Flex-Foot™ pylon. A secondary dynamic alignment is then performed, permitting concentration on sagittal plane characteristics without being distracted by a multitude of adjustments in other planes. Although use of slow-motion video analysis has been of some value in refining the sagittal alignment, we strongly encourage an extended field trial prior to finishing the limb. Application of a PVC bag over the alignment fixture followed by several layers of fiberglass casting tape reinforcement will permit the patient to use the limb clinically for a week or two. Upon return to the laboratory, the fiberglass tape can be removed and the alignment further enhanced. As the patient becomes accustomed to the function of the Flex-Foot™, he will often prefer stronger anterior resistance. A knowledgeable physical therapist can be an asset at this stage, as the person must learn to shift his weight onto the Flex-Foot™ throughout stance phase and "ride it into toe off" in order to achieve maximum benefit from its push off characteristics. Casting tape should be reapplied and the field trial continued. Only when the patient returns, needing no additional alignment changes, can it be assumed the alignment is optimized, permitting transfer and finishing to proceed. A comprehensive fabrication manual is provided by the manufacturer,<a></a> and the instructions should be followed explicitly, particularly regarding reinforcement of the attachment cone. Tremendous stresses are concentrated where the resilient pylon meets the rigid socket, and structural failures of the lamination can occur if improperly fabricated. Cosmetic finishing is difficult and time-consuming, but results in a finished structure that is highly water resistant since the foam provided is used in life preserver construction. If immersion is anticipated, a final sealing coat of Lynadure or other flexible "skin" is recommended. Although our series is small, we have experienced no failures with the Flex-Foot™ system, even on very large and very active individuals. One high school athlete, who destroyed SACH and SAFE feet two or three times per year, has been playing varsity football with the Flex-Foot™ for two seasons without incident. The manufacturer reports an overall failure rate of less than four percent with over 2,500 units in the field. Most failures occurred where the heel pylon bolts attached to the anterior pylon. One common denominator has been a sudden increase in the patient's activity level after being fitted with the Flex-Foot™. A highly active individual (or one who has recently gained weight) using a pylon originally designed for standard duty applications is at risk, so the prosthetist must anticipate the ultimate stresses that will be applied.<a></a> The recent announcement of a "Modular Flex-Foot™" (MFF) represents an effort to expand the usefulness of the Flex-Foot™. Available in standard configurations, these pre-made pylons can be supplied within two weeks. The heel lever arm bolts through the forefoot rather than the highly stressed ankle area, to enhance durability. A refined attachment system permits easier socket replacements, which should encourage application to more recent amputees. And, limited alignment refinements are possible even after permanent attachment to the socket, via Otto Bock "Modular" components or the "pylon connector" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg">Figure 3. Modular Flex-Foot™ (MFF), showing improved socket and heel attachment designs.</a> We believe the cost and complexity of the Flex-Foot™ can be justified due to the degree of function offered. A competitive volleyball player reported her vertical leap nearly doubled when using the Flex-Foot™, and its low inertial drag made activities less tiring.<a></a> A severely debilitated geriatric amputee, who ambulated with a cane due to impaired balance, claimed he could walk "twice as far before my wind gives out" after fitting with the Flex-Foot™.<a></a> And a 47 year old nurse completed the New York Marathon's 26 mile race on the Flex-Foot™ one hour thirty-two minutes more quickly than with a conventional design.<a></a> Hard data to buttress these anecdotal reports are very limited at this time. A motion analysis conducted at the University of Illinois suggests that the Flex-Foot™ allows a more normal range of motion than the SACH foot, even at normal cadences.<a></a> Several centers are reportedly conducting oxygen consumption studies in an effort to verify claims of lowered energy consumption, but none are yet published. Although most Flex-Foot™ prostheses have been used for unilateral and bilateral below-knee amputees, a significant percentage have been applied to above-knee amputees as well, and some hip disarticulation fittings have been completed.<a></a> Our experience at Duke has been chiefly at the below-knee level. Although higher level amputees would benefit greatly from reduced energy consumption, the addition of a passive knee mechanism may dissipate some of the potential return and bears further study. <h3>Carbon Copy II</h3> The Ohio Willow Wood Company introduced the original all-plastic SACH foot a decade ago called the "Marvel" foot. After its demise due to the availability of lighter and more durable feet from other suppliers, they embarked on a research and development project for what they termed the "next generation" of solid ankle feet. A few years ago, Mauch Laboratories approached Ohio Willow Wood to design a foot shell for Mauch's hydraulic ankle. This lead to the development of life-molds, a special micro-cellular polyurethane elastomer blend, and engineering of a carbon composite keel. The result was Carbon Copy I, a relatively rigid shell whose function comes primarily from the ankle mechanism. Development continued, and in May, 1986, Carbon Copy II was introduced as the latest entry into the energy storage arena. In many ways, it represents the synthesis of some of the best attributes of previous designs. This is a conventional solid ankle design, available with three durometers of heel cushion for simulated planter flexion. The keel, however, is a unique dual structure: a rigid posterior bolt block plus flexible anterior deflection plates. The bolt block is a special ultralight reinforced Kevlar/nylon design which recently won the plastic composite industry's "National Award of Excellence" for innovative engineering. A fiberglass/epoxy attachment plate resists deformation by both ex-oskeletal and endoskeletal ankle blocks, while very low density Styrofoam fills the cavities and prevents infiltration of the heavier polyurethane elastomer which forms the outer shell. The anterior deflection plates provide two-stage resistance at heel off. In normal walking, the thin primary deflection plates (which run to the PIP joints of the toes) provide a gentle energy return. At higher cadence or during more vigorous activities, the auxiliary deflection plate provides additional push off. A Kevlar™ glide sock prevents the plate from knifing through the elastomer shell (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg">Figure 4. Carbon Copy II; note rigid bolt block plus dual flexible carbon fiber deflection plates (Photo courtesy Ohio Willow Wood Co.).</a> The exterior design shows a similar attention to practical detail. The contours are lifelike, but not as starkly detailed as the Seattle Foot™. Rather, the veins and retromalleolar undercuts are softened into a more practical "humanoid" configuration. The forefoot width is a bit wider than conventional SACH feet, but less than the Seattle Foot™ version (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg">Fig. 5</a>). Fitting narrow width shoes can sometimes be a problem. <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg">Figure 5. (Dorsal view, L to R) STEN foot, Carbon Copy II, Seattle Foot™ note retromal-leolar contours and forefoot width.</a> The plantar surface is where the Carbon Copy II contour is most unique. Broad and flat (with a full-width carbon composite plate similar to Flex-Foot™), it is shaped to fit the shoe last. Analogous to a well-posted UCBL foot orthosis, this congruence between device and shoe offers maximum mediolateral stability (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg">Figure 6. (Plantar view, L to R) Seattle Foot™, STEN foot, Carbon Copy II; the flatter configuration enhances me-diolateral stability within the shoe.</a> Finally, all these practical details are contained in a package that is extremely lightweight. Significantly lighter than the conventional SACH foot, Carbon Copy II is actually slightly lighter than a geriatric "litefoot." Currently available only in adult male sizes, Carbon Copy II should be available in female sizes in the near future. Some practitioners report that the small keel sizes are noticeably suffer than their full-sized counterparts. In response to that observation, Ohio Willow Wood is retooling for a shorter keel block as well as narrower deflection plates for the women's style, which will initially be offered only in a 10mm (3/8") heel height. We have experienced no failures whatsoever with Carbon Copy II thus far, even for very vigorous applications. The manufacturer reports sales of over 2,000 feet, with known failures in nine cases. Seven were rubber tears at the tips of the toes (reportedly from one particular manufacturing run), plus one split deflection plate and one broken rivet.<a></a> If this early reliability continues, this may be one of the most durable prosthetic feet available. The only other problem noted is insufficient threads on the Otto Bock titanium endoskeletal foot bolt, which can be identified by its bright blue color. Placing one or two spacer washers under the head of the bolt allows it to be tightened firmly without running out of threads. One of the key design criteria for this foot was versatility, and we have found it suitable for many levels of amputation—including unilateral and bilateral below-knee, unilateral above-knee, hip disarticulation and hemipel-vectomy, as well as above-knee/below-knee bilaterals. Overall, the Carbon Copy II and Seattle Foot™ seem to offer similar function to the patient, and the wholesale cost is comparable. At least in the larger keel sizes, most patients have preferred the Carbon Copy over the Seattle Foot™, due to lighter weight and the two-stage resistance. In the smaller keel sizes, the difference is less pronounced, and many prefer the responsiveness of the Seattle design. In general, we consider both Carbon Copy and the Seattle Foot™ design to be good, moderately responsive energy storing designs. <h3>STEN Foot</h3> STEN Foot is one of the simplest designs in prosthetic feet. Externally, it uses the familiar Kingsley foot molds and rubber. This means it is the easiest design to fit in a variety of shoe styles, and comes in the greatest selection of sizes and heel heights: from a child's 18cm keel to an adult's 30cm, including women's widths as well. Soft, medium, or firm heel durometers are available as well.<a></a> Slightly heavier than a conventional SACH foot, the STEN Foot differs in its dual articulated keel. In addition to a metatarsal-phalangeal articulation, it also features a tarsal-metatarsal articulation, thus permitting a smoother, more gradual roll-over than a solid SACH keel (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg">Figure 7. STEN foot; note dual keel articulations and double reinforced belting (Illustration courtesy Kingsley Manufacturing).</a> Although the name stands for "STored EN-ergy" foot, it is our clinical impression that it does not accomplish this goal as effectively as the previous designs. The "keel bumpers" are directly analogous to the toe bumper in an old-fashioned wooden foot; both seem more to dissipate than to return energy. We view the STEN Foot as an additional flexible keel design, similar to the SAFE foot, permitting a smoother roll-over and somewhat greater forefoot supination and pronation than the more rigid SACH design. Since it is lighter than the SAFE foot, fits the shoe more readily, and is available in a broad range of heel heights and sizes, it may offer some advantages. Compared to a SACH foot, patient response has been predominantly favorable. Most preferred the smoother, "softer" roll-over it offers. Some higher level amputees complained of a slight increase in the tendency for the prosthetic knee to "buckle," although this could usually be minimized by plantarflexing or moving the foot more anteriorly. Reliability was a significant problem with early versions of this design, which sometimes failed catastrophically due to rupture of the plantar belting beneath the midfoot articulation. This resulted in a sudden loss of forefoot resistance, causing the amputee to stumble. When three of our initial seven STEN Feet failed in this fashion, we stopped using this component. It has since been redesigned with double belting reinforcements. The manufacturer reports that 3,000 feet have been sold, with no belting failures whatsoever since the reinforcement was added. With the new design, the overall failure rate from all causes is currently under one percent.<a></a> At a recent Academy conference, Richard Carey, CP. reported on over 80 successful applications of the reinforced version of the STEN Foot, and suggested it is particularly appropriate for the new amputee as the softer rollover may facilitate gait training.<a></a> This also might allow an easier transition to a more sophisticated design later, since the flexible keel is a common characteristic of all current "energy storing" feet. <h3>Other Designs</h3> Although not a brand new design, the SAFE foot (Stationary Ankle Flexible Endoskeleton) has recently been advertised as "the original energy storing foot." In our view, this may be stretching the point, since we believe the flexible keel serves primarily to dissipate energy as it accommodates to irregular surfaces. The SAFE foot can be viewed as a solid ankle version of the multi-axis concept, and we consider it an alternate to the well-known Greissinger foot. Both provide significant transverse rotation as well as inversion and eversion, in addition to some degree of plantar flexion and dorsiflexion.<a></a> The SAFE foot has the advantage of requiring no maintenance and being moisture and grit-resistant, while the Greissinger permits independent selection of the plantar flexion and other resistances. We summarize the SAFE foot as an "accommodative" design. It is probably unparalleled for use on uneven surfaces, and many amputees report an increase in residual limb comfort because it absorbs much of the shock of everyday walking. But aggressive racquet sportsmen have complained that it takes a fraction of a second to "wind up" before permitting push off, thus lowering their score. Perhaps the SAFE foot and other soft keel designs should be viewed as offering increased shock absorption and comfort at the expense of responsiveness in a competitive situation. <h3>Clinical Ranking</h3> There are currently no accepted definitions of what constitutes an "energy storing" prosthetic foot. In fact, there is currently no hard data to demonstrate any energy savings at all, despite numerous anecdotal reports. Yet, there is a need to have some means of evaluating and ranking the various designs, to add some measure of rational justification for clinical use of a given component. In reviewing slides of a unilateral below-knee amputee playing competitive volleyball, it was noted that her vertical leap appeared to be noticeably higher with the Flex-Foot™ than with the Seattle Foot™. This difference is likely due to the amount of "spring return" inherent in the components, and may represent one plausible criterion to rank their effectiveness. To test this hypothesis, a simple "pogo stick" apparatus was constructed which permitted interchange of various prosthetic feet (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg">Fig. 8</a>). A non-amputee subject was instructed to jump on the pogo stick for ten hops, trying to attain as much altitude as possible. It is believed that this measures the spring potential of the component as if it were loaded by body weight at midstance. Since the subject's feet both remained firmly on the foot pegs and did not contact the ground, this was felt to be more accurate than measuring unilateral amputees jumping, where the sound limb could partially compensate for the component's deficits. <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg">Figure 8. Pogo stick device used to test vertical spring capabilities of various feet.</a> Using frame-by-frame slow motion video analysis, the amount of ground clearance was measured to the nearest centimeter (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg">Fig. 9</a>). This was not intended to be a controlled study, but rather a simple preliminary investigation; no quantitative judgments should be drawn from this data. Nevertheless, the trends were consistant over multiple trials, and are summarized in <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg">Fig. 10</a>. <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg">Figure 9. Frame-by-frame video analysis of ground clearance in centimeter increments.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg">Figure 10. Ground clearance after vertical leap using pogo stick apparatus; 175 pound male subject, men's size 10 feet.</a> It is interesting to note that <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg">Fig. 10</a> coincides with our subjective clinical ranking of the effectiveness of these designs. Patients given the choice between the SACH and STEN foot, for example, generally chose the more flexible STEN, but patients perferred the Carbon Copy II or Seattle Foot™ to the STEN, because the spring keels "felt more natural." Given the choice between Flex-Foot™ and other designs, the choice was generally for the more responsive composite system. Furthermore, the ranking also reflects the degree of sophistication of the design, and the relative wholesale cost from the manufacturer (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg">Fig. 11</a>). The weight of the components was less straightforward. The inexpensive designs increased in weight as they increased in complexity, weighing progressively more than a conventional SACH foot. However, the two most expensive energy storing designs—Flex-Foot™ and Carbon Copy II—resulted in a lighter prosthesis than a SACH configuration (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg">Fig. 12</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg">Figure 11. Relative wholesale costs for prosthetic foot mechanisms.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg">Figure 12. Weight of men's size 10 foot components, not including ankle block.</a> <h3>Summary</h3> Thanks to the efforts of the Prosthetics Research Study in Seattle, the concept of energy storing prosthetic feet has been widely disseminated.<a></a> Although it is fashionable to claim such benefits, no clear definition of the characteristics required has been established. The author suggests that the ability to leap vertically is one simple measurement of the "springiness" of a component, while reduced oxygen consumption during a measured task would be a more precise definition of an energy-conserving component. All current designs seem to have merit, and have been successfully utilized clinically (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg">Fig. 13</a>). Although limited, the Duke experience has been summarized as a first step toward more clearly delineating the indications and contraindications for each design (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg">Figure 13. "Energy storing" feet through April 1987, Duke University experience.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg">Figure 14. Clinical comparison of prosthetic feet</a>. The conventional SACH foot remains the most widely used design in North America, due to its low cost and reliability. In sports applications, it is particularly well suited for sprinting, since the rigid keel digs into the track, permitting rapid acceleration.<a></a> Multi-axis feet (Greissinger and SAFE) accommodate uneven terrain and dissipate some of the shocks of ambulation, thereby increasing skin comfort. They have been widely used by amputee athletes, although the softer keel resistance may increase the lag between sudden movements. Except for limiting transverse rotation, the STEN foot offers similar function, and may be worth considering for the novice amputee in particular. The Seattle Foot™ and Carbon Copy II are solid ankle devices that attempt to store energy via a spring keel design. They have been well received for a variety of amputation levels, and seem particularly well suited for joggers and weekend athletes. Flex-Foot™ represents the maximum in energy storage potential, and can be individualized for a wide range of applications. It is by far the best design for vertical jumping, thereby lending itself to such sports as volleyball. It has also performed well for long distance running, as well as vigorous sports in general. Finally, all these components have more widespread application than originally assumed. A more flexible forefoot permits an easier roll-over. For the geriatric individual, even a modest decrease in the effort required for walking can offer a substantial improvement in ambulatory potential. The more debilitated the person, the more important the weight and responsiveness of the foot component become. Virtually any lower limb amputee could benefit from the enhanced functioning that a sophisticated prosthetic foot can offer. Although none of these designs will turn the amputee into Superman, each can add a significant dimension to the degree of restoration that can be offered. Jan Stokosa, CP., has noted that although conventional prosthetic limbs restore mobility rather effectively, many patients feel their function has not been restored, so long as vigorous activities remain difficult or impossible to achieve.<a></a> By increasing our collective experience with the components under discussion and pooling our impressions in forums such as this, it is hoped that we can more closely approach that elusive goal: complete functional prosthetic restoration for every amputee. <h3>Appendix</h3> SAFE Foot, Campbell-Childs, Inc., 105 East First Street, P.O. Box 120, Phoenix, Oregon 97535. Flex-Foot™, Flex-Foot, Inc., 14 Hughes, B-201, Irvine, California 92714. STEN Foot, Litefoot, SACH, and Single Axis Feet, Kingsley Manufacturing Company, P.O. Box CSN 5010, Costa Mesa, California 92628. Carbon Copy II, Ohio Willow Wood Company, 15441 Scioto Darby Road, P.O. Box 192, Mount Sterling, Ohio 43134. Greissinger, Single Axis, & SACH Feet, Otto Bock Industries, Inc., 4130 Highway 55, Minneapolis, Minnesota 55422. Seattle Foot™, Model & Instrument Development, 861 Poplar Place South, Seattle, Washington 98144. References: <ol> <li>Beckman, Clarence, personal communication, May, 1983.</li> <li>Brooke, Steve, Marketing Manager, Model Instrument and Development, Inc., personal communication, April, 1987.</li> <li>Burgess, et al., "The Seattle Prosthetic Foot-A Design For Active Sports: Preliminary Studies," Orthotics and Prosthetics, Volume 37, Number 1, pp. 25-32.</li> <li>Burgess, et al., "The VA Seattle Foot," Rehabilitation Research and Development-Progress Reports 1984, Veterans Administration Publications, 1984, p. 5.</li> <li>Campbell, J. and C. Childs, "The S.A.F.E. Foot," Orthotics and Prosthetics, Volume 34, Number 3, 1980, pp. 3-17.</li> <li>Carey, Richard, "The STENFOOT," Continuing Education Course 1-87, American Academy of Orthotists and Prosthetists, Portland, Oregon, March, 1987.</li> <li>Enoka, et al., "Below-Knee Amputee Running Gait," American Journal of Physical Medicine, Volume 61, Number 2, 1982, pp. 66-84.</li> <li>"Flex-Foot™ Fitting and Alignment Procedure," Flex-Foot Inc., 19600 Fairchild, Suite 150, Irvine, CA 92715.</li> <li>Fosberg, Robert, President of Flex-Foot, Inc., personal communication, April, 1987.</li> <li>Graves, J. and E. Burgess, "The Extra-Ambulatory Concept As It Applies To the Below-Knee Amputee Skier," Bulletin of Prosthetics Research, Fall, 1973, pp. 126-131.</li> <li><a href="cpo/1982_04_001.asp">Hittenberger, Drew, "Extra-Ambulatory Activities and the Amputee," Clinical Prosthetics and Orthotics, Volume 6, Number 4, 1982, pp. 1-4.</a></li> <li>Hittenberger, Drew, "The Seattle Foot," Orthotics and Prosthetics, Volume 40, Number 3, 1986, pp. 17-23.</li> <li>Kegal, Bernice, et al., "Functional Capabilities of Lower Extremity Amputees," Archives of Physical Medicine and Rehabilitation, Volume 59, 1978, pp. 109-120.</li> <li>Kegal, et al., "Recreational Activities of Lower Extremity Amputees: A Survey," Archives of Physical Medicine and Rehabilitation, Volume 61, 1980, pp. 258-264.</li> <li>Klenerman, Leslie, The Foot and Its Disorders, Blackwell Scientific Publications, London, 1976, p. 19.</li> <li>"A Material Change for Prosthesis," The Orange County Register, October 31, 1985, Sec.E, p. 12.</li> <li>Martin, Jeffrey, Marketing Director, Ohio Willow Wood Company, personal communication, April, 1987.</li> <li>Michael, J.W., "Prosthetic Feet for the Amputee Athlete," Palaestra, Volume 2, Number 3, 1986, pp. 37-41.</li> <li>Miller, Enoka, et al., "Biomechanical Analysis of Lower Extremity Amputee Running." Final Report to Veterans Administration. Contract Number V5244P-1540/VA Hospital, New York, 1979.</li> <li>Nobbe, Carol, personal communication, September, 1984.</li> <li>Rauch, Colleen, personal communication, November, 1986.</li> <li>Sethi, M.P., "Vulcanized Rubber Foot for Lower Limb Amputees," Prosthetics and Orthotics International, Volume 2, Number 3, 1982, pp. 125-136.</li> <li>Stokosa, Jan, "Total Surface Bearing in Lower Extremity Prosthetics," Region II-III Assembly, American Orthotic & Prosthetic Association, Atlantic City, New Jersey, April, 1986.</li> <li>Truesdell, James, president, Kingsley Manufacturing Company, personal communication, April, 1987.</li> <li><a href="cpo/1987_01_055.asp">Wagner, J., et al., "Motion Analysis of SACH vs. Flex-Foot™ in Moderately Active Below-Knee Amputees," Clinical Prosthetics & Orthotics, Volume 11, Number 1, 1987, pp. 55-62.</a></li> </ol> *John Michael, M.Ed., C.P.O. John W. Michael, M.Ed., C.P.O., is Assistant Clinical Professor and Director of Prosthetics &Orthotics at Duke University Medical Center. <div style="width: 400px;"></div> Page Number(s) 154 - 168 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg Fig 14 cont. http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-15.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/. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_131.pdf Text Any textual data included in the document <h2>Upper-Extremity Prosthetics: Considerations and Designs for Sports and Recreation</h2> <h5>Bob Radocy <a style="text-decoration: none;">*</a></h5> The population of upper-extremity amputees, including congenitally limb-deficient persons, in the United States and abroad is placing increased demand upon the profession for improved prosthetic designs and devices which will allow its members to participate competitively in sports and recreation activities.<a></a> Recreation trends indicate that these demands will most likely increase. Until recently, prosthetics did not directly address the needs of the sports-oriented amputee. Prosthetic designs focused on domestic and vocational needs and did not necessarily target the criteria necessary to perform in the vigorous environments of sports or recreation. Over the years, select prosthetists working with individual amputees have developed "one of a kind" sports devices for their patients. These devices sometimes proved adequate, but most were never made available commercially. Two commercially available sports terminal devices have been available for many years: the Baseball Glove Attachment and the Bowling Attachment.<a></a> Recently, other specialized prosthetic devices have become available to meet the sports-minded amputee's needs. These are the SUPER SPORTs,<a></a> Amputee Golf Grip,<a></a> and the Ski Hand.<a></a> Additionally, new variations in the designs of body-powered terminal devices are allowing amputees to participate in many sports activities without the need for specialized aids or radical modifications.<a></a> The measure of performance by the amputee in any activity, as always, depends upon proper limb design. Socket design, materials, alignment, and components all play a vital role in any amputee's ability to perform competitively. Another important factor is the amputee's physical condition. The prosthesis, no matter how well designed and constructed, cannot supplement atrophied muscle, limited range of motion, or inadequate strength. Sports prosthetics begins with the evaluation of the need and of the capacity of the amputee being served. A physical therapist and potentially a clinic physician will be important components in the rehabilitation of an amputee wishing to become active in sports and recreation. Exercise and conditioning with or without a prosthesis will be required as a preliminary step for an amputee who wishes to excel without injury in sports. Exercise can take multiple forms. Proven exercise techniques exist. Isometric, isotonic, and passive and active resistance all have specific goals and methods. Education is required so that the amputee is knowledgeable about how to proceed with an exercise program and to determine the objectives, i.e. is muscle hypertrophy (bulk) required for strength or is muscle endurance more appropriate? Additionally, how are flexibility and range of motion impacted? Preprosthetic exercise may be required or desired. Weight harnesses<a></a> (Figs. 1, 2, and 3) rather than strap or cuff weights are a better way to approach exercise without a prosthesis. A properly designed harness will prevent weight slippage during exercise and will enable many variations of upper-extremity conditioning (Figs. 4, 5, and 6). Figures 1, 2, and 3. Weight harnesses, rather than strap or cuff weights, are a better way to approach exercise without a prosthesis. Figures 4, 5, and 6. A properly designed harness will prevent slippage during exercise and will enable many variations of upper extremity conditioning. Bilateral exercise using a dumbbell on the non-affected side is important to maintain muscle balance and reduce spinal stress. A full length mirror aids the amputee in viewing him or herself in order to correct postural deficiencies or extraneous movements to optimize resistance exercise efforts. Certain weight machines also allow for non-prosthetic exercise, but exercise will be limited to specific muscle groups (Figs. 7, 8, 9, and 10). Complete upper-body conditioning will be most effectively accomplished while wearing a prosthesis. Furthermore, exercise while wearing a prosthesis will help condition the residual limb to the skin stresses and shears a prosthesis will create when under load. Modern exercise equipment systems, such as Nautilus, Hydra-Fitness, and Universal, are available virtually everywhere in YMCAs, community recreation centers, health and sports clubs. A planned program for the amputee can be structured by professional instructors to the amputee's goals. Free weights are another alternative or can complement a weight conditioning program with the convenience of low cost and home use. Equipped with a proper terminal device (Fig. 11), an arm amputee can safely handle dumbbells or barbells in weight training. Figures 7, 8, 9, (above) and 10 (right). Certain weight machines also allow for non-prosthetic exercise, but exercise will be limited to certain muscle groups. Figure 11. Amputee lifting dumbbell with a terminal device. Proper conditioning balanced by flexibility achieved through passive stretching, aerobics or any number of alternatives will result in the range of motion and strength an amputee will need for high performance in sports and recreation. A regular conditioning program will especially enhance the use of body-powered prostheses which require activation through body-controlled movements. Sound limb design, mentioned previously, is a major component in an amputee's performance potential. Lightweight yet strong prostheses are ideal, but strength should not be sacrificed just to achieve reduced weight. Socket design is dictated to a certain extent by stump configuration, but it is the author's belief that, if at all possible, a supra-condylar socket should be used.<a></a> Supra-condylar sockets with all their variations (Muenster, Bock, etc.) have evolved rapidly with advances in electromechanical limbs. A supra-condylar socket need not be unduly restrictive, and such a limb allows for less complicated harnessing. Carbon fiber and acrylic resins are two materials which lend well to the lightweight but high strength prosthetic objectives. Socket padding,<a></a> whether fully or partially lined, aids in protecting the condyles, olecranon, and distal residual limb end from trauma. If adequately reinforced, ISNY<a></a> style sockets may prove to be applicable for sports as well, but the published data on below-elbow applications is scarce. In addition to padding, the author recommends a heavy residual limb sock or two regular weight socks for most sports activities. Highly absorbent terry lined socks (designed for athletic footwear) are excellent. A polypropylene sock can be used effectively as a liner if heavy perspiration is a problem. An adjustable excursion harness,<a></a> such as the modified Northwestern (Fig. 9) which allows for excellent range of motion and terminal device control, can be applied, although other designs will work. Rapidly adjustable excursion is a plus for actuation of voluntary closing terminal device systems and in sports where gross motion of the arms is required, i.e. archery, golf, baseball, etc. Cable efficiency may also be targeted for consideration. Several experienced amputees known to the author wax the stainless steel cables before assembly into the cable housing. The wax is clean and reduces cable to cable housing friction, thus improving efficiency. Alignment of the prosthesis on the residual limb also requires consideration, depending upon the amputee's sports needs. Preextended, as opposed to pre flexed, socket designs have useful applications in sports. They allow for full elbow extension while limiting flexion only slightly and usually not unacceptably. Wrist alignment is also of consequence and affects the manner in which the prosthesis torques on the residual limb when load is applied. It is important to emphasize the need for prosthetists to be concerned with dynamic forces on the prosthesis. A mere static fitting with a check socket will not suffice because it doesn't accurately duplicate what will occur in the definitive prosthesis. A secondary fitting session with a foamed, but unlaminated, prosthesis donned and the chosen wrist unit and terminal device in place can determine the optimum alignment of the components. Changes can be made accordingly and retested so that the definitive prosthesis will fit correctly. Testing the prosthesis in this manner will also determine if undesirable trim lines exist in the socket or whether extended padding is required. A supra-condylar fit socket on short residual limbs can cantilever on the epicondyles and cut in proximal to the olecranon when the prosthesis is loaded distally making it impossible to carry any significant load (Fig. 12). Extending the trim line can direct pressures to the back of the humerus instead of into the joint. Figure 12. A supra-condylar fit socket with an undesirable trim line. Two other techniques which can aid in creating a more suitable sports prosthesis are external padding and suspension sleeves. Nylon covered neoprene rubber, such as a diver's wet suit material, is readily available and makes an excellent "stretch to fit" cover for a prosthesis (Fig. 13). Thicknesses from 3 mm to 1/4" are available. The material provides a good cushion for contact sports, helps reduce limb trauma during a fall, and the thicker materials have enough bouyancy to float a prosthesis. This technique has satisfied the requirements for a padded prosthesis in several school systems around the country. Figure 13. Nylon covered neoprene rubber, such as a diver's wet suit material, is readily available and makes an excellent "stretch to fit" cover for a prosthesis. Suspension sleeves can improve a supracondylar fit, especially when using a passive recreational device where the cable is absent or does not play a role in prosthetic suspension. Both latex and neoprene sleeves designed for below-knee amputees are available and can be modified for upper-extremity use simply by cutting them down in length (Fig. 14). The advantages of using a commercially available below-knee sleeve is that angulation for a joint is already built in. The author prefers neoprene due to its durability. Both cause increased perspiration within the socket. Designed properly, a neoprene prosthetic cover can function as a suspension sleeve as well. Figure 14. Both latex and neoprene sleeves designed for below-knee amputees are available and can be modified for upper extremity use. The remainder of this article will focus on modifications for specific sports and recreation to which the author has been exposed either directly or indirectly. In some cases, the solutions are simple; in others, performance dictates a more complex technical solution. Photographs and drawings have been used as often as possible rather than the written descriptions to illustrate a modification, device, or technique. Activities are dealt with alphabetically for convenience sake. <h3>Archery</h3> Modern archery equipment is easily adaptable to certain types of terminal devices. Fig. 15 illustrates how a bow riser (handle) can be wrapped with consecutive layers of rubber, foam, and bicycle inner tube to create a durable, functional bow grip.<a></a> A chuck or pin can be used to jam the thumb of the terminal device closed around the riser or the amputee can just "hold on" as illustrated by Fig. 16.<a></a> Performance capabilities are exemplified by the amputee archer in this photo. He is a skilled hunter who has harvested three deer in a four year period. Figure 15. A bow riser (handle) can be modified to create a functional bow grip. Figure 16. An amputee can simply hold on to the bow as shown. <h3>Basketball, Soccer, Volleyball, and Football</h3> Until recently, aids for amputees in ball-sports were limited to padded hooks, cosmetic hands, and custom one-of-a-kind terminal devices. Although these devices were useful, they rarely provided the type of high performance characteristics the sports-minded amputee required to compete successfully. One possible answer or solution is now available. The SUPER SPORTs devices, sized for all ages, are designed specifically for ball-sports and other rigorous recreations in which hand/wrist flexion/extension is needed. Additionally, they absorb shock as well as store and release externally applied energy (Figs. 17, 18, and 19). SUPER SPORTs are passive, not cable activated, but are helpful in catching and ball control when used in opposition to an anatomical hand or another device. SUPER SPORTs combined with padded arm covers create a safe, effective prosthesis for sports, such as football, basketball, and soccer in which interpersonal contact is inevitable. Figures 17, 18 and 19. The SUPER SPORTs devices sized for all ages, designed specifically for ball sports and other rigorous recreations in which hand/wrist flexion/extension is needed. <h3>Bicycling, Tricycling, and Motorcycling</h3> Bicycling or tricycling has proven to be an aggravation for amputees equipped with conventional style hooks. Lack of adequate gripping strength and finger shapes have hampered performance. Presently, however, children and adults equipped with newer style voluntary closing terminal devices (Figs. 20 and 21) can control two or three wheeled cycles as well as their two-handed peers. No modifications are required except when hand brakes are present. Front and rear brakes can be actuated from a single hand lever. Brake pressure must be regulated so that braking forces are always applied to the rear wheel first for safe handling. Your local bicycle shop can usually solve hand brake complications. Figures 20 and 21. Children and adults equipped with newer style voluntary closing devices can control two or three wheeled cycles as well as their two handed peers. Special adapters have been designed for or by individuals interested in competitive bicycle racing (Fig. 22).<a></a> The prototype illustrated is simple and is designed for safety to "quick disconnect" or "break away" at certain levels of force. Figure 22. Special adapter for use in bicycle racing. Motorcycling is a natural extension of bicycling. Again, hand brakes and, in this case, a clutch hand lever complicate the situation. Unilateral amputees missing their left hands can shift and clutch with one hand with practice. Brakes again can be combined. A single foot lever is practical for driving dual master cylinders for hydraulic brakes. The rear wheel braking must occur first however. A local motorcycle mechanic or custom motorcycle shop can provide ideas or adaptations and modifications to standard equipment. <h3>Canoeing and Kayaking</h3> The author's experience with conventional terminal devices proved frustrating during these types of recreation. Split hook finger shapes did not adequately adapt to a paddle or oar. Lack of prehension inhibited the bilateral arm function required for these activities. Locking type terminal devices should never be used in water sports activities. Figs. 23 and 24 illustrate how new technology and minor modifications to paddles can overcome problems in canoeing. Figures 23 and 24. New technology and minor modifications to paddles can overcome problems in canoeing. Kayaking (Fig. 25) with a double-bladed paddle requires only coordination and practice. Rubber rings on the paddle which are used to keep water off the central shaft work equally well in preventing terminal device slippage. Figure 25. Kayaking with a double-bladed paddle requires only coordination and practice. Gross arm movements, such as paddling or rowing, inherently activate voluntary closing devices and keep them closed. Rowing using an oar and oar lock can be enhanced by adding a stop or flange to the oar handle to prevent the terminal device from inadvertently pulling off during a power stroke. <h3>Dance/Floor Exercise and Gymnastics/Tumbling</h3> Activities, such as dance, tumbling and floor exercise gymnastics, have been treated similarly to ball sports in the past due to a lack of specialized terminal devices that were readily available. Padded hooks, cosmetic hands and some custom pedestal style terminal devices have been applied to attempt to satisfy the amputees' needs for balanced bilateral function. Fig. 26 illustrates how the SUPER SPORT terminal devices can be applied to satisfy these specialized recreation niches. Figure 26. SUPER SPORT terminal devices can be applied to satisfy specialized recreation niches. <h3>Fishing</h3> Fishing is a sport and pastime everyone has access to and should be able to enjoy. Amputees using split hooks who wish to have improved control of reels might want to consider the Ampo Fisher I<a></a> which adapts to their prosthesis and reel (Fig. 27). Figure 27. Amputees using split hooks may want to consider the Ampo Fisher I which adapts to their prosthesis and reel. Another alternative for the high level amputee is the Royal Bee Electric Retrieve Fishing Reel system (Fig. 28).<a></a> Figure 28. The Royal Bee Electric Retrieve Fishing Reel systems. Amputees equipped with voluntary closing terminal devices do not require many modifications to fish. A handle modified with some rubber inner tube or tape is usually all that is required to operate a spinning or bait casting reel, due to the improved prehension of these types of terminal devices (Figs. 29 and 30). Figures 29 and 30. A handle modified with some rubber inner tube or tape is usually all that is required to operate a spinning or bait casting reel. Casting with a prosthesis is awkward due to lack of wrist flexibility. Amputees usually control the pole with their natural hand then switch hands to reel or reel with the terminal device. Most reels are available in left and right handed models to suit various physical conditions. Fly fishing poses more of a challenge due to the two-handed dexterity required in handling the fly line. One alternative is the Fly Fishing Reel for Amputees<a></a> (Figs. 31 and 32). This system has been used successfully, although the author feels there is still a need for improved alternatives. Figures 31 and 32. The Fly Fishing Reel for Amputees. Automatic fly reels have been experimented with unsuccessfully due to the difficulties involved in "pulling out line" to wind up the return spring in these reels. Additionally, it was discovered that the spring force was only sufficient to pull in slack line, not with line under drag or a fish engaged. <h3>Golf</h3> Due to its popularity, golf has rules (USGA 14-3/15) regarding artificial limbs established by U.S. Golfing Association for tournament play. Variations in golf aids have evolved over the years primarily as individual designs to suit specific amputee's needs. Recently, however, a device called the Amputee Golf Grip (AGG)<a></a> has been introduced. The AGG is a standardized manufactured product which meets the USGA requirements (Figs. 33 and 34). The device is somewhat similar to the Robin-Aids Golfing device<a></a> (Figs. 35 and 36). Both devices utilize a flexible member to attach to the prosthesis and do not require club modification. They allow for complete wrist/club flexion and extension. The Amputee Golf Grip also allows for unrestricted rotation. Figures 33 and 34. The Amputee Golf Grip is a standardized manufactured product which meets the USGA requirements. Figures 35 and 36. The Robin-Aids golfing device. Other attempts to produce a functional aid should also be noted. One custom device is designed to have clubs attach directly to the prosthesis (Fig. 37).<a></a> Similarly, another model, the Atkins Golf Aid,<a></a> also attaches into the end of the club, but uses a ball-socket swivel. The swivel allows for a limited degree of wrist/ club, flexion/extension, and complete rotation. Figure 37. A custom device designed to have clubs attach directly to the prosthesis. The author has tried several devices and prefers those that do not require club modification and which provide for total flexion/extension/rotation at the wrist/club interface. This allows for a complete back swing and smooth follow through capability. It is important to note that certain of these designs function more easily with one hand than another and must be played cross-handed for opposite side amputations. <h3>Guns/Hunting</h3> Almost any amputee can redevelop the skills necessary to handle a firearm safely with some simple gun modification. In many cases, a standard military sling can prove useful for handling a rifle. Another technique is to add a ring to a forearm sling mount which can then be grasped or engaged with a terminal device. Improved control can be created by adding a custom pistol grip to the forearm of the rifle or shotgun (Figs. 38 and 39). This modification will even allow for the safe operation of pump style shotguns or rifles. Consult with your local gunsmith for help in this regard as he has the knowledge and the tools to perform the modifications correctly. Figures 38 (above) and 39 (left). Improved control can be created by adding a custom pistol grip to the forearm of the rifle or shotgun. Terminal devices can be used to trigger guns as illustrated in Fig. 40, but practice is obviously important. Figure 40. Terminal devices can be used to trigger guns, but practice is obviously important. Other modifications/aids like the Blevin's gun yoke (Fig. 41) illustrate what inexpensive devices amputees have designed for themselves to regain access to a favorite recreation. Figure 41. The Blevin's gun yoke illustrates what inexpensive devices amputees have designed for themselves. Persons with higher level amputations, multiple leg/arm amputations, strokes, or paralysis resulting in para or quadreplegia can also participate in shooting and hunting. Many states have now legalized hunting from parked vehicles to aid severely disabled sportsmen. Additionally, devices such as the SR-7721 (Fig. 42) or home-made Para-Quad Shooting System<a></a> (Fig. 43) offer capabilities not easily accessed in the past. Figure 42. The SR-77. Figure 43. The Para-Quad shooting system. One final design illustrates how an over and under shotgun can be modified to shoot one handed (Fig. 44). Figure 44. An over and under shotgun modified to shoot one-handed. <h3>Hockey</h3> A terminal device for hockey<a></a> (Fig. 45) developed in Canada is an ingenious aid for the hockey enthusiast. It is composed of an adjustable tension ball socket which fits with an adaptor onto the end of a hockey stick. The design allows for the stick to pivot under external force and quick release/flex during a fall. The original model pictured was custom designed for the young hockey player, but if modified with stronger materials, it would be applicable to adults as well. Figure 45. A terminal device for hockey developed in Canada. <h3>Mountaineering</h3> Mountaineering is a less accessible, less popular sport for most of the population, but it does attract enthusiasts and disabled persons. Figs. 46 and 47 illustrate the author during a technical climbing training session. Voluntary closing devices, because of their ability to grasp rope and control gripping force, have proved useful to mountaineering. Instruction and guidance by professional climbing instructors is a must, and "safety first" procedures are always dictated. Figures 46 and 47. The author during a technical climbing training session. <h3>Music</h3> Information and devices to aid amputees playing instruments is scarce. Recently, however, information on a new guitar prosthesis was published in Canada<a></a> (Fig. 48). Dan Roy, the guitarist, in conjunction with specialist Armand Viau have developed a prosthesis which allows Roy to use his shoulder to strum the guitar. The arm is lighter than a conventional prosthesis and can hold a guitar pick. Figure 48. A new prosthesis which enables guitarists to strum their instrument using their shoulders. Figures Figs. 49 and 50 illustrate how some newer terminal devices, such as the ADEPT,<a></a> have proved to be viable solutions for children wishing to "play" musician. Figures 49 and 50. Newer terminal devices, such as the ADEPT, have proved to be viable solutions for children wishing to "play" musician. <h3>Photography</h3> Custom photography and camera adapters have been fabricated for years. Now a device called the Amp-u-Pod<a></a> (Fig. 51) is a standardized, manufactured product which has proved to be an extremely effective aid for the amputee photographer. Designed to replace the amputee's regular terminal device, the Amp-u-Pod mounts directly to the prosthesis and adapts to any 35mm, movie, or video camera equipped to receive a tripod. Figure 51. The Amp-u-Pod has proven to be extremely effective for amputee photographers. <h3>Sailing</h3> Amputees are less restricted in this recreation, but handling rope lines and other types of sailing gear can place demands on the sailor to have two-handed capabilities. Fig. 52<a></a> illustrates a triple amputee who found a GRIP<a></a> terminal device to be one of his best assets for sailing. Figure 52. A GRIP terminal device used for sailing. <h3>Snow Skiing</h3> Amputees have experimented with a number of ways to attach a ski pole to a prosthesis with little functional success. The Ski Hand<a></a> (Fig. 53) is the first standardized manufactured terminal device designed specifically for skiing. Available in varying sizes, the amputee force fits the Ski Hand over a ski pole after removing the standard hand grip. The Ski Hand proved worthwhile for cross-country skiing where upper-body strength is required for propulsion. During downhill skiing, the author found the device of less advantage due to the shallow angle to which the pole enters the hand. The pole basket had a tendency to drag in the snow and was therefore more difficult to control. Novice skiers, however, will find the Ski Hand useful because it enhances maintaining balance and getting up after a tumble. Figure 53. The Ski Hand. <h3>Swimming</h3> Swimming for many upper-limb amputees requires no aid whatsoever. However, for those individuals who wish to perform better or compete in the water, several devices have evolved as custom, one-of-a-kind solutions. The Viau-Whiteside Swimming Attachment<a></a> (Fig. 54) and the P.O.S.O.S./Tablada Swimming Hand Prosthesis<a></a> (Figs. 55 and 56) are two with which the author is most familiar, although others may exist. Figure 54. The Viau-Whiteside swimming attachment. Figures 55 and 56. The P.O.S.O.S./Tablada Swimming Hand Prosthesis. The Tablada hand is flat rather than curved to prevent submarining of the prosthesis during pre-stroke arm extension (Australian Crawl) in order to generate greater stroke volume. Additionally, note that the Tablada system uses a prosthesis which is close to actual anatomical arm length, whereas the Viau system has a shortened forearm section. Both utilize a pre-flexed, rigid elbow design. The Viau arm was designed primarily for back stroke swimming and may therefore account for the curved terminal device shape which would not hamper this style of swimming. The author is also aware of the use of SUPER SPORT devices for swimming, especially for children unaccustomed to the water. Pistoning of the prosthesis can be one of the most common occurrences during swimming. A suspension sleeve can aid in eliminating this action. An additional consideration related to swimming and skin or scuba diving is that the prosthesis is not as buoyant as the body and can seem heavier than normal in water and sometimes will impair performance. <h3>Water-Skiing</h3> Water-skiing can be an extremely dangerous recreation if not approached with caution. The author suggests the following rules of good judgment if water-skiing is on an amputee's wish list of recreational pursuits. First, don't ever lock onto a ski rope handle with any terminal device or use a terminal device which requires a cable and harness system. Second, use a ski rope equipped with a single handle. Third, wear a self-suspending, condylar socket that can be twisted free of under stress. A suspension sleeve will aid support but not impair release of the socket due to the flexibility of the material. Fourth, have a neoprene arm cover for the prosthesis which will float the arm in the water if it comes off. Fifth, always wear an approved floatation vest. The Water Ski Hook<a></a> (Fig. 57) is a simple solution to water skiing that has proved safe when set up and used properly. The Ski Hook should be mounted on the prosthesis in a canted position and tightened into place so that it cannot rotate freely. The shallow hook design provides support, yet will twist off a ski rope handle. Should a fall occur where twisting off is impaired, the supra-condylar socket can be "torqued off" the arm and save the amputee's shoulder from potential trauma. Figure 57. The Water Ski Hand is a simple solution to waterskiing problems. Another solution to prevent injury is to have the tow rope attached to the boat with a quick release, or equipped with a second handle (for small children only) and always manned by an observer/handler. Should the amputee skier go down, the observer can release the rope instantly, preventing injury. The Ski Seat<a></a> (Fig. 58) and E-Ski<a></a> illustrated in Fig. 59 are viable answers for the high level bilateral amputee and the paraplegic or quadraplegic who wishes to enjoy the thrill of skiing. The sled is custom constructed and has two skis. The E-Ski, a newer device, has only one ski and a cage seat. Figure 58. The Ski Seat. Figure 59. The E-Ski. <h3>Wind Surfing</h3> Wind surfing is a relatively new recreation which combines aspects of sailing, surfing, and hang gliding. Load coordination and balance compounded by the need to grasp, maneuver, and rapidly let go of a cylindrical boom as well as uphaul a rope with mast and sail in tow are some of the obstacles the amputee windsurfer faces. A prototype voluntary closing wind surfing terminal device is illustrated in Figs. 60 and 61. Other considerations should include special adjustable harnesses and cable systems for ocean or cold water sailing. Salt accumulation can foul cable function and negate terminal device operation. Wet suits, due to their tight elastic fit, will also interfere with cable function if the cable is worn inside the suit. The harness and cable system must be designed to fit on the outside of the wet suit for unrestricted terminal device operation. Leather on the prosthesis or harness should be avoided, as well as hardware which corrodes. Performance wind surfing is a physically and mentally demanding sport, and the amputee needs to be cautious and prepared to participate safely. Figures 60 (above) and 61 (right). A prototype voluntary closing wind surfing terminal device. <h3>Summary</h3> The varied demands of sports and recreation create a multitude of factors which impact the design, construction, and use of a sports prosthesis. Physical fitness and conditioning, prosthetic design and materials, harness styles, and terminal devices all have roles in determining whether an amputee can engage in a sports activity successfully and safely. New improved prosthetic devices and designs will continue to evolve to meet these varying demands. Communication between professionals is important in order to share information on the improvements which are made. Designs for high performance limbs and devices for sports and recreation may well pave the way for improved prosthetic technology as a whole. An open mind, a fresh outlook, an understanding attitude, as well as the patience and willingness to experiment and develop, will inevitably lead to a brighter future for the disabled in sports and recreation. References: <ol> <li>Chadderton, O.C., C.A.E., "Survey: Consumer Interests," The Fragment, Winter, 1986, Vol. 151, pp. 29-31.</li> <li>Robinson, W.D., B. Pflanz, B. Watkins, and A. Viau "Recreational Limbs AMPUTATION III," The War Amputations of Canada, April, 1986, pp. 19-33.</li> <li><a href="poi/1986_03_129.asp">Mensch, G. and P.E. Ellis, "Running Patterns of Transfemoral Amputees: A Clinical Analysis," Prosthetics and Orthotics International, 1986, Vol. 10, pp. 129-134.</a></li> <li>Products and trade names of Hosmer-Dorrance Corporation, Campbell, California.</li> <li>Products and tradenames of T.R.S., Inc. of Boulder, Colorado.</li> <li>Product and tradename of Recreational Prosthetics, Inc., North Dakota.</li> <li>Radocy, R., "Sports Designs for Upper Extremity Amputees," a symposium presentation at the National Sports Prosthetics and Orthotics Symposium, U.C.L.A. Prosthetics/Orthotics Education Program, October, 1985.</li> <li>"Bow Modifications Serve Amputees," Archery World, February, 1987, p. 22.</li> <li>Weight harnesses designed and tested by Bob Radocy, T.R.S., Boulder, Colorado {not commercially available}.</li> <li>Radocy, B. and Randall D. Brown, "Technical Note: An Alternative Design for a High Performance Below-Elbow Prosthesis," Orthotics and Prosthetics, 1986, Vol. 40, No. 3, pp. 43-47.</li> <li>Billock, John N., "Northwestern University Supracondylar Suspension Technique for Below-Elbow Amputations," Orthotics and Prosthetics, December, 1972, Vol. 26, No. 4, pp. 16-23.</li> <li>Berger, N., et al, "The Application of ISNY Principles to the Below-Elbow Prosthesis," Orthotics and Prosthetics, Winter, 1985/86, Vol. 39, No. 4, pp. 10-20.</li> <li>Radocy, Bob, "The Rapid Adjust Prosthetic Harness," Orthotics and Prosthetics, 1983, Vol. 37, No. 1, pp. 55-56.</li> <li>Courtesy of Bill White, bilateral amputee using two GRIP terminal devices, Waterford, Pennsylvania.</li> <li>Courtesy of Kent Barber & Bill Dalke, Prototype bicycle aid not commercially available. Inquiries to T.R.S. of Boulder, Colorado.</li> <li>Courtesy of Bassamatic, Inc. of Canton, Ohio.</li> <li>Courtesy of Royal Bee Corporation, Pawhuskas, Oklahoma.</li> <li>Courtesy of Robin-Aids Prosthetics of Vallejo, California.</li> <li>Courtesy of The War Amputations of Canada, Ottawa, Ontario.</li> <li>Tradename and product of Innovation Research Corporation, Milwaukie, Oregon.</li> <li>Courtesy of SR-77 Enterprises, Inc. of Chadron, Nebraska.</li> <li>Courtesy of R.F. Meyer's photograph of R. Wityczak, a triple amputee.</li> <li>Courtesy of Carmen Tablada, CP., Professional Orthopedic Systems of Sacramento, California.</li> <li>Ski Seat, Mission Bay Aquatic Center of San Diego, California.</li> <li>E-Ski, Courtesy of E.S.C.I. of Gretna, Louisiana.</li> <li>Courtesy of the Rehabilitation Centre for Children, Winnipeg, Manitoba, Canada.</li> </ol> *Bob Radocy Bob Radocy is President, TRS, Inc. 1280 28th St., Suite 3, Boulder, CO. 80303-1797 <div style="width: 400px;"></div> Page Number(s) 131 - 153 Year 1987 Volume 11 Issue 3 Figure 2 FIGURES 4,5,&6 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-02.jpg Figure 3 FIGURES 7,8,9,& 10 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-03.jpg Figure 4 FIGURE 11 ttp://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-04.jpg Figure 6 FIGURE 13 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-06.jpg Figure 7 FIGURE 14 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision-See Trello Figure 8 FIGURE 15 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-08.jpg Figure 1 FIGURES 1,2,& 3 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-01.jpg Figure 5 FIGURE 12 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-05.jpg Figure 9 FIGURE 16 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-09.jpg Figure 10 FIGURE 17,18,19 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-10.jpg Figure 11 FIGURE 20 & 21 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-11.jpg Figure 12 FIGURE 22 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-12.jpg Figure 13 FIGURE 23 & 24 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-13.jpg Figure 14 FIGURE 25 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-14.jpg Figure 15 FIGURE 26 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-15.jpg Figure 16 FIGURE 27 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-16.jpg Figure 17 FIGURE 28 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-17.jpg Figure 18 FIGURE 29 & 30 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-18.jpg Figure 19 FIGURE 31 & 32 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper-Extremity Prosthetics: Considerations and Designs for Sports and Recreation Creator An entity primarily responsible for making the resource Bob Radocy * https://staging.drfop.org/files/original/d30c1f6a28ca1ae9b9872748df353b4b.pdf bea9517e3f9ca479497da6bb9f227e0e https://staging.drfop.org/files/original/a750a9bac1e87d07cab481c17ed8f158.jpg b460a689a9405e966300e9e773112751 https://staging.drfop.org/files/original/5eabccec270f1f333b918958142dcddf.jpg d490768fd85d0c0b8018f49d16a85e86 https://staging.drfop.org/files/original/5600e2c8cd5d1d88fa9b9dddfdbaa0ab.jpg 9bc59a50d9db0fc1942fd3df98eefa38 https://staging.drfop.org/files/original/b43844ab7b3bfbbcd3bed5d518fcb726.jpg 6522bd5c2e9c92baab4bd7fc742b28e0 https://staging.drfop.org/files/original/4226f93b09b83f690ff1aef286187577.jpg 99fd1f5e60ad04e0e2460c25f9c7e4a2 https://staging.drfop.org/files/original/360d6f76108292390a3bec738558a811.jpg 0d9a1a37077e0ab9f498bc9af862178a https://staging.drfop.org/files/original/dd200e756e224fc90ceb749aad4eb9d6.jpg 34afd61cb2dfbd620fd9e679a63df337 https://staging.drfop.org/files/original/60695ce3ce74c38c73e7ed31980752dc.jpg 41736e0e8258aee5b7615ab1059beead https://staging.drfop.org/files/original/50b652b809ec11dde34512c0dc88a00e.jpg 00068c0d3e0c590537e88b76a244b348 https://staging.drfop.org/files/original/722ac0844615e93397f059ec7b613b07.jpg e7dc454326291f80d2c206b06069c227 https://staging.drfop.org/files/original/035759827aa596e9d8af6a33567f9b91.jpg abc557d705dcabcb1bd8e8bec39a40f6 https://staging.drfop.org/files/original/0b12783a5e83b0a240c3ad7712390754.jpg 79e5817d76fa326b48a2d869f93fd564 https://staging.drfop.org/files/original/979a838ad229b33f0d97d2aa39e41e77.jpg 28b748a551d55bed689fa297ddcf4c68 https://staging.drfop.org/files/original/9ca6580af83082e91121cf0bf46ba5d9.jpg f76154c15e8fd69532e5cbc59df9dd58 https://staging.drfop.org/files/original/0b5165ead816fe48b4cfe8d2d2365829.jpg 9e4ce3a48cbe047abc17a4594fbab36d https://staging.drfop.org/files/original/ca076e884f850efcd021fb6492261232.jpg 2c324897b3b5d60061bcffe678d897ba Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_118.pdf Text Any textual data included in the document <h2>The UCLA Total Surface Bearing Suction Below-Knee Prosthesis</h2> <h5>Timothy B. Staats, M.A., CP. <a style="text-decoration: none;">*</a> Judd Lundt, B.S., A.E. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> While there was clear evidence to support examination of suction as a suspension technique for below-knee prostheses<a></a> in the early 1950s, overwhelming activity was in a direction that led ultimately to the development of the PTB design.<a></a> What is truly remarkable is the almost blind obedience that the practitioners and educators have given to PTB theories, a recognition that has rendered them all but untouchable gospel. Introduction and widespread use of transparent check sockets has probably done more to cause the prosthetist to question the accuracy of his PTB fitting methods than any other development in the last decade. Inaccuracy in socket fit that this powerful tool has revealed has led to the obvious conclusion: more precise casting and modification methods are required. This is the intent of the technique described here. This paper presents a departure from PTB philosophy and technique. The methods described freely borrow from and recognize individuals who have developed alternative ideas, many of which have been integrated into the UCLA Total Surface Bearing Suction Below-Knee Prosthesis. The substance of this paper includes suction as the obvious mode of suspension. However, the essence of suction suspension, and of this article as well, is the critical anatomical accuracy of the socket fit. We refer to it as the total surface bearing or TSB technique. Without TSB, successful long-term suction suspension cannot be achieved. With TSB, the prosthetist can achieve suction if desired or may choose to fit with a sock and without suction if so indicated. Whatever the case, the final result will be improved fit and better patient comfort. <h3>Suction Suspension</h3> Suction below-knee prostheses are unique in that they do not require auxiliary suspension systems such as straps, cuffs, thigh lacers, or sleeves to maintain the socket on the residual limb. This is not to suggest that auxiliary suspension need not be employed as an extra measure of protection, particularly with a very active patient. However, in principle no other suspension should be required (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg">Fig. 1</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg">Figure 1. UCLA Total Surface Bearing Suction Prostheses.</a> Three variations of suction socket are discussed in this article. The first is the "tension suction" variation.<a></a> This socket is made vol-umetrically smaller than the residual limb. Suction is maintained in the same manner as with the rigid above-knee suction prosthesis. This is probably through tension placed on the skin, thereby enhancing the friction between the tissue and the socket. Normally, a valve is placed at the distal end to release air while the socket is being applied. The second classification is "atmospheric suspension," mentioned by Murphy<a></a> in 1950 and later by others.<a></a> In atmospheric suspension, a non-elastic, but flexible interface is used, which virtually collapses around the residual limb when the prosthesis is unweighted. The third type of suction will be called "active compression suction." In this case, the socket interface is made of an elastic or elastomeric material which must be stretched or rolled over the residual limb, thereby gripping the skin through compression as well as through friction created between the skin and the socket.<a></a> <h3>Fitting Variables</h3> The primary concern of any prosthetist attempting to fit a suction below-knee prosthesis should be the general health of the residual limb tissues. The UCLA experience has been similar to studies by Holmgren<a></a> and Bedouin.<a></a> Types of Patients The suction below-knee prosthesis, properly fitted, appears to stimulate circulation and can be used on vascular amputees as well as amputations due to other causes. The suction below-knee may actually help to more quickly stabilize tissue fluid volume. Ages of patients have ranged from five to 88 years. Skin Problems A suction below-knee prosthesis virtually eliminates skin problems caused by movement and friction created between the residual limb and the socket interface. Problems of skin irritation related to hygiene and allergic reaction are covered in a later section. Bony Prominences Grevsten,<a></a> using x-ray evaluation of suction below-knee fittings, found that the movement of skeletal anatomy inside the socket is less than one-half that inside ordinary PTB sockets. The UCLA experience, which employs a more intimate casting and cast modification technique (TSB), suggests an even greater reduction in skeletal movement. More importantly, few problems with bony prominence pain or discomfort were reported by patients in the over 150 fittings conducted at UCLA and other locations during the teaching of this technique. Length We have found no correlation between residual limb length and the ability to wear a suction below-knee prosthesis. Fittings and suction suspension have been successfully achieved with residual limb lengths as short as 3 1/2". However, these are not all long-term results. Volume More important was the finding that many residual limbs initially fit with suction would lose this effect within one or two hours of wear. There is an immediate fluid volume adjustment. Patients fit with suction over longer periods of weeks and months will continue to experience residual limb volume changes until a point of volume stability is achieved. This normally will occur within six weeks. Any loss of body weight will certainly contribute to loss of suction as well. Shape Generally, with enough effort almost any shape residual limb can be fit with suction. However, to achieve suction with conical shape residual limbs, whether bony or fleshy, can be difficult. With such cases, it is often necessary to enlarge the gastrocnemius muscle bulge area of the socket while tightening slightly proximal to this to maintain suction. Many prosthetists might question the long-term effect of this technique on the health of the residual limb. Short term effects have not been adverse and results look encouraging. Patient Cooperation Patients who intend to wear suction below-knee prostheses must be intelligent, cooperative and aware of the critical nature and accuracy required in this type of fitting. Numerous adjustments may be required during the first several months to maintain the intimacy of the fit. The patient must fully understand the function of the valve and the socket liner. It is imperative that any patient wearing a suction below-knee prosthesis, no matter how effectively fit, wear an auxiliary suspension as a back-up in case loss of suction does inadvertently occur. <h3>Comparison of Theories</h3> In the below-knee prosthesis, suction is a mode of suspension that can only be maintained through a precisely fit socket. A major aim of this article is to present a technique whereby such a fit can be achieved. Development of the total surface bearing (TSB) below-knee socket combines a staged precision casting method with a significantly different model modification to yield this result. In order to understand these differences, it is necessary to contrast the TSB and the more traditional PTB sockets. The basic philosophy of the patellar tendon bearing below-knee prosthesis can be stated as follows: Increase weight bearing on areas of the residual limb over pressure tolerant areas and relieve pressure over those areas which are pressure sensitive. With the total surface bearing below-knee prosthesis weight is distributed over the entire surface of the residual limb, including areas which have in the past been considered pressure sensitive. In TSB, the accuracy of fit and careful use of measurements has eliminated the need for relief buildups over bony areas of the residual limb during the plaster casting and model modification procedures. The resulting corrected model for a TSB socket is thus distinctly different from that developed in accordance with PTB modification techniques. <h3>Evaluation and Measurement</h3> Measurements include all standard below-knee prosthetics parameters. The following additional considerations are necessary. Circumferences Carefully located circumferential measurements are taken at one inch intervals. The intervals are laid out from a bony landmark which can be defined accurately during the plaster casting procedure. Normally, the apex of the head of the fibula or the distal anterior tip of the tibia are chosen, depending on which is more prominent. The tibial tubercle may also be used. However, it is necessary to measure at least one interval more proximal when this location is chosen. In very fleshy or redundant residual limbs, it is wise to select the fibular head as some elongation may occur during casting which will obscure the distal end. Length The length measurement must be accurately gauged from the distal end of the residual limb to both the medial tibial plateau and to the inferior edge of the patella while under forceful upward loading. Evaluation Patients with chronic skin problems or burn scar tissue may not be suitably fit in sockets where the skin is directly in contact with the socket liner, unless the interface surface is impervious to body fluids. Perspiration can cause maceration even in healthy skin and an appropriate interface must be selected in such cases. <h3>Plaster Casting Technique</h3> An essential element of a successful TSB socket is a precisely cast residual limb. The diagonal four stage casting technique which draws from work adapted from Fillauer,<a></a> Gleaves,<a></a> Tranhardt,<a></a> Morris,<a></a> Hayes,<a></a> Stokosa,<a></a> and Vinnecour<a></a> was developed to best achieve that end. Unusual elements of the technique include: <ol> <li> Sheer nylon stockings for an ultra-thin barrier between skin and plaster, resulting in a more accurate cast. </li> <li> A beveled anterior first stage splint which is very accurately tailored to encompass the head of the fibula, the shaft of the tibia, and the entire medial flare. This first stage (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg">Fig. 2</a>) is carefully molded to all bony anatomical structures. If properly applied, it will establish the medio-lateral dimension within 1/8" of patient measurement in most situations and require little or no model modification of the anterior aspect of the medial flare of the tibia. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg">Figure 2. The entire medial tibial flare and all bony prominences are carefully molded.</a></li> <li> A second stage of elastic plaster bandage which is wrapped with about half the available stretch applied. This stage must not extend more proximal than about 1" to 1 1/2" below the crease of the skin in the popliteal fold. The anterior stage is maintained in position during this second procedure with firm proximal compression. As the second stage sets, the proximal posterior aspect is lightly compressed to help define the antero-posterior dimension of the cast. The medial lateral dimension is never sacrificed in any attempt to decrease the antero-posterior dimension. </li> <li> A third stage splint, which creates the posterior brim shape and completes the basic cast used when a non-supracondylar trim line, is desired. The salient point of the third stage is the hand molding of the plaster bandage in the hamstring tendon region. When properly applied, the posterior brim will appear premodified with a diagonal trim which accommodates the lower anatomical insertion of the medial hamstring muscle group. It is necessary to do four things simultaneously to create an acceptable third stage, and generally will take considerable practice before re-peatable accuracy and skill is achieved. It is necessary first to locate and create the shape of the tendons; secondly, compress the antero-posterior dimension of the cast both proximally and compression-ally; third, mold the medial and lateral posterior areas of the third stage to prevent looseness in the hamstring areas proximal to the medial tibial plateau region; and fourth, spread the fingers of both left and right hands to stretch the plaster bandage to prevent a ridge from forming in the posterior aspect between the second and third stages (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg">Figure 3. The posterior trim and hamstring muscle reliefs are created during the wrap casting procedure.</a></li> <li> A fourth stage splint is used when supracondylar suspension is planned. It is applied in a manner similar to that used in Fillauer's three stage casting technique. </li> </ol> <h3>Alginate Pressure Fitting</h3> The first step in the fitting process occurs immediately after the hardened cast is removed. Through application of dental alginate to the inside of the wrap and a refitting on the patient, a more intimate contour is achieved. Though somewhat of a messy procedure, this will minimize the need to remove plaster from the model during modification. When casting very obese patients or those with excessive redundant tissue, this step may not be successful and may result in distortions in the final model. The nylon stockings are carefully removed from the cast and a hole is cut in each of the distal, lateral, medial, and posterior aspects to permit air to escape when the alginate is applied. The holes should be approximately 1/4" in diameter and should be cut using a knife. (A hand drill or drill press will likely grab the fabric in the wrap and destroy it.) About eight to ten ounces of dental alginate are mixed to a thick, but creamy consistency and quickly applied to the entire inner surface. The cast is replaced on the residual limb and forced proximal with moderate pressure. Alginate should exude from all cut holes (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg">Figure 4. The wrap cast is alginated and pressure fitted.</a> The instant the alginate stops flowing from the holes, they are covered with the hands or fingers to prevent further leakage. Any excess alginate can be smeared about the proximal brim to perfect the fit in this area (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg">Fig. 5</a>). This procedure must be conducted quickly and precisely or air pockets will occur. If air pockets do occur, we have found that additional algination attempts have been unsuccessful. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg">Figure 5. The completed diagonal four stage wrap cast.</a> <h3>Total Surface Bearing Model Modification</h3> The antero-posterior and medial lateral are modified exactly to residual limb measurements. The anterior modification of the anteroposterior is markedly different from the PTB "Bar." The TSB modification follows the shape of the anatomy in this region as shown in the xeroradiograph of the below-knee amputation (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg">Figure 6. Xeroradiographs lateral view of below-knee amputation. Notice the shape proximal to tibial tubercle.</a> Notice that the shape of the tibia angles posteriorly immediately above the tibial tubercle. Plaster removal follows this shape. The inferior edge of the patellar area is modified as though the patella were being lifted proximally about 1/4". In other words, the true tibial plateau is below the inferior edge of the patella in most cases (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg">Fig. 7</a>). The posterior aspect of the model normally requires only smoothing or only slight reduction to establish the correct AP. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg">Figure 7. Modification inferior to patella simulates shape of anatomy rather than "PTB" patellar bar.</a> Plaster is removed from the posterior aspect of the medial flare of the tibia. This half moon shape sweeps into the medial hamstring area. Up to 3/8" of plaster may be removed in a very redundant residual limb. It is not unusual to see a medial hamstring 1/2 to 3/4" lower than the lateral side. Generally, the lateral side hamstring can be kept almost at tibial plateau level and is maintained at this level across the popliteal fossa. Absolutely no buildups are applied to the crest of the tibia, the head of the fibula, the anterior distal aspect of the tibia, or any other bony prominences. Reliefs are created by removal of plaster from around these areas to accentuate their shapes and to compress the tissues. Usually no more than 1/8" of plaster is carved away using a curved blade flexible knife (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-08.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-08.jpg">Figure 8. No plaster buildups are added to master model. Plaster is carefully removed around bony prominences and over bony prominences.</a> The model is next measured for circumferences using the previously established bony landmark as a guideline for accurately locating the measurement levels (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-09.jpg">Fig. 9</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-09.jpg">Figure 9. Circumference measurements of master model are reduced below patient measurements to achieve suction.</a> It is generally found that the model at this point will be approximately at the residual limb measurement or somewhat larger, even if fairly liberal modifications have been performed. If the model were to be smoothed and a socket fabricated at these measurements (0" to +1/8") it will result in about a two-ply heavy cast sock fit or about one "Socket Liner Stump Sock."<a></a> However, this may not in itself achieve suction. In order to create a suction fit, the model must be carefully reduced in its circumferential measurements starting from a point approximately one inch above the tibial plateau and proceeding distally the entire length of the cast. As a beginning, a minimum of 1/2" of tension reduction less than the patient's measurements is applied at each measured level. Ultimately, in a new patient (any patient who has never worn a suction socket) the tensions may well reach 3/4" to 1" less than the original anatomical measurements. However, it is not a simple matter of initially bringing the tensions on the model to these values. This is inadvisable and potentially harmful for the patient. A gradual reduction process over time must be followed in order to achieve the results just stated. In pilot studies and in pilot courses conducted at UCLA in 1984, an attempt to empirically arrive at appropriate TSB suction tension values was made. Each prosthetist was asked to carefully record how much reduction in residual limb measurements was required to finally achieve suction suspension. The compiled results of these efforts suggest an initial tension value of 3/4" is necessary at each level to achieve suction. This value may vary depending on residual limb musculature, length, and tissue type. <h3>Check Sockets</h3> It is advisable, if not imperative, to use transparent check socket fittings to confirm the accuracy and precision of the wrap cast and subsequent model modifications. The UCLA technique involves two types of check sockets: flexible check sockets and more conventional rigid check sockets. The Flexible Check Socket A check socket is vacuum formed using 1/8" Surlyn® plastic. On a five to seven inch residual limb this will result in a very thin socket probably no thicker than 1/32". A valve is located distally to release air from the socket as it is donned (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-10.jpg">Fig. 10</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-10.jpg">Figure 10. A flexible check socket is vacuum formed with small valve placed distally.</a> Lotion or Vaseline® is used to lubricate the surface of the residual limb to aid in donning<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-11.jpg">Fig. 11</a>). Flexible socket fit can be confirmed by direct palpation of the anatomy from the outer surface. Any air spaces or otherwise loose areas are located and subsequently corrected on the model. It is not unusual for this flexible socket to hold suction even if inadequate tensions were applied to the model (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-12.jpg">Fig. 12</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-11.jpg">Figure 11. The flexible check socket is "wet" fit to the patient.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-12.jpg">Figure 12. Suction, total contact, volumetric and anatomic accuracy of check socket are determined in the flexible check socket.</a> Accordingly, if the socket is made rigid by an application of a roll of fiberglass casting tape to the outer surface, suction will invariably be lost almost immediately. This demonstrates one of the many problems facing anyone wishing to fit or wear a suction below-knee prosthesis. The flexible socket in this case is exhibiting atmospheric suction. The socket collapses around the residual limb as any attempt is made to remove it. Rendering the socket rigid transforms this flexible membrane into a rigid socket and as the socket wall cannot move, suspension is lost. The Rigid Check Socket A rigid check socket may be used after the model corrections, determined by the fit of the flexible check socket, have been performed. With the rigid fitting, it is common to find the need to increase tension values to an average of 5/8" to 3/4". It must be assumed that fluids rapidly leave the residual limb as a more rigid, accurate fitting socket is applied. It might also be speculated that the muscles flatten out somewhat as excess fluid leaves the residual limb. Examination of residual limbs in properly fit rigid transparent suction check sockets after several hours of wear reveal good color and lack of a distal discoloration which one might expect in a "tight" socket. <h3>Socket Materials</h3> A variety of materials and fabrication techniques have been examined for their application to the suction socket. Varying levels of success have been achieved; however, there are usually trade-offs involved. Suction may be achieved with a removable liner/insert alone that keys into the prosthesis much like a liner in a PTB socket. A prosthesis may also be constructed with a hard suction socket with no liner or with a soft liner that is permanently attached. In any case, some type of valve is usually necessary, installed either in the liner, in the socket, or at the end of a tube extending from the distal end of the socket to the outside finish lamination of the prosthesis. Valveless liners are also possible; they will be discussed later. In considering a method of constructing a suction socket, it is important to realize that there will be no sock to absorb moisture; the patient will likely require some type of powder, cream or lotion application to don the socket, and the skin will be in direct and intimate contact with the inner material. All of these factors dictate a non-porous, easily cleaned material that will minimize the growth of bacteria, yet provide the necessary cushioning and comfort for daily or specialized activities. Whichever approach is taken, the prospects of success are limited only to the ingenuity of the prosthetist and the materials employed. Hard Socket Variations This is perhaps the most difficult variation with which to achieve success since the demands of precision required for fit and comfort are the highest. Firm residual limbs of good muscle mass are the most likely candidates for this design. The hard socket is undoubtedly the easiest to fabricate, and for the patient is the easiest to keep clean. Even if accepted by the patient, these sockets will feel hard and, while suitable for walking, they are probably not appropriate for heavy activities such as running. However, hard sockets, with the addition of a single nylon sheath, have been very successful in the long-term with low activity level patients. Flexible acrylic and polyester laminates backed on the outer surface with soft foams such as PE-LITE™ or Aliplast™ have enjoyed about the same level of success as a hard socket. Patients report that these sockets feel hard despite the padding. Additionally, allergic skin reactions seem to be more common when flexible resins are used. Minute cracking in the interface may create a breeding ground for bacteria or lead to skin irritation through surface friction. A number of thermoplastic liners have been successfully fit (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-13.jpg">Fig. 13</a>). Some have been quite comfortable, notably the "total flexible brim" variation suggested by IPOS<a></a> and Sabolich.<a></a> Both are frame-supported polyethylene designs. Since thermoplastics may exhibit "cold flow" and may actually shrink, they are not ideal materials. An interesting characteristic of thin thermoplastic sockets is the enhanced capability of atmospheric suction. However, this advantage is basically negated by a lack of long-term durability. The suggested ease of refabrication and/or inexpensive nature of replacement does not hold up to criticism by patient used to no-nonsense prosthetic care. Another negative characteristic of thin thermoplastic liners such as Surlyn® and polyethylene is the inability to make adjustments after fabrication. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-13.jpg">Figure 13. Surlyn® inner flexible socket with outer frame fitted in 1985 as a suction below-knee prosthesis.</a> A major point of consideration in fitting any socket material that directly contacts the skin is the coefficient of friction at the interface. There are definite differences which are recognized empirically and clinically, but not objectively related to prosthetic fit in the below-knee as well as in above-knee suction sockets. For example, Surlyn® and Durr-Plex both seem to have a surface which adheres very well to slightly damp skin. When these surfaces are lightly sanded, they lose some of this gripping capability. This can be both a positive and a negative factor, depending on the skin tolerance of the patient involved. Generally, hard socket variations of suction below-knee prostheses, while feasible, are not very practical for most patients. Moreover, the instance of inadvertent loss of socket suction must be expected. This is not really considered a problem since we recommend that auxiliary suspension be worn even on the best suction below-knee fitting. Soft Socket Variations Early suction liners were made of leather backed with Neoprene™. Even when given a sealant coating, the leather will begin to deteriorate and develop offensive odors in a fairly short period. However, good comfort has been achieved as has adjustability. Replaceability is not really possible in this variation. PE-LITE™ and Surlyn®-backed PE-LITE™ have both been successfully used for soft suction liners (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-14.jpg">Fig. 14 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-15.jpg">Fig. 15</a>). It wears fairly well and can be cleaned with baking soda, vinegar, or rubbing alcohol to eliminate both odor and dirt. These liners will likely pack-out in time, and thus, normal prosthetic delivery should include a duplicate. Replacement duplication after wearout of thermoplastic foam liners is not really practical to the level of precision necessary to maintain suction. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-14.jpg">Figure 14. Pelite™ liner with Plastozote distal end, distal valve and Surlyn® outer shell fitted as suction below-knee prosthesis in early suction below-knee courses at UCLA in 1985.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-15.jpg">Figure 15. The TSB Suction below-knee can be fitted on almost any length below-knee residual limb. Auxiliary suspension is not shown in this diagram but is recommended for all suction below-knee wearers.</a> Another major advantage of these materials is that they may be easily added to or otherwise adjusted. By use of selectively placed materials of varying durameters, comfort can be achieved in very bony patients and those with poor skin conditions. It is important to further note that some foams are not closed cell and will, therefore, permit moisture, dirt, and bacterial buildup which may not be easily removed. However, coatings have been developed which may solve the interface cleansing problem. Additional considerations in the use of a liner coating are potential allergic reactions, alteration of friction and shock absorption characteristics of the liner material, and adequacy of adherence. Foam liners, it must be remembered, provide comfort by absorbing load forces of axial, shear, and torque. The shock of impact is absorbed in the compression of the foam or in the compression of the gases within the individual cellular structure of the foam. Any buildup of heat within a liner could lead to problems for the patient in an intimate suction fit. In summary, soft foam liners are very practical from the point of view of comfort and the ability to adjust to maintain fit. Their major drawbacks are that they change shape with wear and they do get dirty and smell if not meticulously cleaned daily. Three known types of silicone liners are presently in use or in experimentation at this time. Koniuk<a></a> reported fabricating cast silicone liners (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-16.jpg">Fig. 16</a>) which can be later duplicated from the same mold. There have been some problems with tearing of these liners in early phases of development, but this is viewed as a materials problem only. Early liners were fairly thick and heavy which can be detrimental. Some problems of skin reaction to direct contact with silicone have been reported. Since silicones are relatively inert, skin irritation most likely may be attributed to friction between the skin and the liner. It may actually be holding the skin too well. Some patients may also be allergic to the catalysts used in the preparation of the silicone elastomer. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-16.jpg">Figure 16. Silicone below-knee socket liner with expulsion valve installed.</a> Experiments with very thin laminated sheath-like silicone liners have been attempted with some positive initial results. However, adjustments are not possible because of the inability to cement to the material, a characteristic of the entire silicone group. Bedouin has reported using fills between the socket liner and the outer lamination as a means of reestablishing lost suction. Kristinsson<a></a> has demonstrated a preformed silicone liner which either rolls on or is pulled on the residual limb. The effect is to create distension of the distal tissues. Some problems have been seen in initial demonstrations, among which are tearing of the liners during application, some discomfort by patients with a hairy limb, and heat build-up. It may be too early in the development of these direct-contact silicone liners to determine with fairness their ultimate practicality. It is certainly true that lack of adjustability will likely continue as a source of considerable concern. A relatively new system, the PM Liner, developed by Peyton Massey<a></a> has been used as a suction below-knee liner. While proprietary in nature, it appears to be a vinyl-like foam which may be heated and formed with ease directly over the below-knee model. It has the comfort and padding of silicone but is much easier to work with and does not migrate as is the tendency with some silicone materials. Massey has been adapting this liner for use with adhe-sives so as to make it possible to glue patches of similar material to the PM Liner. A new concept in liners under development, called the Socket Liner Stump Sock,<a></a> offers an additional variation for potential use with a suction below-knee prostheses. It is a neoprene sock that is fabric-backed on both sides. When properly fitted, it maintains suspension by compression. The problem with this variation at present is that the smooth surface of the cloth outer face of the liner against the smooth inner socket surface does not provide sufficient friction to hold suspension. A coating is under development to resolve this problem. This liner offers an excellent compromise for the patient wishing to have an intimate TSB fit without complete suction. There is reportedly very little or no motion between the liner and the residual limb. Suction Below-Knee Valves Several specialized valves have been developed for the suction below-knee prosthesis although any valve can probably be used. An important feature in a valve for suction below-knee application is air expulsion capability. With such a valve, the patient simply forces his residual limb into the socket to expel the air through the distal end. Problems experienced with all valves have been accessibility and leakage brought on by inability to securely bond the valve seat to the liner. <h3>Auxiliary Suspension</h3> As has been previously emphasized, auxiliary suspension is mandatory on all suction below-knee prostheses. Sleeve type suspension offers the best compromise of comfort, security, and maintenance of suction. Cuff suspension in all forms has been tried, but cannot assist in sealing the socket to the residual limb. Three types of sleeves should be considered. The Latex Sleeve This provides the best seal and the most positive suspension, but has the problem of skin irritation, durability, odor, discoloration, and loss of shape. The Neoprene Sleeves These offer an acceptable seal that, while not as positive as the Latex, are acceptable so long as the sleeve has been properly manufactured. Neoprene sleeves are similar to Latex sleeves with respect to skin rashes and durability. Daily cleansing with alcohol can greatly reduce the incidence to skin problems. Providing the patient with multiple sleeves and proper hygienic education will reduce the incidence of skin rashes. Cloth Lined Neoprene Sleeves While these sleeves do not work well for total suspension, they can afford a margin of back-up for good suction wearers. <h3>Some Suggestions for Skin Problems</h3> For any serious rashes or other skin conditions, the patient should always be directed to his physician. A number of techniques have been tried by patients to clear up simple rashes. One technique is to wear a "Baggie®" or a thin polyethylene sheet directly against the skin of the residual limb until the rash clears. Some patients wear this inner protection at all times as a method of preventing rashes which might be caused by friction. When used with sock fittings, this will keep moisture out of the sock, thereby helping to prevent skin maceration. Some athletic patients apply transparent surgical tape over areas that are known to be prone to skin breakdown during heavy sports activities. Some brands that have been successfully used include 2nd Skin™, Op-Site, and Bioclusive Pads®. <h3>Conclusion</h3> The suction below-knee prosthesis, while an excellent option for some patients, may for others be the triumph of valor over reason. Should the decision be made to proceed with suction, both the prosthetist and patient must be completely aware of the long and difficult route involved. There will be obvious changes in the residual limb following initial fit which will require socket adjustment and refabrication over an extended period. There will probably be the need for some experimentation with materials and fabrication methods to arrive at an optimum fit for the patient. However, once these factors have been resolved, the results of a well-fit suction socket will be a marked improvement in patient comfort, satisfaction, and in a prosthesis that the patient "feels" is more a part of his person. If, on the other hand, suction is not a goal, the Total Surface Bearing casting and modification techniques that support a suction fit are entirely valid for every below-knee fitting regardless of the socket interface or method of suspension. In the view of the authors, these improvements over more traditional methods of below-knee prosthetics have been long overdue. Clearly, the superiority of Total Surface Bearing has been established and undoubtedly is the most important dividend of the research and education on suction below-knee fittings. <h3>Suggested Readings</h3> <ul> <li> Roberts, Ruth, "Suction Socket Suspension for Below-Knee Amputees," Archives Physical Medicine and Rehabilitation, Vol. 67, March, 1986, pp. 196-199. </li> <li><a href="poi/1978_01_003.asp"></a> <a href="poi/1978_01_003.asp">Grevsten, S., "Ideas on Suspension of Below-knee Prosthesis," Prosthetics Orthotics International, 2, 1978, pp. 3-7.</a> <a href="poi/1978_01_003.asp"></a></li> <li> Grevsten, S., "Patellar Tendon Bearing Suction Prosthesis Clinical Experiences," (Uppsala) J. Medical Science, 82, 1977, pp. 209-220. </li> <li> Grevsten, S. and L. Marsh, "Suction-type Prosthesis for Below-Knee Amputees: Preliminary Report," Artificial Limbs, 15, Spring, 1971, pp. 78-80. </li> <li> Pearson, J.R., S. Grevsten, B. Almby, and L. Marsh, "Pressure Variation in Below-Knee, Patellar Tendon Bearing Suction Socket Prosthesis," J. Biomechanics, 7, 1974, pp. 487-496. </li> <li><a href="cpo/1984_03_004.asp"></a> <a href="cpo/1984_03_004.asp">Murphy, E., "Sockets, Linings, and Interfaces," Clinical Prosthetics and Orthotics, Vol. 8, No. 3, Summer, 1984, pp. 4-10.</a> <a href="cpo/1984_03_004.asp"></a></li> <li> Schuch, M. and A.B. Wilson, "The Use of Surlyn® and Polypropylene in Flexible Brim Socket Designs for Below-Knee Prostheses," Clinical Prosthetics and Orthotics, Vol. 10, No. 3, Summer, 1986, pp. 105-110. </li> <li> Kay, H. and J. Newman, "Report of Workshop on BK and AK Prostheses," Orthotics and Prosthetics, Vol. 27, No. 4, December, 1973. Abrahamson, M., et al., "Improved Techniques in Alginated Check Sockets," Orthotics and Prosthetics, Vol. 40, No. 4, Winter, 1987, pp. 63-67. </li> <li> Pritham, C, "Suspension of the Below-Knee Prosthesis: An Overview," Orthotics and Prosthetics, Vol. 33, No. 2, June, 1979, pp 1-20. </li> <li> Holley, Teresa, "The Suction BK Prosthesis," UCLA Prosthetics Education Program term paper, 1984. </li> </ul> References: <ol> <li>Murphy, E., "Lower Extremity Components," Orthopaedic Appliance Atlas, Vol. 2, J.W. Edwards, 1960.</li> <li>Radcliffe, C.W. and J. Foort, The Patellar-Tendon-Bearing Below Knee Prosthesis. University of California, Berkeley, Biomechanics Laboratory, 1961.</li> <li>Grevsten, S., The Patellar Tendon Bearing Suction Prosthesis. 1977 Functional Studies, Doctoral Thesis, University of Uppsala, Sweden.</li> <li>Bedouin, Leo, personal communication, Dan Muth Company San Francisco, California, 1981-March, 1987.</li> <li>Friestadt, Ake, "The Swedish Suction BK Prosthesis," presentation at UCLA Advanced below-knee Prosthetics Seminar, October, 1984. Contact Een Holmgren Co., Uppsala, Sweden.</li> <li>Murphy, E.F., "The Fitting of Below Knee Prostheses," Klopsteg PE, Wilson PD (eds), Human Limbs and their Substitutes, New York, McGraw Hill, 1954, pp. 693-735.</li> <li><a href="cpo/1986_02_093.asp">Sabolich, J. and T. Guth, "Below Knee Prosthesis with Total Flexible Socket: Preliminary Report," Clinical Prosthetics and Orthotics, Vol. 10. No. 2, Spring, 1986, pp. 93-99.</a></li> <li>Kristinsson, O., "The ICEROSS System," lecture at UCLA Advanced Below-knee Prosthetics Techniques Seminar, Fall, 1986. Contact: Ossur hf. Reykjavik, Iceland.</li> <li>Holmgren, G., "The Patellar Tendon-Bearing (PTB) Suction Prosthesis," Disability, Strathclyde Bioengineering Seminars, August, 1978, MacMillian Press, Chapter 47.</li> <li>Grevsten, S. and U. Eriksson, "Stump-Socket Contact and Skeletal Displacement in Suction Patellar Tendon Bearing Prosthesis," J. Bone and Joint Surgery, 56, 1974, pp. 1692-1696.</li> <li>Fillauer, C, "A P.T.B. Socket with a Detachable Medial Brim," Orthotics and Prosthetics, Vol. 25, No. 4, December, 1971, pp. 26-34.</li> <li>Gleaves, J.A.E., Moulds and Casts for Orthopedic and Prosthetic Appliances, Charles C. Thomas Publishers, Springfield, Illinois, 1972.</li> <li>Tranhardt, T., "Trimlines for Prosthetics," lecture to California Association of Prosthetists and Orthotists, Lake Tahoe, California, Spring, 1978.</li> <li>McQuirk, A. and A. Morris, Controlled Pressure Casting for PTB Sockets (Teaching Manual), Hangers, Roehamptom Lane, London, England, 1982.</li> <li>Hayes, R., "A Below-Knee Weight Bearing, Pressure Formed Socket Technique," Orthotics and Prosthetics, Vol 29, No. 4, December, 1975, pp. 37-40.</li> <li>Stokosa, J., "Prosthetics for Lower Limb Amputees," in Haimovici, H., Vascular Surgery, Norwalk, Connecticut, Appleton Century-Crofts, 1984.</li> <li>Vinnecour, K., "Clinical Below Knee Prosthetics," lecture at UCLA Prosthetics Education Program Advanced below-knee Symposium, Fall, 1983.</li> <li>Cascade Orthopedics, Chester, California.</li> <li>Staats, Timothy, "Advanced Prosthetics Techniques for Below-Knee Amputations," Orthopedics, 8, 1985, pp. 249-258.</li> <li>IPOS Manual, "Below Knee Supracondylar Flexible Socket," IPOS-USA, Niagara Falls, New York, 1982.</li> <li>Koniuk, W., "A Pure Silicone Below-knee Socket Liner," lecture at American Academy of Orthotists and Prosthetists at San Francisco, California, Winter, 1986.</li> <li>Mr. Peyton Massey, New Life Laboratory, Santa Monica, California.</li> </ol> *Judd Lundt, B.S., A.E. Prosthetics-Orthotics Education &Research at the UCLA Division of Orthopedic Surgery, 1000 Veteran Avenue, 22-56 Rehabilitation Center, Los Angeles, California 90024. *Timothy B. Staats, M.A., CP. Prosthetics-Orthotics Education &Research at the UCLA Division of Orthopedic Surgery, 1000 Veteran Avenue, 22-56 Rehabilitation Center, Los Angeles, California 90024. Page Number(s) 118 - 130 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource The UCLA Total Surface Bearing Suction Below-Knee Prosthesis Creator An entity primarily responsible for making the resource Timothy B. Staats, M.A., CP. * Judd Lundt, B.S., A.E. * https://staging.drfop.org/files/original/2758dcc8f04d4645d2251d024de4b117.pdf 47ba774f7aaadae410bf2c3710d4d082 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_114.pdf Text Any textual data included in the document <h2>Winter Sports for the Amputee Athlete</h2> <h5>Doug Pringle <a style="text-decoration: none;">*</a></h5> Organized participation in winter sports by people with disabilities has a relatively short history. It began in the early 1950s when amputee veterans of World War II began to experiment with skiing despite the loss of limbs. The West Germans are credited with the invention of the outrigger, a crutch with ski tips attached, which are used as balance assisters. This invention helped popularize the sport and several amputee ski clubs were formed in the United States. During the late 50s and early 60s, amputee skiing was the mainstay of the sport. It was during the late sixties and early seventies that others with one "bad" leg, such as polio victims, began to ski using the technique developed for amputees. It was also during this time that amputees began experimenting with skiing with a prosthesis. Simultaneously, visually impaired people began to participate and the sport began to include more than amputees. In the late 70s, the major innovation was development of the "Four-Track" technique, which allowed many types of severely disabled people to ski. The 1980s have contributed the technique known as 'sit skiing.' This technique allows people who are wheelchair bound to participate in the sport. The benefits of participation in skiing are numerous. Physically the participant develops stamina, strength, balance, and coordination. These are all valuable physical traits for a person trying to compensate for a physical problem. Psychologically, participants begin to develop a positive self-image and a "can do" attitude. This positive thought cycle carries over into other aspects of life such as education and employment. Skiing offers a unique opportunity as a sport that can be done with family and friends in a facility open to the public. In that sense it is a mainstreamed activity done with everyone else rather than in a special facility. Finally, there is something wonderful and invigorating about the freedom of movement, speed, risk, and the natural environment of skiing. All these add to the experience. Skiing is the only winter sport offered to people with disabilities through formal programs. These programs offer adaptive equipment, qualified instruction and a competition system. Participation in other winter sports is not extensive. <h3>Downhill Skiing</h3> Alpine Skiing Alpine (or downhill) skiing is the most popular winter sport of people with disabilities in the United States. There are approximately 10,000 disabled skiers. The sport offers unique benefits to participants who are mobility impaired, not the least of which is that gravity supplies the means for movement. The development of adaptive equipment and techniques has made it possible for even the severely disabled to participate. Adaptive skiing is divided into five major categories or techniques: <ol> <li> Three track skiing </li> <li> Four track skiing </li> <li> Blind skiing </li> <li> Sit skiing </li> <li> Other adaptive techniques </li> </ol> Three Track Skiing Above-knee and below-knee amputees, persons with polio or birth defects, and those with a variety of other problems, ski three track in which the common element is having one good leg and two good arms. Above-knee amputees ski without their prosthesis because it is difficult to control. Below-knee amputees can ski with their prosthesis. The advantage is that they can stand on it when stopped. The disadvantage is increased risk of injury. Adaptive equipment for three trackers are outriggers. Outriggers are forearm crutches with ski tips attached. They act as balance as-sistors and are used to "walk" on the flats. Three track skiing derives its name from the three tracks made in the snow by two outriggers and the single ski. Some three trackers, especially racers, learn to ski with ski poles instead of outriggers. In fact, that is how people with one leg skied before the invention of outriggers. While more difficult, "one tracking" is also a possibility for many and skiing with poles is an advanced instructional method. Four Track Skiing Four track skiing is used by people with a wide variety of disabilities including: double leg amputees, spina bifida, cerebral palsy, muscular dystrophy, multiple sclerosis, stroke, head trauma, paraplegia, and polio. An individual with two legs and arms, natural or prosthetic, who is capable of standing independently (static balance), or with the aid of outriggers, could use this method. Many severely disabled people ski using this technique. In addition to outriggers, a lateral stability device is often used. This device is commonly referred to as a "ski bra." It helps keep the skiis parallel and also allows the student's strong side to help control the weaker side. Blind Skiing Visually impaired students are taught the same as any other skier with the exception that the instructor must learn to communicate more clearly. A number of holds or assists have been developed as well. Once the student can ski, the task becomes one of guiding or talking them down the hill. No adaptive equipment is required for the visually impaired. Often the student and instructor (or guide) wear bright bibs which signal to other skiers to be alert. Sit Skiing Sit skiing is the technique used by anyone who cannot ski standing. Sit skiers include people with muscular dystrophy, multiple sclerosis, cerebral palsy, spina bifida, paraplegia, and quadriplegia. This technique has been used since 1980 and it has opened skiing to people who are wheelchair bound. The sit ski has a fiberglass shell and metal edges. It is steered by leaning the body and by dragging a "pole" on the side to which the skier wants to turn. An instructor skies behind the device holding a length of nylon mesh cord in order to stop the skier and to assist with turns when necessary. Sit skiers often become proficient enough to ski "untethered" or without the instructor and safety line. The most recent development in sit skiing is the mono-ski. Here the fiberglass shell is mounted on a single ski and the skier uses outriggers. Use of a mono-ski requires good upper body strength. Therefore, it is a technique that is not suitable to quadriplegics and high-level paraplegics. Other Adaptive Techniques This catch-all category is used for a variety of people with disabilities who don't fit into any of the other four. Among them are upper extremity impairment: people who have lost the use of one or both arms. Those with one good arm use one ski pole and a pole can also be used with an arm prosthesis. Below-knee amputees may choose to ski using their artificial leg or legs. A heel line is usually necesary to achieve a bent knee position. Waist straps and thigh lacers help provide lateral stability, a snug fit, and reduced pis-toning and rotation. A special ski leg can be made if the student decides to seriously pursue skiing. The combination of disabilities and adaptive equipment are numerous. In competitions, some 19 different classes are recognized. But, generally, most people ski using one of the four major techniques. Instruction There are a number of programs of ski instruction available. Most are voluntary, weekend programs. There are five full-time professional ski schools which specialize in adaptive skiing and about 25 voluntary ones. All but a few of these programs are chapters or affiliates of the National Handicapped Sports and Recreation Association (NHSRA). The NHSRA has also developed a clinic team which trains instructors in adaptive ski teaching. The team also advises on program delivery. There is an instructor testing and certification program conducted by NHSRA which is approved and recognized by the Professional Ski Instructors of America. Competition A natural outgrowth of participation in sports is the development of competition. A very well developed system is in place. Learn to Race clinics and training camps are conducted by a few of the instructional programs locally and by the NHSRA nationally. Those interested in competition can race in any number of programs open to the public such as NASTAR and United States Ski Association races. Further, there are ten sanctioned regional championships at which racers can qualify for the nationals. Both the NHSRA and U.S. Association of Blind Athletes conduct annual national championships. Both organizations also select athletes for the U.S. Disabled Ski Team which competes in the World Winter Games for the Disabled and the Winter Olympics for the Disabled. In 1986, the U.S. Disabled Ski Team was number one in the world at the games in Sweden. Resources National Handicapped Sports and Recreation Association 4405 East West Highway, Suite 603 Bethesda, MD 20814 U.S. Association of Blind Athletes Professional Ski Instructors of America 5541 Central Ave. Boulder, CO 80301 Alpine Skiing, contact: Vineland National Center P.O. Box 308 Loretto, MN 55357 <h3>Nordic Skiing</h3> Nordic (or cross country) skiing is also popular among people with disabilities. Since the sport does require more muscular effort for motion than Alpine skiing, it is not an option for some severely disabled individuals. Among the participants are amputees skiing with their prosthesis and some who ski on one leg. Those on one leg must rely upon upper body strength and use their poles to push themselves along. Nordic skiing is well suited for the visually impaired. They may ski with a guide or follow pre-set tracks in the snow. Some more severely disabled people who would be four-trackers in Alpine skiing, such as those with cerebral palsy, muscular dystrophy, multiple sclerosis, stroke, head injury, etc., can also participate in Nordic skiing if they are able to ambulate well. Some will require assistance, pushing or pulling with a rope, and frequent rest breaks are always a safe practice. There is a sit ski for Nordic skiing. The sit skier will need excellent upper body strength to push themselves over any appreciable distance. Again, assistance and rest stops will help. Instruction There are very few Nordic skiing instructional programs in the U.S. The sport is just beginning to develop. Those interested in learning the sport should check with a local cross country ski resort to see if they have an instructor willing and qualified. Most will have difficulty finding a program nearby. Competition The competition program described under Alpine skiing exists for Nordic skiing. Nordic events are held separately from Alpine events, but the U.S. Disabled Ski Team includes both Alpine and Nordic competitors. <h3>Other Winter Sports</h3> Snowmobiling has been a sport in which people with disabilities have participated for at least 15 years. It was one option open to more severely mobility impaired individuals before development of four track and sit skiing. Ice boating and bike sailing are adaptable to a wide variety of mobility impairments. Ice fishing can also be enjoyed by many people. *Doug Pringle Doug Pringle is the past president of the National Handicapped Sports and Recreation Association, 5946 Illinois Avenue, Organeville, California 95662. <div style="width: 400px;"> </div> Page Number(s) 114 - 117 Year 1987 Volume 11 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 Winter Sports for the Amputee Athlete Creator An entity primarily responsible for making the resource Doug Pringle * https://staging.drfop.org/files/original/6212151a4fd93fa9dfd236829b610b9d.pdf 189fa090d4acf3dfea37b1693a79a780 https://staging.drfop.org/files/original/74352196c91439b746c487380d4c7d77.jpg 05c134f6b80ae4f5c032ba27b11de016 https://staging.drfop.org/files/original/10e30ded97b085e2b2892d7eea9365a3.jpg 25847e110d18fb0e9863908ef7b26efb https://staging.drfop.org/files/original/c14ca2b677fa08c269cdf300b3ac8d05.jpg 6aa3d9f3fdbb8117d775aec6125b3749 https://staging.drfop.org/files/original/56605a5d73b41e6c48d52f069c0109e4.jpg 0d4dd9bf592027776b6b43c7fb8e2dfd https://staging.drfop.org/files/original/8b2233e0b1a3db5f4e26c29029c28d52.jpg c9c9ed230bf33f6d1f48fe13e3d4c838 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_109.pdf Text Any textual data included in the document <h2>The Amputee Athlete</h2> <h5>Richard Riley, CP. <a style="text-decoration: none;">*</a></h5> An increasing number of amputees in the United States are moving beyond mere ambulation into active sports and recreation activities. Estimates of the number of amputees actively involved range from 15,000 to 20,000, with over 5,000 participating in organized competitive sports. <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-1.jpg">Figure 1. Below-knee amputee, George Lombard, member of the Fisher-Saloman Marathon Team and the U.S. Disabled Ski Team.</a> Ten years ago, the athletic amputee was a unique phenomenon in our practice. Today few practitioners cannot count two or three among their clientele. These amputees are at the cutting edge of our field because they push us as professionals to expand our perceptions of what is possible. They also provide the positive role models that we hold out to the rest of our clients as an example of what can be done. The able-bodied sports world has taken some giant leaps of perception regarding the amputee athlete. No longer is it just "inspirational" to have a disabled person competing in sports. Today there are amputees that compete in world class events alongside the able-bodied. The skiing world has demonstrated this by naming below-knee amputee George Lombard to the Fischer-Saloman Marathon cross country ski team and awarding above-knee amputee Diana Golden with the U.S. Ski Writers Award for Outstanding Alpine Competitor. Not only are there more elite amputee athletes today, there is a much larger body of rec-reationally oriented amputees. The days are gone when the prosthetist and rehabilitation team could be satisfied with being able to get the amputee to just walk. Expectations of our clients have changed. Not only the younger amputee, but also the active geriatric expects to be able to ride a bicycle, play golf, tennis, or jog around the block.<a></a> Our challenge is to meet these expectations. <h3>Psychology of the Amputee Athlete</h3> What causes one amputee to become an elite cross country skier (one of the most demanding physical sports in the world) and another with the same level of disability to be unable to even return to gainful employment? Part of the answer lies in the individual's ability to handle the stress and trauma of amputation. These are factors that we have little control over. The other part of the answer lies with environmental issues and can be addressed. Most amputee athletes are highly motivated individuals with a strong desire to overcompen-sate for their disability. A percentage of these people will rehabilitate themselves with practically no help at all and go on to accomplish great things in their personal lives as well as in sports. Others need the influence of role models to show them that their limitations are what they place upon themselves. One of the most positive experiences for any new amputee is when they meet another amputee with a positive attitude.<a></a> This positive motivation is best facilitated by a support structure of family, friends, and the rehabilitation team. If any one of these aspects is continually placing limits on the amputee, eventually the amputee will accept these limitations. There are physical limitations for the amputee, but these should be discovered not imposed. There are ways around most physical limitations by keeping an open mind and being willing to innovate. Pain is an aspect of amputation that in many cases is initially the greatest barrier to overcome. All athletes know pain through training and the physical exertion of competition. People who are athletic prior to becoming an amputee will generally be able to deal with pain more easily due to their previous development of strategies to perform while enduring levels of pain. The successful amputee will develop ways of minimizing discomfort, either through increasing the conscious tolerance for pain or seeking a lifestyle that reduces trauma to the residual limb. The amputee athlete not only has the pain of general physical exertion to deal with, but also the added trauma of torques and stresses far beyond normal to the skin and bone structure of the residual limb. Most of these athletes have developed very high pain tolerances and their body readily reacts to pain stimuli by releasing endorphines<a></a> (the body's natural pain medication) into the body. These factors enable the amputee athlete to achieve great physical accomplishments. It also sets up potential for serious damage to the residual limb tissue because of overactivity. Pain is the body's message to the brain that something is wrong and many amputees have developed ways to short-circuit this signal. This is a fact we must all be aware of in caring for and guiding the amputee athlete. <h3>Prosthetic Care</h3> For the prosthetic professional, the active amputee can be either a great source of pride and stimulation or a perpetual problem fraught with frustration. Nevertheless, this group of our clientele will continue to occupy a greater share of our patient load and we must develop strategies to successfully accommodate their needs. As important to the success of the athletic amputee as the prosthesis is his knowledge of how it works. Of equal importance are the limitations of the prosthesis and problem solving strategies for residual limb breakdown. The time spent in educating the amputee about his prosthesis and ways to deal with skin problems is always well spent. Regardless of how well fitting a prostheses is, there is a potential for skin breakdown of the residual limb due to overactivity.<a></a> Athletes will continually push themselves to their limits and beyond. If they are armed with methods to deal with skin breakdown, they will benefit greatly. Advances in sports medicine for runners was bound to spill over into prosthetics. Of particular use is a skin protection material called "2nd Skin™" (Table 1). It is a 1/16" thick piece of gel that is applied directly onto the skin. It prevents friction between the skin and any moving surface. It does not stick to normal skin, yet because of its viscosity, will stay where it is placed. It is perforated so as to let the wound breathe as well as being sterile to prevent infection. 2nd Skin™ absorbs secretions, feels cool, alleviates itching, and can relieve pain. 2nd Skin™ comes with plastic on both sides of the gel material. Before the plastic is removed, cut a piece one third larger than the area to be covered. This allows coverage of the affected area despite migration. The directions recommend removing the plastic from one side or from both sides. Personal experience has shown that removing the plastic from both sides prevents most migration. Because 2nd Skin™ is so thin, it does not increase pressure on blisters or abrasions. It prevents most friction and can actually promote healing even during heavy usage. 2nd Skin™ comes in a variety of sheet sizes which can be cut to the size needed and has to be kept in the zip-lock container provided. Unfortunately, it can be used only once and has to be cleaned off the sock after use. It works very well on below-knee amputees, especially when used beneath a sheath. In above-knee amputees, only suction wearers will experience difficulty in usage due to excessive migration from pulling into the socket. Second Skin™ is an inert material made from 96 percent water and four percent polyethylene oxide. Another product which provides excellent friction reduction and is also reusable is "Spenco® Skin Care Pad" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg">Table 1</a>). This product comes in three thicknesses, 1/2", 3/16", and 1/8". The 1/8" thickness produces the least amount of pressure inside the socket. Spenco® Skin Care Pad acts like a second layer of fat to protect the skin from friction or abrasion. It adheres to the skin without sticking due to its viscosity. Made from a reticulated closed cell elastomer, it can be gas sterilized or washed in soap and warm water. It should also be stored in the zip-lock bag and has a shelf life of two years. It is best used as a preventative measure in circumstances where skin breakdown is a danger.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-2.jpg">Figure 2. Applying 2nd Skin™ to a residual limb abrasion.</a> One of the problems with most skin protection materials is that suction socket wearers cannot utilize them. When the amputee pulls into the suction socket, "2nd Skin™" or "Spenco® Skin Care Pads" become displaced and usually do not cover the areas intended. A product that can be of use to suction socket wearers, or any amputee for that matter, comes with a variety of names. It is a transparent dressing with one adhesive side that is paper thin and porous both to air and water. The trade names are "Op-Site," "Bioclusive," "Tega-derm," and "Acuderm" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg">Table 1</a>). This material can be applied directly to the skin and acts as another layer of protection, while still allowing normal dermal respiration and perspiration to occur. It can be left on the skin for four to five days before it needs to be removed. If left on much longer, the epidermis does not get an opportunity to slough off properly.<a></a> These products work well to prevent friction, but do not provide any relief for pressure problems. The transparency of these materials allow for continual evaluation of the healing process. There is a problem that the adhesive is quite strong and oftentimes pulls hairs out upon removal. Different brands utilize different ad-hesives, but in general it is recommended that some soaking of the covered area in warm water will help remove the covering with minimal discomfort. Careful attention should be paid to the application instructions so as to avoid getting it adhered to itself when applying it. Most brands come with a paper backing and application method that allows it to be cut to the desired size. Until the time when skin abrasions and adherent scars become a thing of the past, we will have the need for skin protection materials. These products can give relief to thousands of prosthetic wearers as well as prevent much discomfort for active amputees. They should become a standard part of the amputee's "survival kit." <h3>Sports Organizations for Amputees</h3> The perceptions that amputees have of their capabilities has risen dramatically in the last decade. Paralleling the growth of competitive sports for amputees has been the organizations that provide the forum for these activities (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-4.jpg">Table 2</a>). Prior to these organizations bringing together amputees from around the nation and the world, there was little opportunity for exchange of ideas on the consumer level. <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-5.jpg">Figure 3. The United States Disabled Ski Team.</a> Organizations such as the "National Handicapped Sports and Recreation Association," sponsor and provide for competitive sports activities. Competition is based on ability and level of amputation with competitive levels ranging from local races to world class and a parallel Olympic structure. The impact of these organizations on the field of prosthetics has been enormous. All of us have fielded questions concerning amputee athletes and their various prostheses. This direction from the people whom we serve has been healthy for prosthetics for many reasons. First, we have had to expand our horizons and adapt technologies and techniques to accommodate these athletic amputees. Secondly, it has created a demand and thus a market for new components to accommodate extra-ambulatory activities. Third, there now exists a forum for amputees to exchange ideas, compare techniques, and services, as well as push each other to greater accomplishments. Another important contribution is the role model aspect of these athletic amputees. They provide inspiration to all of our clientele to continue to expand their perceptions of what is possible. All of these factors have changed prosthetics. Because of publicity surrounding some of the more astounding accomplishments, not only has the field gained more public recognition, but there is a growing acceptance of us as professionals. These organizations will continue to provide and promote sports and recreation as a normal part of the amputees lifestyle. Not only is it our responsibility and challenge to continue to adapt prosthetics to these activities, but it will play a major role in the future of our profession.<a></a> <h3>Conclusion</h3> As leisure time in our society increases, the need to accommodate sports and recreation in our society becomes essential. The perception of the amputee's lifestyle parallels this societal shift. Prosthetics must be able to accommodate this change in our patients' attitudes toward activity. This can best be accomplished through education and communication, as well as further development of componentry geared to the athletically inclined.<a></a> The amputee athlete has given rise to a new specialty in our field. The sports prosthetist is now a viable specialist that as professionals we should recognize and refer our patients to. We will continue to provide state-of-the-art prostheses for our active amputees, and armed with information about proper care, they will be among the best athletes in the world. References: <ol> <li>Riley, Richard, "The Amputee Athlete," Sports Medicine, Volume 4, October, 1984, pp. 31-32.</li> <li>Kegel, Bernice, "Recreational Activities of Lower Extremity Amputees: A Survey," Archives of Physical Medicine and Rehabilitation, Volume 61, June, 1980, pp. 258-264.</li> <li>Foort, James, "How Amputees Feel About Amputation," Orthotics and Prosthetics, Volume 28, March, 1974, pp. 21-27.</li> <li>Gaylor, Michael, M.D., personal communication, April, 1987. Presently Professor, Dartmouth College, Specialty in Sports Medicine.</li> <li><a href="poi/1980_01_037.asp">Levy, W. S., "Skin Problems of the Leg Amputee," Prosthetic and Orthotic International, Volume 4, 1980, pp. 37-44.</a></li> <li>Riley, Richard, "Skin Protection Materials," lecture given at American Academy of Orthotists and Prosthetics Annual Meeting, Tampa, Florida, February, 1987.</li> <li>Riley, Richard, "Sports Organizations for the Disabled and Their Impact on Prosthetics," lecture given at American Academy of Orthotists and Prosthetists Annual Meeting, Tampa, Florida, February, 1987.</li> <li>Riley, Richard, "A Survey of Active Below-Knee Amputees," study undertaken at Northwestern Orthotic and Prosthetic Research Center, Chicago, Illinois, December, 1980.</li> <li>Kegel, Bernice, Sports for the Leg Amputee, 1986.</li> </ol> *Richard Riley, CP. Richard Riley, CP., specializes in sports prosthetics and has a private practice with SportsMedicine Portsmouth, in Portsmouth, New Hampshire. Also a below-knee amputee, Riley is a member of the U.S. Disabled Nordic Ski Team and the Vice President of the National Handicapped Sports and Recreation Association. <div style="width: 400px;"></div> Page Number(s) 109 - 113 Year 1987 Volume 11 Issue 3 Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-2.jpg Figure 3 TABLE 1 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg Figure 4 FIGURE 3 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 5 TABLE 2 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-1.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 Amputee Athlete Creator An entity primarily responsible for making the resource Richard Riley, CP. * https://staging.drfop.org/files/original/c4f7c87a6d3b45eaeeb780028322aac3.pdf 2f3019f3a58522e9c6c9ef279008e662 https://staging.drfop.org/files/original/e3fa45ed04f25031b0eae1b1ae3563f7.jpg 1d480fe476876e4ae28210d460878f00 https://staging.drfop.org/files/original/8d9753f4b6b5322d836534694564a736.jpg 18e2d169d78ebf6f59e41dce49306715 https://staging.drfop.org/files/original/ba2d5caaf2bb5a526891c65720e02f75.jpg 4c419b14d2f5c2e8b85e998eec950f1e https://staging.drfop.org/files/original/1bb426ed68464888794dcdf4a783cf53.jpg d1da7506184096c8d68116798a87facd https://staging.drfop.org/files/original/1c12f7dc0e21d73986874eddb77e705e.jpg 6f0727ef350636789bc9df62f3eccbf4 https://staging.drfop.org/files/original/00d157335a62ec44dbfdf98f9c624906.jpg f4e81019aca87bb8e609ca049e7db794 https://staging.drfop.org/files/original/5e53449d0db91f56ed12371c0939588b.jpg 38d62fb95c884d54aa066fc874713827 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_101.pdf Text Any textual data included in the document <h2>The Cast Off Valve: An Improved Method for Removing and Retaining Above Knee Casts and Prosthetic Sockets</h2> <h5>Albert F. Rappoport, M.A., CP. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> The fabrication of a prosthesis continues to be a labor intensive process. The advent of prefabricated components, together with the use of central fabrication, has allowed many prosthe-tists to utilize their time more effectively. Time saving devices have always been welcomed by the prosthetic practitioner, especially when the quality of work is not compromised. Removal of an above-knee socket from a plaster model is a common procedure in most prosthetic facilities. There are several methods for removing the socket from the cast. These methods will be addressed later in the text and the problems of each discussed. The most improved method is the Cast Off Valve (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg">Fig. 1</a>). The Cast Off Valve uses compressed air, linking it directly to the above-knee socket (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg">Fig. 2</a>). The female coupling of the air hose is attached to the male connector of the Cast Off Valve (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg">Fig. 3</a>). The Cast Off Valve is then threaded into the suction valve housing of the above-knee socket. This method saves manpower, time, and energy by allowing removal of the socket from the cast in a matter of seconds. It is also effective in the duplication of any definitive above-knee suction socket. The concept is credited in its design to Judd Lundt, B.S.A.E., Assistant Director at UCLA's Prosthetic Education Program. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg">Figure 1. The Cast Off Valve.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg">Figure 2. Female couple of air hose to male connector on Cast Off Valve.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg">Figure 3. Cast Off Valve attached to female air hose coupling.</a> <h3>Methods Of Removing Socket From Cast</h3> Several methods have been used, with varying degrees of success, in removing an above-knee socket from a plaster model. The oldest method involves breaking the plaster out of the socket with a cold chisel and hammer, or air chisel. This is a labor intensive process which is still practiced by many prosthetists (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg">Fig. 4</a>). This process is not always necessary to facilitate the removal of a definitive socket. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg">Figure 4. Age old method of removing socket by breaking out plaster by hand.</a> <h3>Bivalving</h3> Many times, the prosthetist would like to save the plaster model for further modification or reference. One approach to saving the model is to bivalve the socket with a cast saw (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg">Fig. 5</a>). Once the socket has been bivalved, the cast can be touched up with minor plastic additions and used again. After the socket is bivalved, it cannot be reused. This process is not only time consuming, but can be eliminated in many circumstances. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg">Figure 5. Bivalving socket to retain cast.</a> <h3>Compressed Air</h3> The use of compressed air is by far the most popular method. It saves labor, time, sockets, and casts. A newly formed check socket or laminated socket may be easily blown off using an air gun. The newly fabricated socket must be trimmed just proximal to the desired trim line. A hole must then be drilled at the distal end of the socket to correspond in size to the tip of the air gun (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg">Fig. 6</a>). One person holds the air gun with compressed air in the hole at the distal end of the socket, while the other person gently taps, trying not to fracture the socket, at the proximal brim. This is continued until the air is forced through the socket and assists in forcing the socket off the cast. Some radical socket shapes may prevent the ease of this technique, in which case it may be helpful to attempt this procedure while the socket is still warm or to refer back to the previously mentioned methods. The compressed air technique is an effective way to remove the socket from the cast without damaging either one. Two drawbacks to this method are: 1) it requires two persons to remove the socket, and 2) it is possible for air to leak through the hole where the air gun is held at the socket's distal end. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg">Figure 6. Removing socket from cast using compressed air. This two-person operation requires one person to use air gun to direct air through hole in bottom of socket and second person to tap proximal socket. </a> <h3>Cast Off Valve</h3> The use of the Cast Off Valve can improve the effectiveness of the compressed air method (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.jpg">Fig. 7</a>). This improved technique can be employed whenever a valve housing is used in either a laminated socket or clear check socket. The Cast Off Valve is designed to fit the valve housing and link the air hose coupling directly to the socket. This approach allows a stronger air pressure to be obtained and little chance for air leakage. The use of this method requires only one person, freeing the hands of a second person who holds the air gun in the hole (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg">Fig. 6</a>). First, the proximal brim of the socket should be trimmed with a cast saw. Once the Cast Off Valve is installed, the air hose can then be connected and the socket will blow off without any further effort. One may need to gently tap the proximal brim with a piece of wood dowling and hammer to assist the removal. (Note: certain radical socket shapes may prevent the use of this method.) In summary, the Cast Off Valve requires only one person to remove a socket from the cast with a minimum amount of effort, reduction of time and improved results over methods previously discussed. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.jpg">Figure 7. The Cast Off Valve is threaded into valve housing and air hose is connected to blow socket off with minimum effort and maximum results.</a> <h3>Socket Duplication</h3> The Cast Off Valve also is excellent when an above-knee suction socket is to be duplicated from a definitive limb. No longer is an alginate impression or use of duplicating foam necessary. The patient's socket should be filled with plaster and a holding pipe inserted once the plaster has set. The valve housing must be cleared of any material so the Cast Off Valve can be inserted. The air hose coupling can then be hooked up and the socket is blown off in a matter of seconds. The socket is duplicated exactly in plaster and ready for lamination or check socket fabrication. <h3>Summary</h3> The Cast Off Valve has been well accepted and tested clinically with great success for the past two years by the staff at UCLA's Prosthetic Education Program and Prosthetic-Or-thotic Laboratory. The UCLA prosthetic staff has found this device to be valuable, in many cases, in removing an above-knee socket in both quadrilateral and CAT-CAM designs. This method allows the cast to remain undamaged for further reference and can be useful when duplicating a definitive socket. When working with an appropriately shaped cast, the Cast Off Valve allows the removal of the socket from the cast with improved results from the previously aforementioned methods. <h3>Acknowledgments</h3> This work is supported by VA Contract #633P-1667 Rehabilitation Research & Developmental Funds. Special thanks to Shirley M. Forsgren for the photography on this article and to Diane I. Lyons for preparation of the manuscript. Special thanks also to Dr. Ernest M. Burgress for his continued support in the research and development of advancing prosthetics. Thanks to Christopher Hoyt, CP, David Litig, CP, Mark Yamaka, CP, Richard Boryk, CPO, and Kenneth Neal, O/P Technician for their clinical evaluation of the cast-off valve at UCLA's Prosthetic-Orthotic Laboratory. *Albert F. Rappoport, M.A., CP. Albert F. Rappoport, M.A., CP., is Chief of Research Prosthetics with the Prosthetics Research Study, 1102 Columbia Street, Room 409, Seattle, Washington 98104, (206) 622-7717. He is formerly Senior Prosthetist-Orthotist at UCLA's Prosthetic-Orthotic Laboratory in Los Angeles, California. <div style="width: 400px;"></div> Page Number(s) 101 - 105 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 7 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Cast Off Valve: An Improved Method for Removing and Retaining Above Knee Casts and Prosthetic Sockets Creator An entity primarily responsible for making the resource Albert F. Rappoport, M.A., CP. * https://staging.drfop.org/files/original/edc28974552d636fa1ea028aa0e21578.pdf 294e8f5e3a6397b4484601b6f361116c https://staging.drfop.org/files/original/781e2b223fa61880bf51b05c4edf135c.jpg 4ad590c6d183512433ec8b8f2b4b339c https://staging.drfop.org/files/original/c7377cf25aabe70d5cb23dd8de0aa0c4.jpg ee7fcf6b5720cb917c7db96963d9ad84 https://staging.drfop.org/files/original/f51761f1329161d2580197578d7d8689.jpg b74b09c28a7f96ffb049050980e2099b https://staging.drfop.org/files/original/66a30e039664be60082b9b8032b9c241.jpg 2557718fb6cbda2e9f4168069b87f242 https://staging.drfop.org/files/original/d399253c84caa386bc8be7d60bf1dd9f.jpg f587df89b78717e6bf8e8b8a8a6dc318 https://staging.drfop.org/files/original/1e2e1ad63b2195562c9cc2f2a67b6085.jpg ca43f84c54cd7bc3d4a8bb5f93af4b53 https://staging.drfop.org/files/original/182b0fc27916a29db2515bef2f1e987c.jpg a32b2f619602dbe88784e5017ad43476 https://staging.drfop.org/files/original/30ccdd27a6c8be6477d61535158ac7a2.jpg f9ae503cf342bcd9591a3274c694a082 https://staging.drfop.org/files/original/2dc72d2c032ba91c99f619f9238b0f6f.jpg 1eb6c0a2bcb4e2c27ff6fda53ffa817b https://staging.drfop.org/files/original/0709f936190c8cd43b0d3c61388f76c3.jpg 31339e09eb509368490509db7a7d804e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_095.pdf Text Any textual data included in the document <h2>The Anterior Shell Orthosis: An Alternative TLSO</h2> <h5>Carrie L. Beets, CO. <a style="text-decoration: none;">*</a> Tom Faisant, R.P.T. <a style="text-decoration: none;">*</a> Vernon Houghton, R.T.O. <a style="text-decoration: none;">*</a> C. Michael Schlich, C.P.O. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Postoperative spinal management has undergone progressive changes in recent years. The merits of early mobilization following spinal surgery are well documented<a></a> and it is now generally agreed that earlier mobilization leads to quicker and more successful patient recovery. The recent advent of DRGs and predetermined payment to hospitals, regardless of length of hospitalization, adds even more incentive to the concept of earliest possible mobilization. Traditional approaches to postoperative spinal immobilization have been plaster body casts,<a></a> Jewett hyperextension orthoses,<a></a> and Knight-Taylor orthoses.<a></a> More recent approaches include the use of total contact TLSO's (body jackets), either with an anterior or posterior opening, or a bivalved, clamshell design.<a></a> Each of the above orthoses has inherent deficiencies with respect to very early patient mobilization attempts. Briefly, plaster casts lack total contact, lack volume adjustability, and do not promote or allow acceptable skin hygiene. Metal frame type orthoses such as a Jewett or Knight-Taylor do not control motion in all three planes, which is necessary for immediate postoperative mobilization. The ability of these orthoses to control lateral trunk flexion and/or rotary motion of the trunk is questionable. On the other hand, total contact TLSO's provide excellent control, but are very difficult to independently don and doff and, more important, they require rolling the patient into a prone position, or use of a Stryker frame, for molding. An additional deficiency of total contact TLSO's is they are too restrictive or confining, and actually slow the rehabilitation/recovery process by limiting range of motion necessary for independence. <h3>Development And Description</h3> In late 1977, Richard Rosenberger, CP. (deceased March, 1985) and physicians with the Department of Orthopaedics and Rehabilitation at the University of Virginia Medical Center developed the "anterior shell" orthosis as an alternative TLSO, designed to address all of the above mentioned deficiencies found in these other orthotic approaches. As its name implies, the anterior shell orthosis is a TLSO that provides total contact coverage to the anterior three quarters of the trunk, with the anterior trimlines the same as those of any standard body jacket type TLSO, and the lateral trim-lines just posterior to the lateral midline of the trunk (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg">Fig. 1</a>). Suspension and immobilization are afforded by this total contact anterior section coupled with a Jewett type posterior pad with adjustable straps and a two inch wide Velcro® posterior strap across the sacral-coccygeal junction of the pelvis (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg">Fig. 2</a>). Although quite flexible upon first impression, this TLSO becomes sufficiently rigid when properly tightened on a patient (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg">Fig. 3</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg">Fig. 4</a>), deriving its strength and rigidity from the tubular principle. This orthotic design provides a three point pressure system which is effective from T5 to L5; however, a cervical extension can be added to the orthosis to extend its support to the upper thoracic region. Originally designed for postoperative spinal management following Harrington rod instrumentation secondary to traumatic injury, the anterior shell orthosis permits the cast impression to be taken with the patient comfortably supine without the need for proning or other patient movement. <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg">Figure 1. Anterior view of Orthoplast™ anterior shell orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg">Figure 2. Posterior view of Orthoplast™ anterior shell orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg">Figure 3. Anterior view of patient wearing orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg">Figure 4. Lateral view of patient wearing orthosis. Note Jewett type posterior pad and strap arrangement.</a> <h3>Advantages</h3> In addition to the advantage of not having to move the patient while casting, the anterior shell orthosis is felt to be superior to the bi-valved and circumferential TLSO designs for postoperative management in other respects. Additional .advantages offered by the anterior shell orthosis include ease of donning and doffing the orthosis initially for the nursing staff and later, the ability to independently don and doff the orthosis by the patient while in the supine position (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg">Fig. 5 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg">Fig. 6</a>), ease of inspection of the surgical wound site without having to doff the orthosis, increased air circulation to the surgical wound site, and more efficient cooling due to less body containment within the orthosis. The anterior shell orthosis provides anterior, posterior, lateral, and rotary control, however, because there is no posterior section, the lateral aspects are slightly more flexible than in a circumferential design. This quality of slight flexibility facilitates maneuverability during transfers and activities of daily living, yet the orthosis provides sufficient external stabilization to protect the Harrington rod instrumentation. <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg">Figure 5. Patient in supine position donning orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg">Figure 6. Patient, lying down, rolls to side and fastens the posterior pad and strap. Allowing for the posterior pad and strap to fasten on the same side facilitates donning and doffing in the lying position.</a> <h3>Indications</h3> As the advantages of the anterior shell design were proven with experience with postoperative patients, opportunities were sought for its use with other spinal diagnoses (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-07.jpg">Table 1</a>). Indications for use of the anterior shell orthosis now include various vertebral fractures, treated surgically or non-surgically; vertebral degeneration and pain due to diffused malignancy; progressive kyphosis due to osteoporosis, ankylosing spondylitis, and neurological conditions; degenerative joint disease; and postoperative management of spinal stenosis. <h3>Experience</h3> Over a period spanning 1979-1985, 232 patients were treated orthotically with the anterior shell; 137 of these patients were treated postoperatively (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-08.jpg">Table 2 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-09.jpg">Table 3</a>). Over this seven year period, no postoperative patients experienced failure of surgical instrumentation while in the orthosis. During the initial development phase in 1978, only one postoperative patient experienced failure of his surgical instrumentation while in the orthosis. <h3>Treatment Regime</h3> Current treatment of thoracic and lumbar spinal cord injuries at the University of Virginia Medical Center includes molding and subsequent fit and delivery of an anterior shell orthosis within a few days post-surgery. Patients are usually maintained supine in bed until the orthosis is fit and delivered, with rehabilitation beginning immediately after fitting and delivery. At two weeks post-surgery, patients are allowed unlimited forward leaning in the orthosis for level and uneven surface transfers (wheelchair to bed, wheelchair to mat, etc.). Once the basic transfers are mastered, appropriately supervised advanced wheelchair transfers are permitted, including wheelchair to floor, floor to wheelchair, ascending and descending stairs in a sitting position, and in and out of a bathtub. At three to four weeks post-surgery, patients are taught independent donning and doffing of the orthosis in the supine position. <h3>Technical Information</h3> Material Selection At the University of Virginia Medical Center, the anterior shell orthosis is normally fabricated utilizing Orthoplast™. This thermoplastic material offers quick and easy fabrication that permits removal from the mold immediately after cooling without risk of shrinkage or other distortion. This allows for quick fabrication and delivery of the orthosis. Other noteworthy advantages of Orthoplast™ include pre-ventilation for air circulation, light weight, and due to its low temperature thermomolding properties, it is easily adjusted or modified in hospital and clinical settings. In cases where the orthosis is going to be used definitively, thermoplastics such as polyethylene or Vi-trathene are used in lieu of Orthoplast™. Patient Molding To cast a patient for an anterior shell orthosis, a piece of 12 inch wide stockinette is split lengthwise and placed over the patient with the edges of the stockinette tucked under the patient to prevent shifting during casting. A piece of narrow stockinette is passed carefully under the patient in the lumbosacral region of the back and through to the other side. The two ends are pulled tight over the iliac crests, tied off, and placed under tension as for pelvic traction (Fig. 7). Indelible anatomical markings are made and include the xiphoid process, sternal notch, costal margins, anterior superior iliac spines, and the superior border of the symphysis pubis. Plaster splints ase then applied making sure to cover from the symphysis pubis to the sternal notch anteriorally and down to the surface of the table on the sides, being sure to follow the patient's contours. When hardened, the plaster cast impression is removed and sealed and the positive model is poured. <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-10.jpg">Figure 7. Patient, in supine position, is ready to be casted. Patient does not have to be rolled or turned to complete casting.</a> Model Modification The positive model is modified in a normal TLSO modification fashion, including flattening the anterior lower thoracic and abdominal area for increased intraabdominal pressure and defining the area above the iliac crests for good suspension on the pelvis. Plaster buildups are added over the anterior superior iliac spines if the patient is thin. The lateral posterior border is extended two inches in the posterior direction from the iliac crests inferiorally, to cover the gluteals laterally and increase lateral stability. Because the anterior trimline of the orthosis extends to within an inch of the sternal notch, female patients require design variations in the model modification and the subsequent orthosis. For large busted female patients, an opening is frequently designed in the breast area to free the breasts. For smaller busted female patients, the breast area is built up on the plaster model to permit room for the breasts in the orthosis with the patient upright. In both situations, the area superior to the breast area is reduced on the plaster model to ensure good contact within the orthosis; also, the area superior to the breasts is reinforced in the fabrication process to ensure rigidity. When total contact for support and/or dispersement of pressure over a greater area is needed, as in cases of degenerative disease, such as osteoporosis, arthritis, and diffused cancer, the breast area is built up slightly on the plaster model and incorporated into a solid design in the orthosis. Fabrication Techniques When molded with Orthoplast™, reinforcement is provided by a double thickness of Orthoplast™ in appropriate areas: the anterior superior and the lateral posterior edges. The metal anchor plates for attachment of the posterior pad straps are sandwiched in between layers of Orthoplast™ and later drilled and tapped for 8-32 screws. If vacuum formed using a more durable thermoplastic, reinforcement can be provided with hybrid carbon composite inserts (available from Durr Fillauer). In this fabrication technique, the metal anchor plates for the posterior pad straps can be mounted on the plaster model for incorporation into the vacuum formed shell. In either case, the posterior pad is patterned after the Jewett orthosis posterior pad and has two sets of 1/2 inch dacron straps with 3/16 inch diameter holes, 1/2 inch apart in both ends for connection to the anterior shell. The posterior pad floats freely on the dacron straps, which are permanently attached to the metal anchor-plate on the left side of the orthosis with 8-32 screws and have roller buckles on the right hand ends of the straps. The right side straps, which are attached under 8-32 screw studs, pass through the roller buckles and double back on themselves for adjustable tension control and attachment to the stud-heads of the 8-32 screw studs. The roller buckle system acts as a pulley system, thereby reducing the mechanical force needed to properly tighten the posterior pad. The final component in the system is the two inch wide Velcro® sacral-coccygeal strap, which is permanently attached on the left side of the anterior shell, passes through a two inch stainless steel loop on the right, and doubles back on itself for a secure closure. This adjustable closure system is described as was originally designed by Rosenberger, et al. It is not necessarily deemed to be the simplest. Any of the adjustable closure systems utilized in the available prefabricated spinal extension orthoses should provide a suitable alternative to the above closure system. <h3>Summary</h3> The anterior shell orthosis provides quickly accessible orthotic support for early mobilization of patients with spinal cord injury and other diagnoses, allowing for independent donning and doffing with relative ease. Though sufficiently rigid to protect surgical instrumentation while boney fusion takes place, the anterior shell orthosis allows maximum maneuverability possible for a patient in a TLSO. <h3>Acknowledgments</h3> The authors would like to acknowledge Michael Smith for his efforts in the chart reviews. References: <ol> <li>Albee, F.H., E.J. Powers, and H.C. McDowell, Surgery of the Spinal Column, F.A. Davis Co., 1945, pp. 213-215.</li> <li>Bauer, R., "Preoperative Correction and Post-operative Fixation Using Harrington Instrumentation," Operative Treatment of Scoliosis, George Chapchal, editor, 1973, pp. 82-85.</li> <li>Bradford, D.S. and R.C. Thompson, "Fractures of the Spine," Minnesota Medicine, 59:1976, pp. 711-720.</li> <li>Dickson, J.H., P.R. Harrington and W.D. Erwin, "Results of Reduction and Stabilization of the Severely Fractured Thoracic and Lumbar Spine," Journal of Bone and Joint Surgery, 60A:1978, pp. 799-805.</li> <li>The Unstable Spine, edited by S.B. Dunsker, H.H. Schmidek, J. Frymoyer and A. Kaan, pp. 12-15.</li> <li>Edmonson, A.S. et al., "Report: Panel on Spinal Orthotics," Orthotics and Prosthetics, Vol. 31, No. 4, December, 1977, pp. 67-71.</li> <li>Edmonson, A.S., "Spinal Orthotics," Orthotics and Prosthetics, Vol. 31, No. 4, December, 1977, pp. 31-42.</li> <li>Flesch, J.R., et al., "Harrington Instrumentation and Spine Fusion for Unstable Fractures and Fracture-Dislocations of Thoracic and Lumbar Spine," Journal of Bone and Joint Surgery, 59A:1977, pp. 143-153.</li> <li><a href="http://www.acpoc.org/library/1976_01_007.asp">Friddle, W.D. and L.P. Brown, "Greenville Spinal Orthosis, Polypropylene," Inter-Clinic Information Bulletin, 15(9&10):Sept.-Oct. 1976, pp. 7-12.</a></li> <li>Norton, P.L. and T. Brown, "The Immobilization Efficiency of Back Braces," Journal of Bone and Joint Surgery, 39A:1957, pp. 111-139.</li> <li>Van Hanswyk, E.P., H.A. Yuan, and W.A. Eckhardt, "Orthotic Management of Thoraco-Lumbar Spine Fractures With A Total-Contact TLSO," Orthotics and Prosthetics, Vol. 33, No. 3, September, 1979, pp. 10-19.</li> <li>Wallace, S.L. and K. Fillauer, "Thermoplastic Body Jackets for Control of the Spine After Fusion in Patients With Scoliosis," Orthotics and Prosthetics, Vol. 33, No. 3, September, 1978, pp. 20-24.</li> <li>Wharton, G.W., "Stabilization of Spinal Injuries For Early Mobilization," Orthopedic Clinics of North America, 9(2): April, 1976, pp. 271-276.</li> </ol> *C. Michael Schlich, C.P.O. C. Michael Schuch, C.P.O. is Assistant Professor in the Department of Orthopaedics and Rehabilitation and Associate Director in the Division of Prosthetics, Orthotics, and Rehabilitation Engineering Services at the University of Virginia Medical Center in Charlottesville, Virginia. *Vernon Houghton, R.T.O. Vernon Houghton, R.T.O. is an Orthotic Assistant in the Division of Prosthetics and Orthotics at the University of Virginia Medical Center in Charlottesville, Virginia. *Tom Faisant, R.P.T. Tom Faisant, R.P.T. is a Supervisor of Physical Therapy in the Adult Rehabilitation Unit at the University of Virginia Medical Center in Charlottesville, Virginia. *Carrie L. Beets, CO. Carrie Beets, CO. was formerly with the Division of Prosthetics and Orthotics at the University of Virginia Medical Center in Charlottesville, Virginia. Page Number(s) 95 - 100 Year 1987 Volume 11 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg Figure 7 Table 1 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 Table 2 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg Figure 9 Table 3 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-09.jpg Figure 10 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Anterior Shell Orthosis: An Alternative TLSO Creator An entity primarily responsible for making the resource Carrie L. Beets, CO. * Tom Faisant, R.P.T. * Vernon Houghton, R.T.O. * C. Michael Schlich, C.P.O. * https://staging.drfop.org/files/original/e596fe333824d5e3e2ff725137adec85.pdf 22d8a4a169b4a0521aefc4ea4c48e32d https://staging.drfop.org/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg 4cc537e63119f220d2a5d43722b3f2c2 https://staging.drfop.org/files/original/1ada071125459a546f751d970b00a5c8.jpg f8a160cd40afca3e0239b722030d3ecf https://staging.drfop.org/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg 637f5bc31f36cb709581380fd3907536 https://staging.drfop.org/files/original/7abe20d1503c047c2ec9ee334918231e.jpg 6323600ff95773536016f3121ee8684a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_091.pdf Text Any textual data included in the document <h2>Knee Joint Materials and Components</h2> <h5>M.L. Stills, CO. <a style="text-decoration: none;">*</a></h5> The primary purpose of any orthotic knee joint, regardless of material or design, is to aid in providing stability to the patient's anatomical knee during loading of the extremity. In the paraplegic patient population, resistance to flexion of the knee is required during the periods of ground contact that occur during reciprocal gait. Orthotic knee joints can be used to provide medial-lateral control while permitting free flexion and extension, provide stance phase stability only during gait, or maintain locked knee extension during all phases of gait. Materials used in the fabrication of knee joints for management for people with paraplegia are generally a hybrid of various metals, or in some cases, high-strength, reinforced composite plastics. Aluminum, and/or stainless steel machined preformed components, are common and can be considered state-of-the-art. Mechanical knee joints are only a single component of a very complex system (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg">Fig. 1</a> and <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg">Fig. 2</a>). How that component is incorporated into the entire system has an effect on the outcome of successful orthotic management. The success or failure of the entire orthotic system is dependent on many variables, i.e., accuracy of the original prescription, fabrication procedures, placement and alignment of mechanical joints relative to anatomical joints, lever arms, overall fit, training in the use of the orthosis, and the motivation of the patient. <a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg">Figure 1.</a> Conventional metal and leather bilateral knee-ankle-foot orthosis with single axis drop lock knee and double adjustable ankle joint. <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg">Figure 2.</a> Bilateral polypropylene knee-ankle-foot orthosis with single axis drop lock knee and semi rigid ankle. FES was used with KAFO to facilitate swing through during gait. <h3>Free Knee Joints</h3> Free knee joints, having only hyperextension stops, are used to provide medial-lateral stability to the knee, or in situations when the patient has adequate extension power, but due to knee ligament laxity or muscle imbalance, is unable to control hyperextension. Care must be taken when using free knee joints to check hyperextension. The orthotist must be assured that the patient has adequate voluntary muscle control to maintain knee extension. The orthosis may be required to permit a limited amount of hyperextension in order to provide stability during stance. <h3>Offset Knee Joint</h3> The purpose of the offset knee joint is to provide stance phase stability of the knee while permitting free knee flexion during swing phase. This should provide a more anatomical reciprocal type of gait and should reduce energy consumption. The patient must have adequate voluntary muscle control to place the mechanical joint in a fully extended position and to move the ground reaction force anterior to the axis of rotation. The combination of ground reaction force, posteriorly offset orthotic knee joint, and a mechanical extension stop can provide stance phase stability for the paraplegic. Many of the same factors that influence stability of the bilateral above-knee amputee also can be applied to the paraplegic patient using bilateral offset knee joints. Voluntary hip extension power is required. The use of crutches or assistive devices are almost always mandatory. Consideration must be given to the problems of uneven walking surfaces, changes in heel heights, and patient endurance. Dynamic extension assists are often added to this type joint, or an extension lock may be added and dropped into place when additional security is required. <h3>Locked Knee Joints</h3> A locked knee joint (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg">Fig. 1</a> and <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg">Fig. 2</a>) provides stability during the stance phase of gait and remains locked even during phases of non-ground contact. A mechanism is generally provided to unlock the knee for cosmesis and comfort during sitting. Mechanisms for locking the knee joint in extension vary from simple gravity ring (drop) locks, spring-assisted drop locks, cams, pawls, and Swiss locks. Difficulty in unlocking the knee to permit sitting has led to the development of a variety of designs, again beginning with the simple ring lock, extensions added to drop locks, and bails (mechanical links between medial and lateral locks on a single extremity). To avoid accidentally unlocking a joint, designers have added ball retainers, springs, and elastic straps, all in an attempt to prevent accidental, unintentional flexion of the knee joint and subsequent falls and possible injury to the patient. There does not exist, however, a failsafe system that will completely eliminate the possibility of inadvertent knee flexion. Solid knee orthoses have been used with limited success because of functional difficulties. Granted, the knee is stable during gait, but the inability to flex the knee during sitting makes the use of public and private transportation difficult and many times impossible. Social and public functions are difficult to manage when the user of a solid knee type device tries to sit and avoid blocking aisles or passageways. Difficulties related to a stiff knee have greatly reduced the use of surgical knee arthrodesis. The use of medial and lateral components when fabricating knee-ankle-foot orthoses (KAFO) is commonplace. The use of such bilateral double upright construction certainly increases the weight of an orthosis and requires that the fabricator use techniques that ensure both medial and lateral joint surfaces are absolutely parallel and in alignment with each other. Nitschke in 1971 reported the results of using a single lateral upright in the fabrication of KAFOs. This technique reduced the weight of the KAFO and the problem of joint alignment. Incorporation of knee joints into a conventional metal and leather type KAFO provides the orthotist with the option of adjustability and limited skin contact (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg">Fig. 1</a>). Incorporation of knee joints into laminated and thermo-formed KAFOs (<a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg">Fig. 2</a>) provides a means for more intimate fit, better control of the extremity, improved cosmesis, and lighter weight, but limited adjustability in alignment and fit of the orthosis. The Lower Extremity Telescoping Orthosis (LETOR) (<a href="/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg">Fig. 3</a>) incorporates a new concept in knee joints. It really does not have a knee joint, but a telescoping posterior rod that, when in its extended position, bridges the anatomical knee joint and does not permit knee flexion. By lowering the telescoping rod, knee flexion is permitted during sitting. This simple telescoping bar attachment and a solid ankle system provides knee stability in ambulation and becomes a valuable training system and may be used as a definitive orthosis for the limited household ambulator. <a href="/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg">Figure 3</a>. LETOR-Posterior telescoping rod bridges the knee and prevents knee flexion. Other methods of controlling the knee joint externally must include the use of Functional Electrical Stimulation. These externally applied electrodes provide a means of electrically stimulating the muscles controlling the knee. Work has been done using electrical stimulation with and without forms of external knee support with mixed results. This work is still considered experimental, but there is every indication that it may become a means of providing control of the knee in the paraplegic population. <h3>Conclusion</h3> A number of knee joint designs exist. Those developed from metal, i.e., stainless steel and/ or aluminum, are best used when orthotically managing the paraplegic patient. Thermoplastic knee joint designs can be used in the unilaterally involved patient or when the problem is related to structural instability and not voluntary muscle control. Knee joints are made stable by including mechanical locks or stops, by alignment techniques to ensure that the ground reaction force is anterior to the axis of rotation, or by the addition of springs, elastic straps, or cords that dynamically extend the knee. Ground reaction forces can be combined with the paraplegic's own intact anatomical knee joint to provide knee extension without orthotic extension above the knee joint (<a href="/files/original/7abe20d1503c047c2ec9ee334918231e.jpg">Fig. 4</a>). This has been used with limited success in selected pediatric paraplegic patients. <a href="/files/original/7abe20d1503c047c2ec9ee334918231e.jpg">Figure 4.</a> Floor reaction orthosis—posterior directed force on knee producing knee extension. Note hyperlordosis due to hip flexion contracture. Present and future research may drastically alter components and materials used in the future. At present, however, the combination of appropriate prescription, components, fabrication and fitting skills, along with skilled training in the use of an orthosis, will result in the potential for successful orthotic management of the paraplegic patient. References: <ol> <li>Anderson, E.G., and J.T. Henshaw, "The Design and Prescription of Above Knee Orthosis." Orthotics and Prosthetics, Vol. 31, No. 3. September, 1977, pp. 31-40.</li> <li><a href="cpo/1986_03_111.asp">Bajd, T., B.J. Andrews, A. Krulj, and J. Katakis, "Restoration of Walking in Patients with Incomplete Spinal Cord Injuries by Use of Surface Electrical Stimulation-Primary Results." Clinical Prosthetics and Orthotics, Vol. 10, No. 3, Summer, 1986, pp. 111-114.</a></li> <li>Clark, D.R., J. Perry, and T.R. Lunsford, "Case Studies-Orthotic Management of Adult Post Polio Patients." Orthotics and Prosthetics, Vol. 40, No. 1, Spring, 1986, pp. 43-50.</li> <li>Condie, D., C. Pritham, A.B. Wilson, III, and M. Stills, Lower-Limb Orthotics, A Manual, First Edition, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, PA.</li> <li>Foster, R., and J. Milani, "The Genucentric Knee Orthosis-A New Concept." Orthotics and Prosthetics, Vol. 33, No. 2, June, 1979, pp. 31-44.</li> <li>Glancy, J., and R.E. Lindseth, "The Polypropylene Solid Ankle Orthosis." Orthotics and Prosthetics, Vol. 26, No. 1, March, 1972, pp. 14-26.</li> <li>Pokora, M.B., J. Ober, and P.T. Milewski, "Lower Extremity Telescoping Orthosis LETOR." Prosthetics and Orthotics International, Vol. 8, No. 2, August, 1984, pp. 114-116.</li> <li>Pritham, C, and M. Stills, "Knee Cylinder," Orthotics and Prosthetics, Vol. 33, No. 4, December, 1979, pp. 11-18.</li> <li>Rubin, G., M. Dixon, and M. Danisi, "VAPC Prescription Procedures for Knee Orthosis and Knee Ankle Foot Orthoses," Orthotics and Prosthetics, Vol. 31, No. 3, September, 1977, pp. 9-25.</li> <li>Stills, M., "Lower Limb Orthotics." Report: The Current Status of Prosthetics and Orthotics and Trends for Future Research and Development, University of Miami, April 1-3, 1977.</li> </ol> *M.L. Stills, CO. M.L. Stills is an Instructor of Orthopedic Surgery in the Division of Orthopedics at the University of Texas Health Science Center in Dallas, Texas and Assistant Professor at the University of Texas School of Allied Health Sciences. Page Number(s) 91 - 94 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-3.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/1987_02_091/1987_02_091-4.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 Knee Joint Materials and Components Creator An entity primarily responsible for making the resource M.L. Stills, CO. * https://staging.drfop.org/files/original/22f2bcc00fd13d3ee3dbba5a01cf9dfd.pdf f5dcb905e27a0297a27464a85893dcbb https://staging.drfop.org/files/original/739b1a9158b00278582d96d76ac19145.jpg 925b8b94e9c4b16ea14a5b8e612748f3 https://staging.drfop.org/files/original/c03ea9b706c703a0c23b955ca07c7da5.jpg 6114438d0c7b0f11b4f55fa8ed817d8b https://staging.drfop.org/files/original/13144e1ac56398758d04b22fc4b25fc5.jpg 464fa1a98a48cb3d50fe5a79ca02b7ba https://staging.drfop.org/files/original/d621137e255ef9d7c7e242e2122776f2.jpg 3a8ed62b5588399a696c3c1e1529768f https://staging.drfop.org/files/original/360efe6c756b05e84d50d65ed85add45.jpg cb981259d0b15353cd7336e14fd68c8c https://staging.drfop.org/files/original/8d2cd187f502495317c736775b95b3b1.jpg 7fe8a40aa682646a3bc9513370614734 https://staging.drfop.org/files/original/12aab77dddaf713fca6201a3a944eb99.jpg 89aa7327ec6c0d36aaacad28471c6ea0 https://staging.drfop.org/files/original/743a4583056a4ffceb44d54938b38c0f.jpg c26243f82589c6280ee0cb1f38b09bd7 https://staging.drfop.org/files/original/7bde68b6fc67e46a86f42233817d383a.jpg 8f117df5f4cf67539777c80e85427227 https://staging.drfop.org/files/original/2c4626ebe0deef97dca3a79434d65014.jpg 1774df62ca57088bb04d63e5bfb1501e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_082.pdf Text Any textual data included in the document <h2>Wheelchairs for Paraplegic Patients</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration: none;">*</a></h5> The best current estimates of the incidence and prevalence of spinal cord injury in the U.S. is 30-32 and 900 cases per million of population respectively.<a></a> About half of these cases are paraplegic. Added to this are paraplegics due to spina bifida, a few polio cases, etc. By definition, paraplegics have to rely on one or more assistive devices if mobility is to be achieved. Only a small segment of the paraplegic population make use of lower-limb orthoses, and even those who do have orthoses, and use them, need a wheelchair as well, in order to make the most of their available energy. For the very few who can "walk" enough not to feel the need for a wheelchair in work and activities of daily living, wheelchairs permit participation in athletic activities that would otherwise be impossible. Wheelchairs can be classified as either "manual" or "powered". The manual wheelchair is designed to be propelled by the occupant or by an attendant. Tests have shown that the energy cost of using a manual wheelchair for mobility on a smooth, level surface can be appreciably less than that of unimpaired persons walking on the same type of surface.<a></a> The conditions, of course, are reversed when uneven surfaces or ascending surfaces are encountered. The "powered" wheelchair is designed to be propelled by a battery-powered electric motor or motors. Originally conceived to be used by patients unable to propel themselves, powered chairs are sometimes indicated so that a paraplegic can make more effective use of his own energy. The basic manual wheelchair has two side-frames connected by a cross-bar that is pivoted about its intersection and a flexible seat and back to allow folding, two large driving wheels at the rear, and two caster wheels at the front (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-01.jpg">Fig. 1</a>).<a></a> This is a configuration that has evolved over the years since the original patented design of Everest and Jennings<a></a> in 1936 for the folding mechanism, and represents a rather elegant compromise between maneuverability, stability, and portability. Many concerted attempts, especially in recent years, to develop better designs have not been very successful. The use of new materials has made it possible to produce significantly lighter wheelchairs, but the original configuration is basically the same. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-01.jpg">Figure 1. The basic wheelchair-folding frame, 24-inch diameter wheels in the rear, 8-inch diameter casters in the front, flexible seat and back.</a> It must be remembered that a change in the design to emphasize one feature generally affects adversely one or more of the other features. An example is when the wheelbase of the basic chair is lengthened to provide more stability for the bilateral leg amputee; maneuverability is sacrificed. Designers of some of the "sports" chairs, in order to reduce weight, have eliminated the folding mechanism. Portability is achieved by connecting and disconnecting driving wheels for transport in an automobile. <h3>Prescription Considerations</h3> Variations of the basic chair are available for amputees, hemiplegics, and others, but the basic chair of proper dimensions is generally the most suitable for paraplegic patients. The range of dimensions of the basic wheelchairs available in the United States are shown in<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-02.jpg"> Fig. 2.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-02.jpg">Figure 2. Dimension ranges for the basic adult wheelchairs from major U.S. manufacturers.</a> Even when sensation is present, the hammock type seat is seldom used without cushions, which are needed to provide a better distribution of pressure over the thighs and buttocks for comfort, if for no other reason. Cushions and other seating systems affect the relationship between the user and the chair and, therefore, must be selected and taken into account before the final dimensions of the chair are determined. The importance of selecting the most appropriate chair and seat cushion cannot be over emphasized. The dimensions of the chair must distribute the forces of the body properly while also placing the user in a position, with respect to the driving wheels, to provide maximum efficiency during propulsion. <h3>Seat Width And Depth</h3> Selection of the proper seat width is important to comfort and stability. A seat that is too narrow is not only uncomfortable, but access to the chair is made difficult. Furthermore, the chances of pressure sores developing is increased. A seat that is too wide encourages the user to lean toward one side, thus promoting scoliosis and increased pressure over the buttocks on one side. In addition, a seat wider than is necessary makes propulsion more difficult. A seat that is too shallow reduces the area in contact with the buttocks and thighs and causes more pressure on the soft tissues in contact with the seat than is necessary or safe. Furthermore, the location of the footrests is changed so that the feet and legs are not supported properly, and the balance of the user can be affected. A seat that is too long can restrict circulation in the legs. <h3>Seat Height</h3> The height of the seat above the ground of the basic adult chair is 19 1/2 - 20 1/2 inches. Tall persons require a seat that is higher and deeper; short persons require a seat that is lower. Usually these requirements can be met by a stock chair; if not, properly dimensioned units can be had on special order. Obviously, the cushion or seating system to be used will affect the end result. <h3>Seat Type</h3> Seats available from wheelchair manufacturers are sling or hammock types, made of a flexible material, and solid seats which are generally removable (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-03.jpg">Figure 3. Seat types-a. hammock or sling; b. solid.</a> The sling seats are, by far, the type most used. A solid seat installed to permit folding is available, or a removable solid wooden seat may be purchased or made. <h3>Backrest</h3> The backrest of the basic chair is made of a flexible material stretched between the two side frames which are fixed with respect to the seat. The backrest should be high enough to provide support without inhibiting motion, yet not so low that the scapulae can hang over the back of the chair and cause discomfort. <h3>Arms</h3> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-04.jpg">Fig. 4</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-04.jpg">Figure 4. The basic wheelchair with the most popular types of arms-removable full-length, removable desk-type, and removable, adjustable desk-type.</a> The lightest chairs have fixed arms or none at all. But an overriding factor in wheelchair prescription is transfer into and from the wheelchair, especially when the patient is unable to stand for a brief period. For this reason, most patients require chairs with arms that can be removed easily. Chair arms not only provide support for the patient's arms in a resting attitude, but also provide lateral support and a reaction point for the hands when the asensitive patient elevates his body at regular intervals to prevent restriction of circulation and thus pressure sores. Both removable and fixed arms are available in full-length and desk models; both of these styles are available with the height fixed or adjustable. The desk models are foreshortened to permit the user to get closer to a desk or table top. The removable desk arm is by far the most popular type. The full length models are indicated when the forepart is needed to support the arms of the user in rising from the chair, or when lordosis, obesity, or some other physical factor makes it necessary to use the front part of the arm for support. The standard removable desk model can be reversed to provide this feature. <h3>Wheels And Tires</h3> The basic chair has two 24 inch diameter rear wheels and two eight inch caster wheels in the front (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-05.jpg">Figure 5. Basic wheelchair with standard 24-inch diameter wire-spoke wheel and two options: the cast magnesium wheel and a wheel with special built in hand rim.</a> The standard rear wheel for many years has been a wire spoke wheel, but wheels of cast metal alloy and wheels of cast plastic have been made available recently to overcome the maintenance problems inherent in the wire wheel design without adding more weight. Three types of tires are available in several widths and tread types. Pneumatic, semi-pneumatic, and solid tires are available (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-06.jpg">Fig. 6</a>). The eight inch diameter wheel with solid rubber tires is standard on the basic chair, and is suitable for use on smooth surface and indoors. The semi-pneumatic and pneumatic tires provide shock absorption, and, thus, are more suitable for rough surfaces and outdoor use. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-06.jpg">Figure 6. Basic wheelchair and optional casters available. Shown on the chair is the standard 8-inch diameter wheel with solid rubber tire. Next in order are: the 8-inch wheel with the semi-pneumatic tire; the 8-inch wheel with pneumatic tire; a 5-inch diameter wheel with solid rubber tire.</a> Pneumatic tires provide a more cushioned ride and their shock absorber action tends to prolong the life of a wheelchair when kept inflated properly. <h3>Handrims</h3> Handrims are attached to the driving wheels of wheelchairs to permit control without soiling the hands. The standard handrim is a circular steel tube. For users who have problems gripping the smooth surface of a metal ring, vinyl coated rings and a variety of knobs and projections can be added to the ring. <h3>Casters</h3> Casters make steering possible and are available in two diameters: eight inches and five inches. The five inch model is available only with solid tires, and is used on children's chairs and in special circumstances on adult chairs and basketball chairs, when more maneuverability is desired. <h3>Parking Locks</h3> Most users need some means of securing one or more wheels to keep the chair from rolling down inclines or to provide stability during transfer to and from the chair. Two types of parking locks are available from the large wheel (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-07.jpg">Fig. 7</a>): toggle and lever. Selection depends upon user preference. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-07.jpg">Figure 7. Two types of parking locks-left, toggle type; right, lever type. Variations of these two types of locks are available.</a> Pin type locks are also available. These retain a caster in the trail position and are used to prevent swiveling during lateral transfer. <h3>Cushions</h3> The vast majority of paraplegics require, and can use successfully, seat cushions that are mass produced and are widely available at reasonable prices. A great many designs of seat cushions are available. Some have been developed by trial and error, the designs being based on what has proven to be acceptable to the inventor or his customers; other designs have a more scientific basis, but because the exact cause of decubitus ulcers is not known, precise criteria for design of wheelchair seating have not been established.<a></a> Although each of the cushion designs available has advantages and disadvantages, most of which are not clearly defined, selection of seat cushions for individual cases is seldom simple or straightforward. Commercially available cushions may be divided roughly into five categories, including "miscellaneous" or "other", based on material and design (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-08.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-08.jpg">Figure 8. Various types of seat cushions that are available.</a> <ol> <li> Foam </li> <li> Viscoelastic foam </li> <li> Gel </li> <li> Fluid </li> <li> Other </li> </ol> Foam Cushions Foam cushions generally use polyurethane or polyether foam, and are available in various configurations. The simplest are homogeneous rectangular blocks 2-4 inches thick; some are contoured; and others are composed of two or more layers of material of different densities, some of which may contain hollow spaces or cores in an attempt to distribute the load to specific areas. Viscoelastic Foam Cushions Viscoelastic foam is less resilient than ordinary foam. Gel Cushions Gel cushions consist of rather firm emulsion enclosed in a "non breathing" plastic casing. Fluid Flotation Cushions Water, air, or water-and-foam particles are used in a flexible, tailored plastic bag to provide distribution of forces. The overall effect varies with the amount of fluid introduced. Other Types Many other designs that combine several elements are available. Prominent among these are the ROHO, which uses a collection of air-filled tufts to distribute the loads and the VASIO (Veterans Administration Spinal Injury Orthosis), in which foams of two different densities are combined and contoured to meet the special needs of paraplegic patients. Each type and design has advantages and disadvantages, and, therefore, selection of the type most appropriate for individual patients is not easy. Until more is known, selection has to be made on a trial basis. <h3>Sports Chairs</h3> Since the introduction of wheelchair basketball shortly after World War II, a constant stream of modifications and refinements has been made to the basic wheelchair to meet the needs of wheelchair athletes. Development of the lightweight, high-performance, sports chair has led to racing among wheelchair users and has made playing tennis from wheelchairs practical and enjoyable. These chairs have also been found useful in non-competitive recreation, such as camping and mountain climbing. Much that has been learned in developing and using sports chairs has resulted in improved performance and quality of prescription wheelchairs, just as automobile racing has led to improvements in the family car. At the same time, many of the people who have been using conventional wheelchairs are now using sports chairs full-time. Like the basic prescription wheelchair, the sports chair (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-09.jpg">Fig. 9</a>) has evolved through a series of refinements to where the general configurations of most chairs are strikingly similar. At least 20 manufacturers at this time offer one or more models. Most use 24 inch diameter wheels; some use 27 inch wheels. Weight varies from 16 to 38 pounds, due mainly to material selection and whether or not the chair can be folded. A number of designs incorporate provisions for folding; Others use wheels that can be disconnected (and connected) quickly without tools to make transportation easier. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-09.jpg">Figure 9. Three types of sports chairs. The one shown at the top is limited primarily for use in racing. The other two are more versatile.</a> Nearly all use five inch diameter front castors, except one manufacturer that uses four inch wheels. Two make eight inch castors available as an option. Nearly all, if not all, have a feature that permits a choice of rear wheel axle position with respect to the frame (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-10.jpg">Fig. 10</a>). Only a very few offer arm rests. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-10.jpg">Figure 10. Schematic showing adjustability often found in sports chairs that permit an optimum relationship between position of the user and the wheels.</a> Many active wheelchair users prefer to use a sports type chair all the time, and in many instances options are offered that make regular use practical. Many models have adjustable features, and most manufacturers will provide a chair with dimensions to suit a given individual. A feature found on most sports chair, but not on other types, is the easy adjustability of wheelbase and seat height afforded by the positioning plate for the rear wheels. In many models, the position of the castor wheels can also be adjusted. Such adjustability, of course, permits the user to be seated in a position which puts the muscles in the upper limbs and shoulders in the optimum arrangements for maximum biomechanical efficiency. Because refinements and advances are being introduced so frequently, the periodical SPORTS 'N' SPOKES, published by the Paralyzed Veterans of America, has been devoting one issue each year to sports chairs and their specifications.<a></a> <h3>Summary</h3> Because of increased competition and refinements brought about by the sports chair movement, paraplegics now have available high quality wheelchairs. No single chair design is apt to meet all the needs of each individual, but careful thought and attention to detail in prescription preparation can result in a chair that meets most of the needs of the paraplegic. References: <ol> <li>Cochran, George Van B. and Vincent Palmieri, "Development of Test Methods for Evaluation of Wheelchair Cushions," Bulletin of Prosthetics Research, 10-22, 17:1:9-30, Spring 1980.</li> <li>Everest, H.A., et al., U.S. Patent No. 2,095.411, October 12, 1937.</li> <li>SPORTS 'N' SPOKES, 5201 N. 19th Avenue, Suite 111, Phoenix, Arizona 85015.</li> <li>Grimby, Gunnar, "On the Energy Cost of Achieving Mobility," Scand. J. Rehab. Med., Supplement 9, 1983, pp. 49-54.</li> <li>University of Alabama at Birmingham, Spinal Cord Injury Project, "Spinal Cord Injury - The Facts and Figures," 1986.</li> <li>Wilson, A. Bennett, Jr., Wheelchairs: A Prescription Aid, Rehabilitation Press, Charlottesville, VA, 1986.</li> </ol> *A. Bennett Wilson, Jr. A. Bennett Wilson, Jr. is an Associate Professor with the Department of Orthopedics and Rehabilitation at the University of Virginia, Charlotteville, Virginia 22908. Page Number(s) 82 - 90 Year 1987 Volume 11 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-07.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/1987_02_082/1987_02_082-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-01.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Wheelchairs for Paraplegic Patients Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/934d9d58cdc431c9e0221d32ee8fe951.pdf 9ab98303a3e42383d5edd757b0da7d06 https://staging.drfop.org/files/original/9a0943f435a6d9fe4ed610d2caba0b86.jpg b20aa7224fab12563b41462c3dd6fe20 https://staging.drfop.org/files/original/ac1c440073b39ee145136d5d5c0f8990.jpg caadd7555cef407c05e9e41c66a61ecb Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_079.pdf Text Any textual data included in the document <h2>A New Look at the RGO Protocol</h2> <h5>Lou Ekus, C.P.O. <a style="text-decoration: none;">*</a> Linda McHugh, R.P.T. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> The L.S.U. Reciprocal Gait Orthosis (RGO) is an orthotic device that gives structural stability to the patient with lower trunk and lower limb paralysis while allowing, through a cable coupling system, reciprocal hip joint motion for ambulation. The device has been used at the Shriners Hospital in Springfield, Massachusetts since December, 1980. Our experience with the Reciprocal Gait Orthosis has led us to a simplified approach in the selection, fitting, and training of patients suitable for fitting with this device. <h3>Patient Distribution</h3> Sixteen fittings with the Reciprocal Gait Orthosis have been reviewed for this article. Seven of these children were under the age of four years at the time of their first fitting, with a total of 12 children under the age of eight at the time of first fitting. All 12 children were discharged from the hospital using the orthosis effectively. One child in this group later rejected the orthosis because he was able to ambulate with bilateral knee-ankle-foot orthoses and felt the Reciprocal Gait Orthosis was too much bracing. Out of this group, the remaining 11 children are currently community ambulators and wear the orthosis for most of the day. In addition to these 12 children, we have four young adults who are fit with the Reciprocal Gait Orthosis. Three of them were 13 years old at the initial fitting. Two of these children were discharged from the hospital using the orthosis effectively and are currently household ambulators. The last of the 13 year olds rejected the brace due to an extreme fear of the upright position. Our last fitting was done on a 21 year old male with severe hip and knee flexion contractures. This patient had a tremendous desire to ambulate and so the fitting was attempted. However, after numerous fittings and adjustments, the attempt was abandoned as a result of the severity of his contractures. <h3>Protocol</h3> Our first patient was fit with a reciprocator in December, 1980. Subsequently, 12 children were fit following the general guidelines established by Louisiana State University. In November, 1985, we developed our own written protocol. The protocol was extremely specific, outlining prerequisites before fitting with the Reciprocal Gait Orthosis. The protocol included such criteria as, 1) hip and knees free of flexion contractures greater than 20 degrees, 2) patient required to demonstrate independent mobility in a parapodium, and 3) parents required to admit children for training. After a review of our series up to that point, we realized that few of the patients actually met 100 percent of the criteria in our existing protocol, and yet our success rate was quite high. After a further review of the fittings was done, a revised protocol was written and instituted in June, 1986. Our new protocol for fitting with the Reciprocal Gait Orthosis is outlined below: <ol> <li> Parents and child will watch a video prepared by the hospital showing the fitting and training process for the Reciprocal Gait Orthosis. </li> <li> A team meeting will be held prior to admission with parents and child, physical therapist, orthotist, nurse, social service representative, and physician. At this meeting, goals are set for admission and parents are given the opportunity to ask any member of the team questions that they might have. The child's abilities will be discussed, including a) ability to stand and move in the parapodium, b) emotional and cognitive ability to tolerate training, c) upper extremity strength, and d) any existing joint contractures and their influence on fitting and training. </li> <li> Goals will be set, regarding a) cooperation for training, b) balance and confidence with movement, c) quality of mobility, d) independency in transfers, and e) donning and doffing of the orthosis. </li> </ol> Following fitting and dynamic alignment of the Reciprocal Gait Orthosis, gait training begins. It includes 1) momentary standing balance, 2) training on the parallel bars (patient instructed to "shift weight" and "push back"), 3) progression to a rollator walker when consistent orthotic control, good balance, and even stride length are demonstrated in parallel bars, and 4) progression to Loftstrand crutches when improved independence in balance is achieved and the patient is cognitively able to use them. Three weeks into training, a second team meeting is held. Each goal is addressed and the team determines the best way to continue training based on the reassessed goals. At discharge, the patient will 1) ambulate with the walker, 2) exhibit consistent control in step length, balance and stability, 3) exhibit good standing balance, and 4) be able to negotiate a ramp. <h3>Fitting Problems</h3> Without a doubt, the most consistent problem we've seen in fitting the Reciprocal Gait Orthosis is existing hip, knee, and ankle contractures. We have fit patients with significant contractures of these joints and have accommodated for the contractures in alignment by wedging the shoes (<a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg">Fig. 1</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.jpg">Fig. 2</a>). Our intention is to enable the child to exhibit effective ambulation and then to consider joint releases when possible. <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg">Figure 1. Front view of patient showing extensive pre-existing contractures and shoe wedging to accommodate the contractures.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.jpg">Figure 2. Lateral view.</a> We have seen, in a few cases, where it is difficult for the patient to comprehend that pushing back will advance the leg. To make this concept more easily understood in the early stages of training, the hip joints are flexed slightly more than usual to allow the patient to grasp this concept easily. This usually makes standing balance impossible. However, after a day or two, the orthosis can be extended and standing balance can be addressed. We found this to be an extremely useful tool in expediting the initial stages of training. <h3>Early Intervention</h3> Taking into consideration the importance of upper limb strength, preservation of range of motion, and weight control before fitting a patient with the reciprocating orthosis, it is easy to see the importance of early intervention in cases of congenital deficiency. Through our myelodysplasia clinic, we are able to follow the patients on an ongoing basis from birth to insure continuing follow up in these areas. It is also possible to insure the delivery of an infant Stander at the appropriate time. The clinic also gives us the opportunity to observe the child in the Stander or parapodium. Mobility in these devices is a good indication of motivation, balance, and the child's awareness of his body moving through space. The myelodysplasia clinic gives us an invaluable opportunity to insure that all of the prerequisites are being nurtured and that we can initiate a fitting with the Reciprocating Gait Orthosis at the appropriate time. <h3>Results</h3> Included in our series of 16 patients are 12 children who are community ambulators. In addition, two children are ambulatory in their household or for short distances, and two rejected the Reciprocal Gait Orthosis as their means of mobility. The age of initial fitting for these children spanned two years to 21 years, with children under the age of eight all being community ambulators. <h3>Conclusion</h3> Clearly, the results demonstrate the importance of both early intervention and early fitting with the Reciprocal Gait Orthosis. We hope that children with congenital paraplegia who initiate ambulation with a Reciprocal Gait Orthosis at an early age will continue to be ambulatory further into adult life than those who have used knee-ankle-foot orthoses in the past. In conclusion, we would like to propose the idea that, based on experience with our protocol, the fitting and training of a child using the Reciprocal Gait Orthosis is no more difficult than other bracing modalities and can be approached with the same ease. References: <ol> <li>Douglas, R., P. Larson, R. Ambrosia, and R. McCall, "The LSU Reciprocation-Gait Orthosis," Orthopedics, Vol. 6, No. 7, July, 1983, pp. 834-838.</li> <li>McCall, R., R. Douglas, and N. Rightor, "Surgical Treatment in Patients with Myelodysplasia Before Using the LSU Reciprocation Gait System," Orthopedics, Vol. 6, No. 7, July, 1983, pp. 843-848.</li> <li>Shanks, K., "LSU Reciprocating Gait Orthosis," Durr-Fillauer Medical, Inc.</li> <li><a href="http://www.acpoc.org/library/1985_03_046a.asp">Ekus, L., "Reciprocator Orthosis: A Protocol," ACPOC, April, 1985.</a></li> </ol> *Linda McHugh, R.P.T. Linda McHugh, R.P.T. is also with Shriners Hospital for Crippled Children. *Lou Ekus, C.P.O. Lou Ekus, C.P.O. is Director of Orthotics and Prosthetics at Shriners Hospital for Crippled Children, 516 Carew Street, Springfield, Massachusetts 01104. <div style="width: 400px;"></div> Page Number(s) 79 - 81 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.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 A New Look at the RGO Protocol Creator An entity primarily responsible for making the resource Lou Ekus, C.P.O. * Linda McHugh, R.P.T. * https://staging.drfop.org/files/original/9dbe52f7fdd35578cf5246376f655c2a.pdf a3efeb93b0ab8f0a71f9da3dd1aae1cc https://staging.drfop.org/files/original/49c519d9cfc114bc2adb3d22a688c55c.jpg 019d282606c1c336d88f88bb227ae5f9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_074.pdf Text Any textual data included in the document <h2>Post-polio Syndrome: An Overview</h2> <h5>Neil R. Cashman, M.D. <a style="text-decoration: none;">*</a> Irwin M. Siegel, M.D. <a style="text-decoration: none;">*</a> Jack P. Antel, M.D. <a style="text-decoration: none;">*</a></h5> Poliomyelitis was a dreaded disease in developed countries, affecting tens of thousands of children and adults during each of the epidemic years up to the mid-1950s. The polio virus is a small RNA virus whose only natural host appears to be man. The vast majority of exposed persons develop either an inapparent infection or a non-specific flu-like illness (non-paralytic poliomyelitis). Secondary invasion of the brain and spinal cord is associated with infection and death of motor neurons, with loss of innervation to muscle fibers, and consequent muscle weakness and atrophy. Postmortem studies show that muscle weakness in poliomyelitis is clinically apparent only when more than half of the corresponding motor neurons are destroyed.<a></a> Frequently, muscles can be reinnervated by healthy neighboring motor neurons by a process of axonal sprouting. Thus, partial or complete recovery of muscle bulk and strength can occur, in which subnormal numbers of motor neurons support increased (up to 8-fold) numbers of muscle fibers.<a></a> It is estimated that about 250,000 people in the United States have survived paralytic poliomyelitis and are alive today.<a></a> Recently, it has become clear that some patients who had paralytic poliomyelitis may develop new complaints after decades of stable function.<a></a> These new symptoms have been designated the "post-polio syndrome" (PPS) or "late sequella of poliomyelitis." Although some reports of new weakness following polio can be found in the medical literature since 1875,<a></a> recent epidemiologic studies indicate that new symptoms are common, occurring in approximately 25 percent of patients with antecedent paralytic poliomyelitis.<a></a> If this estimate is correct, over 50,000 persons in the U.S. are at risk of developing PPS. From published reports, the mean latency of onset has been calculated to be 36 years.<a></a> Thus, an increasing incidence of new cases will probably continue into the early 1990s, reflecting the last epidemics of the mid-1950s. The risk of developing PPS appears to correlate with severity of the original poliomyelitis. Thus, a patient with four-limb involvement and a history of respiratory dependence during his polio is more likely to develop new symptoms than a patient with one-limb involvement.<a></a> The severity of the original onset of polio also seems to predict the latency of developing the syndrome; severely affected patients may develop new symptoms after only 10-20 years, whereas mildly affected patients are more likely to exhibit extended delays in time of onset of PPS.<a></a> What causes PPS? Why should a patient who has had stable function for decades develop new symptoms? At the present time, there is little definitive data on this subject. Early conjecture focused on a possible reactivation of the polio virus which had remained latent in the nervous system since the original infection. However, there appears to be little or no evidence for inflammation in post-polio patients; spinal fluid is without the cells, protein, and immunoglobulin which characterize other nervous system viral infections. Some investigators have suggested that the normal attrition of neurons with aging may trigger the post-polio syndrome when superimposed on previous static damage of polio.<a></a> However, aging-related loss of neurons in the spinal cord normally begins at about age 60<a></a>; the onset of PPS most commonly occurs 30 years after polio and does not correlate with chronological age of the patient.<a></a> Weichers and Hubbel<a></a> and Dalakis, et al.<a></a> have suggested that motor units grossly enlarged by reinnervation in recovery from poliomyelitis may begin to experience peripheral disintegration with the passage of time. Our own data support this hypothesis in part; late denervation is most common in muscles with the greatest degree of reinnervation. However, we find that group atrophy, a putative indicator of motor neuronal disease (and not terminal axonal degeneration), is also common in patients with prior poliomyelitis.<a></a> Although a bewildering variety of new symptoms are recognized as occurring in PPS,<a></a> most new complaints appear to be subsumed under the three major problems of new pain, new weakness, and fatigue (Table 1). Some investigators have theorized that new muscle atrophy and weakness constitutes a separate syndrome, "postpoliomyelitis progressive muscular atrophy" or PPMA.<a></a> In this scheme, other symptoms of PPS, such as pain and fatigue, are thought to be manifestations of a separate "musculoskeletal" syndrome due to chronic strain of muscles and joints that have been forced to bear weight in an unnatural fashion.<a></a> Common orthopedic deformities in patients with poliomyelitis include knee valgus, varus, and recurvatum, as well as ankle equinus.<a></a> However, new weakness can result in new joint instability, and new joint problems may interfere with efficiency of movement. Although a symptomatic approach to separate complaints of PPS patients is warranted, there is little scientific data that supports a division of sub-syndromes of PPS at present. We have found that even patients without new symptoms have evidence of an ongoing neuromuscular disorder. Table 1 <img src="/files/original/49c519d9cfc114bc2adb3d22a688c55c.jpg" /> New pain is the most common symptom in PPS based on our experience (Table 1) and is a frequent complaint in other series as well.<a></a> We have evaluated patients experiencing pain in conjunction with an orthopod experienced in neuromuscular disease. Several causes of pain are commonly identified in PPS patients. Perhaps the most common cause is insertional tendonitis and/or bursitis from chronic overuse and strain of muscle groups with subnormal strength. Palpation of tendons and bursae at common sites of involvement, such as the pes tendon at the medial knee and the trochanteric bursa, will often reveal profound point tenderness consistent with this syndrome. A trial of rest and non-steroidal anti-inflammatory agents may induce remission in this remitting/relapsing syndrome. For certain local sites, a steroid injection may be useful; weight reduction and readjustment of weight-bearing (through retraining and/or orthotic devices) may also produce long-range benefits. Degenerative arthritis, found most often in weight-bearing joints (where walking aids are used, the joints of the upper extremities may indeed become weight-bearing), may also respond to the same regimen. Nerve compression syndromes characterized by pain and paraesthesias, secondary to positional or repetitive stress, should also be considered in the differential diagnosis of pain in PPS patients. Another type of pain, unrelated to joint "wear and tear" is muscle pain. This occurs frequently during or after exercise and may be associated with cramps, fasciculations, or intense local fatigability. This may be related to muscle substitution and/or overwork in denervated muscle, and may ultimately be associated with permanently increased weakness.<a></a> Treatment of this muscle pain includes avoiding the circumstances which induce it. Rest, orthoses, or even intermittent wheelchair use should also be considered to reduce the load on overworked muscle. Medications which reduce muscle cramps (quinine, diphenylhydantoin) may increase weakness and should be avoided. Fatigue is also a common complaint in PPS patients, occurring in over 60 percent of our series (Table 1). Two types of fatigue are reported by patients: generalized fatigue requiring rest or sleep, and local muscle fatigue. Local muscle fatigue is most common in muscles previously severely affected by polio and is often associated with cramps and fasciculations. Local fatigue may be a manifestation of ongoing muscle denervation and is also reported by patients with classic denervating diseases such as amyotrophic lateral sclerosis.<a></a> Generalized (systemic) fatigue is common in PPS, but may also be a symptom of a variety of other states, including medical conditions such as diabetes mellitus, cardiopulmonary dysfunction, and thyroid disease. Depression ("low energy") may also lead to systemic fatigue. Once medical and psychiatric diseases have been ruled out, systemic fatigue in PPS may be a symptom of widespread neuromuscular junction transmission defects. We have found that patients with fatigue and marked increased jitter in single-fiber electromyography (an indicator of defective neuromuscular transmission) respond to agents which enhance neuromuscular transmission, such as the anticholinesterase pyridostigmine (Mestinon). Rest, ambulatory aids, and activity planning may also alleviate generalized fatigue. New weakness is the third major component of the "post-polio triad" (Table 1). When new weakness occurs with new muscle atrophy, PPS patients are thought by some investigators to suffer from a specific syndrome of post-poliomyelitis progressive muscular atrophy (PPMA).<a></a> It has been suggested that evidence of ongoing denervation (fibrillations and positive waves on EMG, increased jitter on single-fiber EMG, and atrophic muscle fibers on muscle biopsy) are diagnostic for this syndrome.<a></a> However, we have found that electrophysiologic and muscle biopsy evidence of denervation is as common in polio patients who are not having new symptoms, as in patients who have clinically defined PPMA.<a></a> Moreover, evidence of denervation is most severe in muscles which show the most signs of old polio.<a></a> Thus, late denervation appears to be a concomitant of massive monophasic antecedent denervation and not a sign of new disease. In addition, we found that although 14 out of 15 patients who complained of new atrophy also reported new weakness, only about one-half of patients who reported new weakness noted new atrophy.<a></a> Thus, the relationship of atrophy to weakness is not clear. New muscle weakness may put extra stress on a previously borderline compensated muscle, producing pain, cramping, and an "overwork myopathy," with accelerated weakness as an end result.<a></a> It has been estimated that a partially denervated muscle graded "good" must work two and a half times as hard as a normal muscle to accomplish the same task.<a></a> We caution patients with new weakness to reduce activity. Exercise programs must be undertaken with extreme caution, and exercise should never be performed to the point of pain or muscle cramps. We advise patients to exercise limbs not previously affected by polio or, if this is impossible, participate in a carefully graded program in a therapeutically heated pool. One should exercise enough to prevent atrophy of disuse, but not enough to cause damage from overuse. High repetition, low resistance exercises are favored, as well as stretching and isometric drills. Orthotic devices, including the ankle-foot orthosis and knee-ankle-foot orthosis, may provide support for certain critically weakened muscle groups, although adequate function of other muscle groups (e.g., knee and hip extensor function for an ankle-foot orthosis) is a prerequisite for effective use. Wheelchair use should also be considered, sometimes only intermittently, as prolonged activity may predispose the patient to osteoporosis or venous thrombosis. Training in effective transfers, efficient movements, etc. by the physical and occupational therapist may also be useful, as can home help aids such as a shower chair and raised toilet seat. Limb weakness may result in new joint instability, which in turn may be associated with new pain and increasing deformity. It has been noted, for example, that floor reaction with knee hyperextension serves a knee-locking function when the quadriceps is weak.<a></a> However, profound degrees of weakness can provide a "positive feedback" situation where posterior knee ligaments are subjected to more torque stress, leading to further stretching.<a></a> A knee-ankle-foot orthosis (fit with a posterior offset knee hinge) may prevent progressive joint damage in this situation. Pulmonary complaints may occur in patients with previously weakened diaphragm, intercostals, abdominal, or accessory muscles. Frequently, a patient with previous paralytic poliomyelitis, involving muscles of respiration, will have borderline respiratory compensation for decades and will undergo precipitous respiratory failure later in life.<a></a> Increasing scoliosis, aspiration pneumonia, gradual loss of motor units with aging, and other factors may contribute to respiratory insufficiency. Respiratory symptoms (daytime somnolence, snoring, dyspnea, etc.) must be sought in all patients, particularly those with a history of respiratory involvement with polio. Baseline spirometry is also obtained in patients attending clinics. Muscle relaxants and medications which suppress respiratory drive should be avoided. Vaccines (pneumonia and flu vaccines) and cessation of smoking are also important in patient management. New respiratory muscle weakness may also present as sleep apnea, which may respond to medication (e.g., protripty-line), or may require night time oxygen or mechanical ventilation. Pulmonary complaints should always be evaluated and treated in conjunction with a pulmonary physician versed in neuromuscular diseases. The prognosis of the post-polio syndrome depends upon the symptoms experienced by the patient and upon individual (as yet uncharacterized) differences in disease progression. General health care measures (proper rest, nutrition, weight management, etc.) as well as psychosocial support are important. Inflammation in joints and muscles may be managed well with the treatments cited above. At least some patients with PPS fatigue respond to anticholinesterase medications. Progressive weakness, with or without atrophy, is the least responsive symptom of PPS. Respiratory complaints, particularly, should be considered seriously. Fortunately, weakness progresses slowly (about one percent per year according to a recent study),<a></a> and plateaus in function are observed. Although rapid progression of weakness does occur in some PPS patients, other diagnoses such as medical illnesses or superimposed neurologic and orthopedic problems must be considered. A common complaint of post-polio patients is that health professionals do not understand or even believe their new symptoms. Although a breakthrough of understanding on PPS may not occur in the immediate future, it is the responsibility of all health personnel to listen carefully to patients with new problems and provide the best care possible. Specific symptomatic treatment should be made available where appropriate. The patient who has been rehabilitated from the effects of acute polio must now be helped to accept the activity aids and lifestyle modifications necessary to ameliorate his "second disability." <h3>Acknowledgments</h3> This paper was based on our experience at the University of Chicago Post-Polio Clinic, which was made possible by the fruitful collaboration of R. Maselli, R. Wollmann, R. Roos, E. Salazar, F. Brown, E. Nichols, R. Simon, P. Heidkamp, and R. Martia. We thank C. René de Cotret for preparing the manuscript. References: <ol> <li>Sharrad, W.J.M., "Correlation Between Changes in the Spinal Cord and Muscle Paralysis in Poliomyelitis", Proceedings of the Royal Society of Medicine, 40, 1953, p. 346.</li> <li>Cöers, C, and Woolf, A.L. The Innervation of Muscle: A Biopsy Study, Blackwell Scientific Publications (Oxford), 1959.</li> <li>Halstead, L.S., and D.O. Weichers, "Introduction," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. xv-xx.</li> <li>Codd, M.B., D.W. Mulder, L.T. Kurland, CM. Beard, and W.M. O'Fallon, "Poliomyelitis in Rochester, Minnesota, 1935-1955: Epidemiology and Long-term Sequelae: A Preliminary Report," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 121-134.</li> <li>Jubelt, B. and N.R. Cashman, "Neurologic Manifestations of the Post-Polio Syndrome," Critical Reviews in Clinical Neurobiology, in press.</li> <li>Halstead, L.S., D.O. Weichers, and CD. Rossi, "Late Effects of Poliomyelitis: A National Survey," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 11-31.</li> <li>Tomlinson, B.E. and D. Irving, "Changes in Spinal Cord Motor Neurons of Possible Relevance to the Late Effects of Poliomyelitis," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 57-70.</li> <li>Weichers, D.O. and S.L. Hubbell, "Late Changes in the Motor Unit After Acute Poliomyelitis," Muscle and Nerve, 4, 1981, pp. 524-528.</li> <li>Dalakis, M.C., G. Elder, M. Hallett, et al., "A Long-term Follow-up Study of Patients with Post-poliomyelitis Neuromuscular Symptoms," New England Journal of Medicine, 314, 1986, pp. 959-963.</li> <li>Cashman, N.R., R. Maselli, R.L. Wollmann, R. Roos, R. Simon, and J.P. Antel, "Postpoliomyelitis Syndrome: Evidence of Ongoing Denervation in Symptomatic and Asymptomatic Patients," Proceedings of the Second Annual Symposium on the Late Effects of Poliomyelitis, Symposia Foundation (Miami, FL), in press.</li> <li>Maynard, F.M., "Differential Diagnosis of Pain and Weakness in Post-polio Patients," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 33-41.</li> <li>Tomlinson, B.E. and D. Irving, "The Number of Limb Motor Neurons in the Human Lumbosacral Cord Throughout Life," Journal of Neurological Sciences, 34, 1977, pp. 213-219.</li> <li>Clark, D.R., J. Perry, and T.R. Lunsford, "Case Studies-Orthotic Management of the Adult Post Polio Patient," Orthotics and Prosthetics, Vol. 40, No. 1, 1986, pp. 43-50.</li> <li>Bennett, R.L. and G.C. Knowlton, "Overwork Weakness in Partially Denervated Skeletal Muscle," Clinical Orthopedaedics, 12, 1968, pp. 22-29.</li> <li>Mulder, P.W., E.H. Lambert, and L.M. Eaton, "Myasthenic Syndrome in Patients with Amyotrophic Lateral Sclerosis", Neurology, 9, 1959, p. 627.</li> <li>Perry, J., "Orthopedic Management of Post-polio Sequellae," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 193-206.</li> <li>Ringel, S.P. and R.J. Martin, "Respiratory Complications and Their Management in Neuromuscular Disorders," Interdisciplinary Rehabilitation of Multiple Sclerosis and Neuromuscular Disorders, F.P. Malone, J.S. Burks, and S.P. Ringel, J.B. Lippincott Co. (Philadelphia), 1985, pp. 211-227.</li> </ol> *Jack P. Antel, M.D. Jack P. Antel, M.D. is Professor of Neurology and Neu-rologist-in-Chief at the Montreal Neurological Institute. *Irwin M. Siegel, M.D. Irwin Siegel, M.D. is an Associate Professor in the departments of Orthopaedic Surgery and Neurological Services, Rush-Presbyterian-St. Luke's Medical Centre, Chicago, IL; Chairman of the Department of Orthopaedic Surgery at Louis A. Weiss Memorial Hospital in Chicago, Illinois; and Director of Muscular Dystrophy Clinics of the above facilities. *Neil R. Cashman, M.D. Neil R. Cashman, M.D. is an Assistant Professor of Neurology at the Montreal Neurological Institute, 3801 University Street, Montreal, Quebec H3A 2B4, CANADA. He developed and directed the University of Chicago Post-Polio Clinic 1985-86. Page Number(s) 74 - 78 Year 1987 Volume 11 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 TABLE 1 http://www.oandplibrary.org/cpo/images/1987_02_074/1987_02_074-1.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 Post-polio Syndrome: An Overview Creator An entity primarily responsible for making the resource Neil R. Cashman, M.D. * Irwin M. Siegel, M.D. * Jack P. Antel, M.D. * https://staging.drfop.org/files/original/57984a195780837231c3d47547393acc.pdf 11789779a85e2b709280689bf0e71309 https://staging.drfop.org/files/original/229e5d0143847fe4a628fb14ddec46e4.jpg be7e746d002f06941f613b3ffcdfe220 https://staging.drfop.org/files/original/c42e1a9caf2711b34235fffd340b847a.jpg b9f313905f981a7b1b591b553ac76025 https://staging.drfop.org/files/original/65483353f040cfd3076c229f9103ba79.jpg f7f25aeeda8fcb9417fcb2a3f14480d5 https://staging.drfop.org/files/original/48332643526aa1b923893a54d16f1d14.jpg 6fdbc24c287659b506d32920ab794a07 https://staging.drfop.org/files/original/2bfcb2f521edd120186e036fda6d7d8f.jpg 6ecc7fab73b16908b5797aa5757d6bfd Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_066.pdf Text Any textual data included in the document <h2>A Physiologic Rationale for Orthotic Prescription in Paraplegia</h2> <h5>Robert L. Waters, M.D. <a style="text-decoration: none;">*</a> Leslie Miller, R.P.T. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> A difficult clinical decision to be made when treating a paraplegic patient is deciding if walking is a realistic goal, if orthoses should be prescribed, and what the functional outcome will be. It has been demonstrated that the energy expenditure for paraplegics, utilizing a crutch assisted swing-through gait pattern, is markedly elevated. Many patients have learned to walk with crutches and orthoses, but discontinued their use after discharge from a rehabilitation center.<a></a> Studies of other forms of bracing also reveal elevated energy expenditure.<a></a> In this review, we will describe the indications for prescribing ankle-foot orthoses and knee-ankle-foot orthoses. We will then outline the criteria used at Rancho Los Amigos Medical Center to determine whether or not a paraplegic is a candidate for ambulation. These criteria are based on the results of energy expenditure measurements of 150 patients with traumatic paraplegia.<a></a> Further investigation of the data collected revealed that the proprioception level or pattern seemed a reliable indicator of which patients would achieve ambulation, while muscle function seemed to determine the quality of their ambulation. These results have helped us to develop guidelines for projecting the functional outcome of ambulation of paraplegics. <h3>Orthotic Prescription</h3> The goal of orthotic management in paraplegia is to provide the external support necessary to compensate for the motor and sensory deficits. Joint range of motion, muscle strength, proprioception, sensation, and spasticity are evaluated when determining the orthotic prescription. Knee-Ankle-Foot Orthosis (KAFO) Quadriceps strength less than "Fair+" on manual muscle testing is the most common indication for a KAFO. The KAFO is locked at the knee while walking. Although some patients with less than "Fair+ " strength are able to ambulate a short distance without a locked knee (knee stabilization), knee instability usually occurs after a few steps. The exception is the patient with severe quadriceps spasticity which maintains the knee in extension, eliminating the need for external support. Another indication for a KAFO is impaired or absent knee proprioception. The lack of proprioception can result in knee instability even when the quadriceps strength is "Fair+" or greater, as the patient is unable to monitor joint position. If light touch sensation is present on the front of the thigh, a KAFO which allows knee flexion is usually sufficient to control the knee. The anterior stop of the knee mechanism limits extension at 180 degrees and the patient feels pressure from the anterior thigh cuff. In this regard, the brace serves as a transducer that converts proprioception (which is not perceived) into pressure (which is perceived). The final indication for extending bracing above the knee is a severe hyperextension thrust during stance. Paraplegics whose gait is characterized by a hyperextension thrust may develop ligamentous instability, due to attenuation of the posterior cruciate ligament and posterior knee capsule resulting in hyperextension deformity. Range of motion at the hip from 0 degrees of extension to 110 degrees of flexion should be present. In the absence of hip extensor muscles, full hip extension range is necessary to allow the patient to lean backwards and move the center of gravity of the trunk posterior to the hip joint (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg">Fig. 1</a>). Hip flexion to 110 degrees, with the knee extended, enables the patient to come to standing with locked KAFO's and rise from the ground after a fall. Full knee extension is required for optimal fit. <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg">Figure 1. Standing posture.</a> Ten degrees of dorsiflexion at the ankle is the minimum necessary for unassisted upright balance (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg">Fig. 1</a>). Normal proprioception in at least one hip also facilitates unassisted standing. Inability to meet the joint range requirements described above commonly occurs and is most often due to spasticity or contracture. If satisfactory orthotic fit and posture cannot be achieved, a physical therapy regime that includes stretching exercises or serial casting is often successful when spasticity is mild and the deformity is not longstanding. When severe spasticity or deformity is present, or the deformity has been present for an extended time, the patient should be referred to an orthopedic surgeon. Good trunk strength is necessary to maintain an erect posture in the standing position without excessive weight bearing in the arms. High level paraplegics without adequate trunk strength must exert a strong upwards force by the arms throughout the entire gait cycle to prevent forward collapse and accomplish forward progression. This contributes to the high energy demand. (All swing-through gait candidates are required to perform 50 consecutive dips on parallel bars to insure they have sufficient upper extremity strength and endurance.) Ankle-Foot Orthosis (AFO) Quadriceps strength greater than "Fair" should be present to stabilize the knee if an AFO is prescribed. The patient must also have adequate hip flexion strength to swing the leg forward to achieve a reciprocal gait pattern. The indications for AFO are numerous and include any or all of the following: plantarflexion strength less than "Good," dorsiflexion strength less than "Fair," impaired ankle proprioception, and moderate to severe plantar-flexion spasticity. During normal walking, the plantarflexors are active during the stance phase of gait to prevent excessive forward advancement of the tibia. As a result of forward momentum, the knee passively extends as the body advances forward over the stabilized tibia, and the demand placed on the quadriceps is minimal. Customary manual muscle testing methods fail to place a sufficient load on the plantarflexors to evaluate the force required during gait. The strength required to provide ankle and knee stability is present in patients who can perform 15 to 20 toe raises on one leg. Failure to provide adequate orthotic stabilization of the ankle in patients with inadequate plantarflexion strength may result in ankle instability and knee instability, if the quadriceps and/or hip extension strength is also inadequate. Knee wobble can be a sign of impaired ankle proprioception and/or weakness. This can be eliminated by an AFO with a rigid ankle or anterior ankle stop, which provides distal stability and kinesthetic information via the calf cuff. An AFO may be utilized to hold the ankle in the neutral position when dorsiflexion strength is impaired or there is excessive plantarflexion spasticity. When spasticity is severe, it may not be possible to maintain the foot in neutral, and the patient should be referred to an orthopedic surgeon if non-operative measures prove inadequate. When the ankle is held in a rigid orthosis, ankle stability is gained during midstance. However, a forward thrust is imposed, forcing the knee into flexion at the moment of heel contact. (This knee flexion torque is generated because the rigidly immobilized ankle rotates forward about the point of heel contact.) During normal gait, this torque is avoided by ankle plantarflexion, minimizing the effect of the heel lever. There are two courses of action available to provide ankle stability during stance, while still maintaining knee stability at heel strike. If the patient has "Fair+ " or better ankle dorsiflexion strength and intact proprioception, we fit a metal AFO with a double adjustable ankle joint. A set screw in the anterior channel provides an adjustable stop that prevents excessive dorsiflexion. The posterior stop is left open to allow free ankle plantarflexion. Springs can be added posteriorly if dorsiflexion strength is less than "Fair+." The advantage gained is that restriction of motion during terminal stance is maintained while the normal plantarflexion motion during heel contact is preserved, avoiding the undesired knee flexion torque. If the patient has less than "Fair" dorsiflexors or absent proprioception at the ankle, then the ankle is locked and either metal or plastic is used. To avoid the excessive knee flexion torque when the AFO is locked, the heel of the shoe is undercut. This decreases the heel lever and, thus, the knee flexion torque. <h3>Orthosis Weight</h3> Weight is an important factor to some patients, as is the availability of joint motion of the orthotic system. Plastic, because of its potential to be lighter than metal, is sometimes preferable. For the patient with weak hip flexors, efforts to minimize weight are warranted since any extra weight at the end of the limb will make it more difficult to lift the foot and advance the leg. Lehneis, et al.<a></a> found that improving orthotic stability at the ankle reduces energy costs. It follows, then, that in any orthotic design, stability (control about a joint) should not be sacrificed merely to achieve lighter weight. <h3>Exercise Physiology</h3> It is necessary to understand several fundamental principles of exercise physiology to interpret the results of energy expenditure measurements in paraplegic patients.<a></a> The use of oxygen consumption is based on the fact that during sustained exercise, most of the ATP for muscle contraction is generated by aerobic metabolic pathways. After several minutes of exercising at a constant submaximal workload, the rate of oxygen consumption rises until it reaches a level sufficient to meet the metabolic demands of the exercising muscle. Measurement of the rate of oxygen consumption at this time reflects the energy cost of the activity and indicates the exercise intensity. The oxygen cost per meter walked determines the efficiency of ambulation. The principle fuels for aerobic metabolism are carbohydrates and fats. The oxidation of glucose can be summarized by the following equation: GLUCOSE + 36 ADP + 6 O2 --> 6 CO2 + 44 H2O + 36 ATP During exercise, the extent to which anaerobic pathways contribute to the production of energy depends upon the intensity of the effort. In mild to moderate exercise (approximately 50 percent of the maximal aerobic capacity for untrained individuals), the oxygen supplied to the tissue for the aerobic energy producing reactions is usually sufficient to meet energy requirements. During more strenuous exercise, anaerobic oxidation processes also occurs. The amount of energy that can be produced by anaerobic means is limited. Nineteen times more energy is produced by the aerobic oxidation than by anaerobic oxidation. Also, accumulation of lactate in muscle and blood leads to acidosis, limiting the extent to which intense exercise can be performed. From a practical standpoint, anaerobic oxidation provides an extra supply of energy for sudden bursts of strenuous effort, but these pathways cannot be routinely utilized for a prolonged time. In contrast, when exercise is performed below anaerobic threshold, an individual can sustain exercise for many hours without exhaustion. <h3>Maximal Aerobic Capacity</h3> The maximal aerobic capacity (VO2 max) is the single best indicator of physical work capacity and fitness. It measures the individual's maximum energy production capability. Generally, an individual is able to reach the VO2 maximum within two to three minutes of instituting strenuous exercise. Any disorder of the respiratory-cardiovascular muscle or metabolic systems that restricts the supply of oxygen to the muscle decreases the VO2 max. A physical conditioning program can increase aerobic capacity by several processes which include improving cardiac output, increasing the capacity of the muscle to extract oxygen from the blood, increasing the level of hemoglobin, and increasing the muscle mass. On the other hand, the maximal aerobic capacity can be reduced due to blood loss, paralysis, surgery, negative nitrogen balance, or bed rest.<a></a> The important clinical implication is that the paraplegic patient is usually severely deconditioned as a consequence of the injury. The prescription of orthoses and a walking program should not be initiated until the patient has sufficient strength and maximal aerobic capacity to meet the required energy demand. The deconditioned paraplegic patient will respond to a physical conditioning program just as an able bodied subject with respect to increased strength, endurance, and maximal aerobic capacity.<a></a> In able bodied subjects, the VO2 max also depends on the type of exercise. During lower limb exercise, the VO2 max is greater than the VO2 max for the upper limbs. Since paraplegic patients rely on the upper extremities to walk with the aid of crutches, their energy production capability is inherently limited. The problem in paraplegics is further compounded by the effects of the spinal injury. The upper extremity VO2 max for paraplegics is lower than for able bodied subjects, presumably due to the effects of paralysis and interruption of the autonomic neurological pathways which regulate blood flow and cause venous pooling in the lower extremities.<a></a> For the typical adult male paraplegic, we establish a VO2 max of 20 ml/kg-min during upper arm cranking as the minimal criteria acceptable for entering gait training if a swing-through crutch assisted gait pattern will be required. <h3>Energy Expenditure</h3> Wheeling Versus Normal Walking On a hard, level surface paraplegic wheelchair use is as efficient as normal walking. A comparison of the data in <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a> indicates that when propelling a chair around a 60.5 meter circular track, the speed was almost as fast as normal walking (72 versus 80 m/min).<a></a> The oxygen rate was approximately the same (11.5 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>), as was the oxygen cost (.16 versus .15 ml/kg/ min). The heart rate was higher in paraplegics using the wheelchair than in normal walking (123 versus 100 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>). As previously mentioned, this relates to the lower upper maximal aerobic capacity in paraplegics during arm exercise. From a clinical standpoint, it may be concluded that the wheelchair is a highly efficient means of transportation whose speed and energy requirements are comparable to that of normal walking. <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Figure 2. Average velocity in normal subjects and in patients using wheelchairs or orthoses.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Figure 3. Rate of oxygen consumption in normal subjects and in patients using wheelchairs or orthoses.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Figure 4. Heart rate in normal subjects and in patients using wheelchairs or orthoses.</a> Swing Through Gait Crutch walking with a swing-through gait requires the arms and shoulder girdle to lift the entire weight of the body and swing it forward with each step. The average speed in paraplegics trained to use a swing-through crutch assisted gait was 64 percent lower than normal walking (20 versus 80 m/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a>); the rate of oxygen consumption was 38 percent greater (16.5 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>); the oxygen cost was 560 percent greater (.84 versus .15 ml/kg/min); and the heart rate was increased 46 percent (145 versus 99 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>).<a></a> This rate of energy expenditure requires most of the aerobic capacity of the typical adult male paraplegic with a complete T12 lesion and is well above the anaerobic threshold. The extreme exertion required for a swing-through gait demands a greater intensity of physical effort than a normal individual customarily expends on sports activity such as recreational jogging. Consequently, it is not surprising that while the athletic paraplegic may be willing to expend this level of exertion for recreational purposes, he is unwilling to sustain these efforts for normal activities of daily living. Even those patients, who are physiologically capable of sustaining the intense physical effort of a swing-through gait for a sustained time period to travel longer distances, find tachypnea (rapid breathing), tachycardia (rapid heart rate), and hidrosis (sweating), unacceptable for routine activities of daily living. We believe that the highly motivated paraplegic who is willing to exercise strenuously should not be discouraged from walking, but a more realistic approach should be taken for the average patient. The average patient should be given walking training and bilateral knee-ankle-foot orthoses only if walking is necessary for psychological reasons, for purposes of exercise, or because of architectural barriers in the living environment. It should be clearly explained that the wheelchair should be considered as the primary means of mobility. We have tested three patients with "Fair+" hip flexors who used bilateral KAFO's and preferred a reciprocal gait pattern.<a></a> Interestingly, the effort expended by these patients was just as great as in swing-through gait (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>). Energy Expenditure: Reciprocal Gait In a review of spinal cord injured patients, Hussey and Stauffer found that those patients who were able to walk in the community had pelvic control with at least "Fair" hip flexor strength and at least "Fair" extensor strength in one knee so that a maximum of one KAFO was required, enabling the patient to achieve a reciprocal gait pattern.<a></a> Having "Fair+" or greater quadriceps strength sufficient to stabilize one knee eliminates the need for one KAFO and enables the patient to walk with a crutch assisted reciprocal gait pattern at a rate of energy expenditure and heart rate that are significantly below that required for a swing-through gait pattern (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>). Surprisingly, we found no difference in the speed and rate of energy expenditure in patients with one free knee or two free knees and requiring bracing only below the knee (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>). Nevertheless, paraplegics who have intact hip flexion and knee extension bilaterally require orthoses only below the knees, and those who use a reciprocal crutch assisted gait pattern are still severely impaired (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2,</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3,</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>). Compared to normal walking, the rate of oxygen expenditure is 20 percent greater (16.3 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>), the heart rate 31 percent greater (131 versus 100 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>), and the speed 67 percent slower (80 versus 20 m/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a>).<a></a> The typical paraplegic who uses crutches and a reciprocal gait still exerts a force of 25 to 50 percent of total body weight on the crutches with each step, accounting for the increased rate of energy expenditure. The only spinal cord injured patients we have tested whose energy expenditure during walking does not exceed normal values are those patients with minimal involvement who have intact sacral function (in addition to lumbar function) and a sufficient hip abductor and extensor strength to maintain an erect posture without crutches. The average distances necessary to perform different daily living activities are listed in <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg">Fig. 5</a> and were obtained from numerous measurements made in different types of urban areas in Los Angeles.<a></a> Since the average speed of walking in low lumbar paraplegics who used bilateral ankle-foot orthoses and a reciprocal crutch assisted gait pattern was only 26 m/min, it would take more than five minutes to travel 150 meters. Because five minutes of walking will require a strenuous effort, it is apparent why even the typical low lumbar paraplegic is a limited walker outside the home and is not able to routinely ambulate comfortably for activities which require walking a longer distance. In this regard, clinicians are justified in prescribing a wheelchair to any spinal injury patient who requires crutch assistance. The patients should be encouraged to use the wheelchair as necessary and be reassured that reliance on the wheelchair, when necessary, should not be considered a failure. <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg">Figure 5. Average distances necessary to perform customary activities of daily living.</a> References: <ol> <li>Aastrand, P.O. and K. Rodahl, Textbook Work Physiology, Ed. 2, McGraw-Hill, Inc., New York, 1977.</li> <li>Cerny, K., R. Waters, H. Hislop and J. Perry, "Walking and Wheelchair Energetics in Persons with Paraplegia," Physical Therapy, 60:1133-1139, 1980.</li> <li>Clinkingbeard, J.R., J.W. Gersten, and D. Hoehn, "Energy Cost of Ambulation in the Traumatic Paraplegic," American Journal of Physical Medicine, 43:157-165, 1964.</li> <li>Gordon, E.E., "Physiological Approach to Ambulation in Paraplegia," JAMA, 161:686-688, 1956.</li> <li>Huang, C.T., A.B. McEachran, K.V. Kuhlemeier, M.J. DeVivo, and P.R. Fine, "Prescriptive Arm Ergometry to Optimize Muscular Endurance in Acutely Injured Paraplegic Patients," Arch. Phys. Med. Rehab., 64:578-582, 1983.</li> <li>Hussey, R.W. and E.S. Stauffer, "Spinal Cord Injury: Requirements for Ambulation," Arch. Phys. Med. Rehab., 54:544-547, 1973.</li> <li>Lehneis, H.R., E. Bergofsky, and W. Fresina, "Energy Expenditure with Advanced Lower Limb Orthoses and with Conventional Braces," Arch. Phys. Med. Rehab., 57:20, 1976.</li> <li>Lerner-Frankiel, M.B., S. Vargas, M. Brown, L. Krusell, and W. Schoneberger, "Functional Community Ambulation: What Are Your Criteria?" Clin. Man. in Phys. Ther., 6:12-15, 1986.</li> <li>Waters, R.L., H.J. Hislop, J. Perry, and D. Antonelli, "Energetics: Application to the Study and Management of Locomotor Disabilities," Orthop. Clin. North America, 9:351-377, 1978.</li> <li>Waters, R.L. and B.R. Lunsford, "The Energy Cost of Paraplegic Locomotion," Journal of Bone Joint Surgery, 67A: 1245-1250, 1985.</li> <li>Wolf, E. and A. Magora, "Orthostatic and Ergomet-ric Evaluation of Cord-injured Patients," Scandinavian Journal of Rehabilitation Medicine, 8:93-96, 1976.</li> </ol> *Leslie Miller, R.P.T. Leslie Miller, R.P.T. is a spinal cord injury clinical specialist at Rancho Los Amigos Medical Center. *Robert L. Waters, M.D. Robert L. Waters, M.D. is Chairman of the Department of Surgery at Rancho Los Amigos Medical Center, HB-121, 7601 E. Imperial Highway, Downey, California 90242. Page Number(s) 66 - 73 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Physiologic Rationale for Orthotic Prescription in Paraplegia Creator An entity primarily responsible for making the resource Robert L. Waters, M.D. * Leslie Miller, R.P.T. * https://staging.drfop.org/files/original/3ffbae347395bd6358c27cde8e640cb0.pdf 3c1e43504bc5fe368e6d0b52b9ee3f23 https://staging.drfop.org/files/original/9ac99d90904964fbf707150717e8a50d.jpg e8ed5e738c54bbb55d742a611ae695ee https://staging.drfop.org/files/original/ae0d69cc03a931e61faf1371e769a573.jpg d2fbffa8ce932cf04e3bbdd2c30ac089 https://staging.drfop.org/files/original/d14a435b32caa77db0a8b81558fc2602.jpg 7ce6b179856dd2279ee95f246865d131 https://staging.drfop.org/files/original/ae0b927d201ab181204f175621d042cd.jpg 83325cd779700fe7327eb2b2a9fe16c2 https://staging.drfop.org/files/original/579595b2c3c9b825d4166f0f46b2ddcb.jpg b4f9c82d3f4974e187d4f4d785cde9cb https://staging.drfop.org/files/original/5ec23f79cd46fa212e8306f193030545.jpg e405e2a5b3e94e3baf1ae65b44e6f8c6 https://staging.drfop.org/files/original/b0762e6b36e5df9b2a7e8c7426c8d107.jpg 2c44ad68219084068c067bd70e3bf532 https://staging.drfop.org/files/original/9cfc6bce48e4a77f4899bd6853abaaca.jpg 7559251e1534b6a37a9dafafac9208f5 https://staging.drfop.org/files/original/f0f4b6501a67d0595fce6cd598f39cdb.jpg b7c470836998260c1b30dccb65f3d5e6 https://staging.drfop.org/files/original/b5efb724727d5b4455261299add09b51.jpg 7cbd41bff0429cfb9b1ca402ec264ca7 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_049.pdf Text Any textual data included in the document <h2>Modular Seat-Shells and Standardized Manufacture of Individually Shaped Seats for the Severely Disabled: The Tubingen Experience</h2> <h5>George Neff <a style="text-decoration: none;">*</a> Klaus Fischer <a style="text-decoration: none;">*</a></h5> From the Editor: This article was received too late for inclusion in the Fall, 1986 issue devoted to seating and thus is presented in this issue. The authors' effort in submitting it is greatly appreciated. Over the years, proper seating for the severely disabled has been neglected. Often, an approximate position of the patient in commercially available "grandfather-chair" seats, upholstered with cushions, seemed to be sufficient for the needs of these individuals. Custom shaped seats manufactured in the usual manner to taking a plaster cast, and molding the seat-shell of plastic material on this plaster model, after rectification, have proven to be helpful at least for limited periods, especially for growing children. However, often, during the time of plaster taking, an unfavorable position of a child, especially in cerebral palsy children, could be achieved, causing a permanently defective position for the child in such a seat. Moreover the entire process was time consuming, requiring the presence and active participation of an experienced and, therefore, expensive orthotic specialist. Also, the presence of the patient for a long period was necessary in comparison to our present procedure. In 1978, we started a program for the improved manufacture of seats, using prefabricated seat shells and standardized patterns for the manufacture of individually shaped and adjusted seats for patients with seating problems, due mainly to neuromuscular diseases like cerebral palsy, muscle dystrophy, multiple sclerosis, and so on. The idea was to improve the seating comfort of our patients and to increase the adjustability for growth and clothing. At the same time we wanted to reduce the amount of work necessary, especially for the orthotist. Presently, there are six different sizes of prefabricated seat shells made from glassfiber-reinforced polyester resin. These are divided in the seat and the back section and are connected with strong hinges integrated into the laminated resin (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-01.jpg">Fig. 1</a>). For each size of these seat shells, standardized inserts of polyethylene are necessary to form a second, innershell. The inner shells consist of one seat, one back, two upper and lower lateral parts (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-02.jpg">Fig. 2</a>). The parts of the innershell are fixed to the outer seat-shell with screws. The holes are drilled with the use of a permanent pattern or die (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-03.jpg">Fig. 3</a>). This allows for the quick exchange of one or the other part of the seat. They can also be removed for easy cleaning, reshaping, or for the addition of spacers between the inner and outer wall for proper fit with respect to clothing and climate (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-04.jpg">Fig. 4</a>). Foot-rests, headsupports, handles, quick-exchange boards are also prefabricated in standardized sizes and on stock in the workshop. By this means, the orthotist gains more time to devote attention to the needs of the patient and to optimize his position, because he does not need to devote time to the production of these items. <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-01.jpg">Figure 1. Four of six sizes of the modular seatshell. Two hinges connect the back and seat sections.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-02.jpg">Figure 2. Seat, back, two upper side, and two lower side inner sections to be mounted in the seatshell.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-03.jpg">Figure 3. Use of the permanent pattern, or die, for drilling of screw holes, in a standardized array, in the seatshell for mounting of the inner sections.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-04.jpg">Figure 4. In the foreground, spacers for insertion between seatshell and inner shell to allow for seasonal variation in clothing. In the background can be seen foam rubber pieces to be glued to the inner shell.</a> Prior to the initiation of this fitting procedure, the responsible physician, physiotherapist, occupational therapist, and the orthotist have to decide what they want and how the patient is to be best positioned with respect to his daily living and physical abilities. The individual fitting of the module is achieved by optimal positioning of the patient in a seat shell of appropriate size and by positioning roughly cut foam rubber pieces between the patient's body and the sidewalls, seat, and back of the seat shell. After having made a rough alignment of the foam rubber pieces, they are glued to the inner parts of the seat. Then they are removed entirely and ground down to the proper shape until each of the six pieces fit properly (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-05.jpg">Figure 5. Foam rubber pieces have been glued in place and ground to proper contour and fit.</a> Another solution is used for children with extensive spasticity. After selection of the proper size seat shell and inner-liner, the child is covered completely, including legs, arms and head, with layer of foam rubber and isolated by a piece of plastic foil or film. This is to prevent polyurethane foam from coming into direct contact with the patient's clothing or skin and to prevent burns. The patient is then positioned as well as possible in the modular seat shell. This is preferably done by the therapist or the mother of the child so as to prevent spasticity as much as possible and to optimize the posture of the child. If necessary, a foam rubber wedge is placed between the knees to create slight abduction of the legs. Then, the free space between the body and the seatshell module is filled with polyurethane foam (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-06.jpg">Fig. 6</a>). After the foam hardens, the child is removed from the seat and the foam is cut along the borderlines of the six parts of the insert, including the lengthened backpart for a headsupport if its use is necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-07.jpg">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-06.jpg">Figure 6. The child is held in place while the void between him and the seat is filled with polyurethane foam. Child is protected against exposure to foam with a layer of plastic film and against thermal burns with a layer of foam rubber. This also allows for the layer of foam rubber to be subsequently added for comfort.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-07.jpg">Figure 7. Seat following completion of the foaming procedure.</a> Each piece of foam is then ground to the proper fit and covered with a layer of foam rubber to prevent pressure sores and for sitting comfort. The same procedure is carried out for those seats for which polyurethane foam was not used. By adding more foam rubber and grinding the six different parts to proper fit, an individually optimized shape of the interior of the modular seat shell is achieved. A headrest may be made from a separate piece of polyethylene padded with foam rubber and shaped to properly fit the individual patient. It is fixed with adjustable metal bars on the backside of the seatshell. Another solution is the so-called integrated headsupport which is not removable, in contrast to the above-mentioned type. It is made from a sheet of polyethylene as an elongation of the polyester inner-layer of the back (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-08.jpg">Fig. 8</a>) on which foam rubber is glued and shaped to size. An additional pillow for the neck and head is easily removed and attached to the headrest by means of Velcro® fasteners. <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-08.jpg">Figure 8. Section of polyethylene added to the top of the innershell to serve as the foundation upon which an integrated headrest will be built.</a> In most cases, additional fixation of the patient is necessary to prevent him from falling out of the seat, e.g. during a sudden spastic convulsion. In moderate cases, safety belts adapted to the seat may be sufficient. If a more secure purchase is necessary, the lateral parts of the backrest are elongated at the level of the sternum and closed in around the front of the chest by an additional belt (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-09.jpg">Fig. 9</a>); or, an entire thoracic pad, made of a sheet of polyethylene, covered with foam rubber and ground to a snug fit, is fixed firmly to the seat by a hinge on one side and a clasp on the other to provide proper hold of the body. In severe cases, for example in athetoid spasticity, we use a kind of apron with a belt-system (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-10.jpg">Fig. 10</a>) to keep the pelvis and the trunk in proper position within the seat. <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-09.jpg">Figure 9. Completed seat showing restraint system and anterior thoracic extension.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-10.jpg">Figure 10. Completed seat showing apron and belt arrangement for restraint.</a> It is essential to provide enough free space for the bent knee joints. If necessary, the module and the seat part have to be cut out to allow for comfortable sitting. The abduction wedge must fit correctly too; otherwise it may increase spastic adduction patterns. Due to the hinges between the seat and the backpart, and a stop on either side of the seat module, the patient can be leaned back in his seat, if desired. In patients with limited movement in the hip joints, the seat part may be divided longitudinally. Then, each half can be adjusted independently to the individual position of either leg. Additional armrests are used to prevent injuries to hands and arms if they are uncontrollable. For children and wheel-chair-bound adults a removable table may be added to the seat within the range of motion of both arms and the body, providing enough space for playing with toys, eating, paper work, and so on. Finally, prefabricated footrests make sure that the entire body is in a proper and comfortable position. Our footrest is adjustable to height and inclination as dictated by the patients' needs. The quick-exchange board system allows for easy removal of the entire seat from the wheel chair, normal chair, or the regular seat of a car. The wooden board of the seat is fixed with one or two special clasps and a "U" shaped metal stop to a second board which is screwed to the wheel chair or another chassis. This disconnecting device provides stable and safe fixation of the seat and the patient to the respective underlying surface. If it seems preferable to first try the unfinished seat before finishing, the patient uses the seat at home for one or two weeks. After a final check and correction, the different parts of the insert are removed once more and covered with a strong and long lasting colored nylon-velour. This gives the entire assembly a lively appearance, quite different from the ordinary "medical" wheelchair design. Since we started this seating program, approximately 500 patients have been fit with this device. Each was provided with an individually shaped seat by using modular seat shells and pre-fabricated componentry to the largest extent possible. Only a few severely handicapped individuals had to be fit in the conventional manner by taking an individual plaster of Paris cast to create a mold for a seat. Thus, we recommend the use of prefabricated modular seat shells and componentry for satisfying the seating needs of the physically disabled. *Klaus Fischer Klaus Fischer, Orthopadie-Mechanikermeister, can be contacted c/o Fa. Brillinger at Orthopadie-Technik, Rhein-landstraBe 18, D-7400 Tubingen, Federal Republic of Germany. *George Neff Priv. Doz. Dr. Med. Georg Neff is with the Department Technical Orthopaedics at the Orthopaedic University Hospital, Calwer Straße 7, D-7400 Tubingen, Federal Republic of Germany. Page Number(s) 49 - 54 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-07.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/1987_01_049/1987_01_049-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Modular Seat-Shells and Standardized Manufacture of Individually Shaped Seats for the Severely Disabled: The Tubingen Experience Creator An entity primarily responsible for making the resource George Neff * Klaus Fischer * https://staging.drfop.org/files/original/c4b9c484b01dbcb349e2f7553d8c16d3.pdf a0e06974f43dc39c32206828207898bb https://staging.drfop.org/files/original/6b9aa45d405b3eb6edf60ed6f2583718.jpg ec3cec476e908cf5388f484ed47c4021 https://staging.drfop.org/files/original/ad87bb362ff24b53b0bd4c87f0bc9055.jpg e2e1755f9d34505fd352ad608b70b1b4 https://staging.drfop.org/files/original/e4ef8c646c8299dea2dcaf82690c7033.jpg 6f834bb52cdba95d3228c37cdfe360fe https://staging.drfop.org/files/original/0495aa63dee60d41844c8045ccfe9f17.jpg 8ed64542446ac701a3e0cb8696d61f00 https://staging.drfop.org/files/original/2b9b8acc8d0d10ae27922541c7846cf9.jpg b1aeeea2be400bc3155d32ec17438c86 https://staging.drfop.org/files/original/838448779f3df30146197fb16d701a12.jpg 67e983e840d84f6fd7d70e0ac5bdc721 https://staging.drfop.org/files/original/2c2e777bb3d61d2e18a76c9eb109d2fc.jpg 3d695f19795573f5c956f14eba7bf3d5 https://staging.drfop.org/files/original/905f9f7a7990bdd2e91147c76b480421.jpg 8097f171d6eaefdbbdd1b0648a85ccbb https://staging.drfop.org/files/original/d365de13e8ef358378928b8d72c355f6.jpg a155984092d328cef91c3a43e36ed846 https://staging.drfop.org/files/original/c00d56cd7eb635ebe196a82082567556.jpg 728482c9abdc3071fab1d4d5a219c141 https://staging.drfop.org/files/original/bc6d72ff9c92b0b0b491c095cb2c1e9a.jpg 3e9426381c4011ee132611a0e63a8988 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_045.pdf Text Any textual data included in the document <h2>Transparent Preparatory Prostheses for Upper Limb Amputations</h2> <h5>Terry J. Supan, C.P.O. <a style="text-decoration: none;">*</a></h5> The use of preparatory prostheses for lower extremity amputations has been widely published and publicized throughout the United States. Although techniques may differ from thermoplastic, laminated, or synthetic casting material for the socket, the concept of early fitting with a prosthesis to reduce the volume of the residual limb are fairly well adhered to. However, little has been publicized about preparatory fitting for arm amputations. Since 1982, the Southern Illinois University School of Medicine has extensively used preparatory prostheses within the 30 day post-amputation time period. Techniques have changed gradually over the last four years, but a fairly constant, successful technique has evolved at the present time. Although myoelectric prostheses with their ease of therapy training have been the componentry of choice, the prosthesis design can also use conventional componentry. The technique has also allowed us to utilize different componentry on an experimental basis to best determine the optimum componentry for the individual amputee. Prostheses have been used on all levels of amputation from wrist disarticulation through forequarter amputation (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg">Fig. 1</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg">Fig. 2</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg">Fig. 3</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg">Fig. 4</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg">Fig. 5</a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg">Fig. 6</a>). Since 1984, all prosthetic interfaces have been fabricated out of transparent material. Materials have either been Surlyn® or Durr-Plex. The transparent materials were chosen to improve monitoring of the residual limb during volume change. Surlyn™ is used for below and above fitting sockets, while Durr-Plex is used for shoulder disarticulation and forequarter frames. With each of these systems, the prosthesis can be altered through heat forming as the patient's volume changes. <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg">Figure 1. Left wrist disarticulation amputation secondary to trauma.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg">Figure 2. Left wrist disarticulation myoelectric prosthesis with supracondylar cuff to maximize supination and pronation.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg">Figure 3. Right mid-shaft below-elbow amputation, secondary to trauma and reattachment failure.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg">Figure 4. Right below-elbow prosthesis with supracondylar suspension and electric wrist rotator. Note that electronic controls, Otto Bock #, are mounted parallel to the electric rotator.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg">Figure 5. Right humeral neck above-elbow amputation secondary to trauma.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg">Figure 6. Shoulder disarticulation frame type prosthesis fitted to short above-elbow amputation.</a> Standard electric prosthetic componentry has been used in all cases. However, minor modifications to the prosthesis/componentry interface have been necessary. Componentry which utilizes separate stainless steel electrodes from the amplifiers (Motion Control, VANU, and UNB) have been modified to use the stainless steel electrode developed for the Motion Control systems. Prostheses which utilize one piece electrode amplifiers (Otto Bock, Liberty Mutual) are primarily held in place utilizing Velcro® compression straps (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg">Fig. 7</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg">Fig. 8</a>). All loose wires are held in place with either strapping tape or duct tape. Manufacturers' recommendations concerning shielding of wires and electrodes are also followed. <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg">Figure 7. Close-up view of electrode site in Surlyn® wrist disarticulation prosthesis. The area of the Otto Bock electrode extension tabs have been modified in the socket with a Dremmel tool to prevent rotation of electrode on skin.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg">Figure 8. Otto Bock electrode mounted into preparatory prosthesis. Velcro® maintains the electrode from passing completely through the socket.</a> An amputee's decrease in limb volume is monitored monthly until the volume has stabilized. If revisions of scar tissue, skin grafts, etc., are necessary, it is recommended that they be done during this time period as well. Modifications to the prosthesis must be made to maintain good electrode contact as well as suspension. Sockets may be split and Velcro® compression straps added if necessary. Electrodes may be replaced or locations adjusted if necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg">Fig. 9</a>). Although this is easily done with the Motion Control stainless steel electrodes by simply drilling another hole, it also can be accomplished with the Otto Bock or Liberty Mutual electrodes. If a hole saw is used to drill out the new location for the electrode, the cut-out material can be utilized to repair the previous location in the preparatory prosthesis. <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg">Figure 9. Close up view of preparatory below-elbow prosthesis. Hook Velcro® adhesive backing is used to suspend the electrode in the prosthesis. Previous incorrect electrode site is repaired with cut-out from new electrode site. Battery pack is held in place with adhesive backed Velcro® as well.</a> Since 1982, 25 upper extremity amputees have been fit with this system. It has allowed us to closely monitor the development of the maturation process of the residual limb. Adjustments to the prosthesis have been made with minimal fabrication time. Total replacement of the preparatory prosthesis was only necessary in two cases. All other cases could be accommodated by modifying existing prostheses. All but one patient (forequarter amputation) went on to fitting and delivery of their permanent prosthesis. The results of these patients' permanent prostheses are consistent with the findings of Malone, et al.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg">Fig. 10</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.jpg">Fig. 11</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg">Figure 10. Posterior view of preparatory shoulder disarticulation prosthesis. Elastic strap superior to the shoulder improves comfort. Split of posterior frame into sections allows sitting comfort without electrode displacement.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.jpg">Figure 11. Lateral view of shoulder disarticulation prosthesis. Auxiliary switch is used to alternate EMG control between electric wrist rotation, hand opening, and closing.</a> References: <ol> <li>Malone, J.M., M.D., et al., "Immediate, Early, and Late Postsurgical Management of Upper-Limb Amputation," Veterans Administration Journal of Rehabilitation, Volume 21, No. 1, May, 1984, pp. 33-42.</li> </ol> *Terry J. Supan, C.P.O. member of the clinical faculty at Southern Illinois University School of Medicine. Correspondence should be addressed to Southern Illinois University, Orthotic and Prosthetic Services, Room 102. 707 North Rutledge Street, Springfield, IL 62702. <div style="width: 400px;"></div> Page Number(s) 45 - 48 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.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/1987_01_045/1987_01-045-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.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 Transparent Preparatory Prostheses for Upper Limb Amputations Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * https://staging.drfop.org/files/original/d49da90fa9f0c0ee8147b96e291908d3.pdf 7f08e42eea8bbbd23d3d4d6b91d0a0d2 https://staging.drfop.org/files/original/943afc173437b395a3f94b4ff2659a5e.jpg aa7edcef18db620b1fa2f490e5abf250 https://staging.drfop.org/files/original/e5efcf538172dab88f36c526b06a5f91.jpg aba531f72f2e4837c3a0a0b0996a73b8 https://staging.drfop.org/files/original/4ccde9a701dd6d5771ce107d46ac1bc2.jpg 5982b814b207265768b8e8750f90685f https://staging.drfop.org/files/original/aa05931a1d684780719bffdfc3498e7a.jpg b880cef406760c7ee2e1a038abc28149 https://staging.drfop.org/files/original/421de63be1138b2062533ad526050cd9.jpg 88152a35fb9192cc5d5b0a5e982bf642 https://staging.drfop.org/files/original/f4ec3d7373a8b0783fac25fe09b090b3.jpg 3f7eebb64f66e1965cf88142303178ed https://staging.drfop.org/files/original/f65c0df2d21adfa0a03a47a88fbf4c89.jpg d1a7c7c76a17d4b01701aa2a3b301a19 https://staging.drfop.org/files/original/4d3edf70ddb64346ebd926f557b44423.jpg df371f26240fe9a9af112a646a920e90 https://staging.drfop.org/files/original/130be2ed482165f3c83e4db139d76775.jpg 1e67cc03d90ff9c36c754e076e4cf71d https://staging.drfop.org/files/original/7559e1b4fd16d73a7c5698a4499dd5a7.jpg 225d1d21859fd91c9ebad5bc7191a4ed https://staging.drfop.org/files/original/08cd8d811779f982414986d31a527e19.jpg d3771dbd56799b33182af35d1c92d2ae https://staging.drfop.org/files/original/0939223082872fe05d76f44303b19cca.jpg 93a3a96df839aeb10aef4f65b4baf868 https://staging.drfop.org/files/original/df210d8c1bc8a0526c3cc9c380a65f3b.jpg ab58e114ecbeb9a449d2ccc395937275 https://staging.drfop.org/files/original/95e5e807e78ed5211798f516f1166caa.jpg 788a7ede4aa0a25137bd4a58b820245d https://staging.drfop.org/files/original/a0b47ea6e200a0bd2d2c28ae25937015.jpg 866795b24cb4c9e1f5970dc549e5e4dc Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_033.pdf Text Any textual data included in the document <h2>Removable Rigid Dressing for Below-knee Amputees</h2> <h5>Yeongchi Wu, M.D. <a style="text-decoration: none;">*</a> Harold Krick, CP. <a style="text-decoration: none;">* </a></h5> <h3>Background</h3> According to the National Center For Health Statistics, there were 274,000 patients with amputations of major limbs in 1971 in the United States. This number rose to 358,000 in 1977. Kay in 1975 reported 53.8 percent of the 6,000 reviewed new patients had had amputations at the below-knee level.<a></a> If the percentage and the number of amputees remained unchanged, there would be at least 200,000 below-knee amputees in this country at any given time. It is possible that this number could have been doubled in the past ten years. The most recent information regarding amputation available to the authors was the Vital and Health Statistics published by the U.S. Department of Health and Human Services in April, 1986. A review of 192,000 medical records from the 407 hospitals that participated in the 1984 National Hospital Discharge Survey showed an estimated 32,000 below-knee amputations alone. Therefore, improvement in the management of below-knee amputees will certainly benefit a significant number of patients. At the V.A. Lakeside Medical Center (VALMC) and Rehabilitation Institute of Chicago (R.I.C.), members of Northwestern University-McGraw Medical Center, Chicago, three techniques have been developed for treatment of below-knee amputees. These include the Removal Rigid Dressing (R.R.D.), Scotch-cast™ preparatory prosthesis, and the "one-step socket lamination definitive prosthesis." These approaches have been invaluable in the management of below-knee amputees. This paper describes the Removal Rigid Dressing for postoperative management of the below-knee amputee. Clinical experiences since 1977 have shown the benefits of the R.R.D. to be the following: <ol> <li> Rapid residual limb shrinkage </li> <li> Prevention of edema </li> <li> Possibility of frequent residual limb observations </li> <li> Soft tissue immobilization to facilitate wound healing </li> <li> Elimination of skin breakdown commonly seen in elastic bandaging </li> <li> Simplicity of donning and doffing </li> <li> Development of tolerance to weight bearing </li> <li> Prevention of residual limb trauma </li> <li> Reduction of wound pain </li> </ol> With nine years clinical experience at this university medical center and dissemination through the Northwestern University Prosthetic School, it appears to us that this technique has its merits in the postoperative and pre-pros-thetic management of the below-knee amputee. In a study done in 1977, the average hospital stay for amputees at VALMC was reduced by 90 days after the development of the R.R.D.<a></a> This was achieved primarily by complete elimination of skin breakdown seen previously from elastic bandaging and by speeding stump shrinkage with the R.R.D.<a></a> In the 1970s, at the VALMC in Chicago, there were many problems in postoperative below-knee residual limb care. For many years, the below-knee amputees were managed with a soft dressing or thigh high cast, i.e. Immediate Post-Surgical Fitting (IPSF) without pylon, followed by elastic bandaging, as many hospitals did at that time. The technique was done by the therapists, nurses, and patients, following the procedure learned directly or indirectly from the Northwestern University Prosthetic/Orthotic School. There was no special team or particular therapists assigned to amputee care. Inevitably, many techniques differing from the original were used by different individuals. For a long time, the staff was puzzled by the very high frequency of skin breakdown and distal edema (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg">Fig. 1</a>). At times, it was a surprise at the V.A. Prosthetic Clinic when a patient presented who was free of any residual limb complications. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg">Figure 1. A typical pressure sore over the tibial tubercle and distal edema from conventional elastic bandaging.</a> It was apparent that inconsistent limb care techniques by the staff and the patient himself was a contributing factor (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg">Fig. 2</a>). Many thoughts came to mind and many attempts were made to remedy this problem, such as using a protective covering made of thermoplastic or a donut shaped sponge over the tibial tubercle to prevent skin breakdown. Nothing was promising until one afternoon in early 1977 when the idea of the R.R.D. came to light. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg">Figure 2. A conventional elastic bandage is an unreliable technique in a patient's hand.</a> This happened after seeing a 90 year old man develop a tibial pressure sore on his well healed limb only three hours following the change from a thigh high plaster cast to an elastic bandage. We decided that the elastic bandage was guilty and should never be used for below-knee amputees again, and the thigh high cast could be modified to continue the excellent results. We analyzed the principles behind the thigh high plaster cast and incorporated them into the R.R.D. system. The design was completed on the same day and the same principles have been kept until this date without any further modifications. This system is a below-knee plaster cast suspended by a stockinette to a supracondylar suspension cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg">Fig. 7</a> (a, b, c) and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg">Fig. 7</a> (d, e, f)). Underneath the below-knee plaster cast, sport tube socks are added to provide-continuous controlled compression. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg">Figure 7 d, e, and f. Application of the Removable Rigid Dressing: d) the supracondylar cuff, e) pull the stockinette, and f) fold the suspension stockinette to make sure the cast is secured over the supracondylar cuff.</a> <h3>Why Does R.R.D. Work?</h3> No matter how successful this method has been, we certainly were inspired by the important pioneer work by Dr. Weiss in Poland, and later by Dr. Burgess<a></a> in this country. A few of the principles that made the R.R.D. an effective procedure were originally utilized in the IPSF system: <ol> <li> Use of a non-expandable dressing prevents the development of edema following amputation. </li> <li> Use of supracondylar suspension keeps the cast in place. </li> <li> Rigid dressing is effective in immobilization of soft tissue, which is essential for wound healing and pain control as well as trauma prevention. </li> <li> Controlled compression of the residual limb avoids skin breakdown and facilitates shrinkage. </li> </ol> <h3>Fabricating The R.R.D.</h3> The R.R.D. consists of four components: a) tube socks, b) below knee plaster cast, c) suspension stockinette, and d) supracondylar cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Figure 3. Components of the Removable Rigid Dressing: a) athletic tube socks with the elastic band removed, b) below-the-knee cast, c) suspension stockinette, and d) thermoplastic supracondylar suspension cuff.</a> Tube Socks The idea of using tube socks arose because of the difficulty in obtaining wool socks from the V.A. supply center in early 1977 and the necessity of hand care of wool socks. By replacing the elastic bandaging with R.R.D., we noted that below-knee residual limbs changed from their previous conical shapes to cylindrical contours. The measurements of properly fitted wool socks for our patients differed from those supplied by the V.A. supply center. For a while there was a shortage of socks for our patients. This led to the need for alternatives. One day, we tried a large size tube sock on sale at the V.A. canteen store. To this date, we still use tube socks routinely at the V.A. hospital and R.I.C. They can be changed daily by the patient and are machine washable. They also provide excellent sock marks on the skin for determining the degree of pressure over the residual limb. They are cheaper and available at most department stores (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3A</a>). We simply cut off the elastic tops and use them as nice fitting #2 size, 2 ply socks. Tube socks are cut in long and short lengths. Short tube socks are effective for localized compression with a bulbous limb so that progressively diminishing shrinkage can be achieved from the distal to proximal area. For the large residual limb, when the tube socks may not be long or wide enough, Soft-socks (Knit-Rite, Inc.) can be used. Plaster Cast The cast for a R.R.D. (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3B</a>) is shorter than that of the IPSF. It extends only up to the knee level for easy removal. The casting procedure also differs slightly for pressure relief. In the IPSF, felt paddings are used to bridge the bony areas. In the R.R.D., cotton paddings, six layers at the center and tapered to the margins, are used as "spacers" over the bony prominences of the tibial tubercle, tibial crest, fibular head and any pressure sensitive areas. Once the cast is made, the spacers are discarded. An empty space between the cast and the skin is formed to provide a controlled pressure relief (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg">Figure 4. Cotton paddings are used as spacer for pressure relief.</a> The trim line of the plaster cast is up to mid-patellar level anteriorly and lower posteriorly to allow knee flexion. It is wider proximally in order to ensure easy removal and reapplication of the cast. This is especially true with a bulbous limb where the concave side needs additional padding to avoid a cast that is too tight at the top (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg">Fig. 5</a>). In case of a narrow proximal opening, a longitudinal cut on the back of the cast can be used to widen the proximal part and allow reapplication (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg">Figure 5. Adequate medial padding is needed to assure a wider proximal opening for easier cast re-application (a). A narrow opening makes cast reapplication impossible (b).</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg">Figure 6. If cast opening is too narrow, a longitudinal cut on the back of cast allows widening of the cast proximally while still maintaining distal compression.</a> Suspension Stockinette The suspension stockinette, made of 4-inch casting stockinette with one end tied, secures the cast to the suspension cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3C</a>). Supracondylar Suspension Cuff The suspension cuff is made of thermoplastic material. It has a Velcro® closure to keep the cuff in place and a strip of Velcro® hook along the upper edge to secure the suspension stockinette (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3D</a>). For the obese patient who has very limited purchase over the femoral condyles because of tissue bulk, a fork strap with a waist belt can be used. <h3>Application Of The Removable Rigid Dressing</h3> After the surgical wound is properly dressed, the proper number of tube socks are applied layer by layer to avoid possible wrinkles. Then the plaster cast is applied and followed by the suspension stockinette and the supracondylar cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg">Fig. 7 (a, b, c)</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg">Fig. 7 (d, e, f)</a>). To make the application easier, a semi-circular mark is made on the cast and another on the supracondylar cuff so that the patient can match both marks to form a circle over the patella. <h3>When To Apply The R.R.D.</h3> The R.R.D. can be applied at the completion of surgery or when the first thigh-high rigid dressing is removed for wound inspection. It can be used whenever there is a need for limb shrinkage in any new or old amputee. <h3>Adding Socks</h3> When possible, additional socks are applied to maintain a comfortable snug fit and to facilitate progressive shrinkage. Sometimes short socks distally are preferred to provide localized distal compression without building up the thickness proximally (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg">Fig. 9</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg">Figure 9. Short tube socks provide localized compression in bulbous stump.</a> <h3>Weight Bearing Exercise</h3> It is not possible to say how many days after amputation one can start weight bearing. In general, initiation of weight bearing exercise is determined by the state of wound healing, usually seven to 14 days after surgery. Immediate postoperative weight bearing is likely to cause mechanical shearing from movement and delay wound healing during the first two weeks after amputation, as reported by Mooney.4 However, steady pressure without mechanical shearing on the residual limb using a wheelchair strap can be very beneficial (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg">Fig. 8</a>). We have found this can be used even within the first week after surgery. While in the wheelchair, the patient is encouraged to push frequently with the R.R.D. against resistance of the strap. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg">Figure 8. A strap is attached to the arm rests for the patient to exert partial weight bearing exercise while in the wheelchair (left). A car jack mounted onto plywood becomes an inexpensive adjustable stool for weight bearing and balance exercise (right).</a> Because it is removable, one can decide the time to start body weight bearing exercise based on the wound condition. The R.R.D. allows observation of the limb after each graded weight bearing exercise. By doing so, one can plan both the amount and duration of the next weight exercise. For unilateral amputees, the weight bearing exercise can be done by standing on a padded car jack (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg">Fig. 8</a>). For bilateral amputees, the tilt-table is used for weight bearing. The degree of weight stress is controlled by the inclination of the tilt table and the duration of standing. This proceeds progressively to the upright position and is followed by ambulation with walking heels attached to the casts (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg">Fig. 10</a>). Walking with Rigid Dressings helps bilateral amputees develop balance and sometimes is preferred by the obese and cardiac patients at home (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg">Fig. 10</a>). Walking with the R.R.D. also assists the evaluation of questionable candidates for prosthetic fitting. Ambulatory use of the R.R.D. produces simulation of prosthetic stress, allowing the amputee to quickly adapt to the actual prosthesis, an impossible step when using the conventional elastic bandaging method. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg">Figure 10. A) For bilateral amputees, weight bearing exercise is done on the tilt table. B) The stump is examined to modify the amount of weight bearing, i.e. the degree of inclination and duration of weight bearing. C) Weight bearing continues to the upright position in the parallel bars, and D) eventually to ambulation with walking heels attached to the casts or with a preparatory prosthetic fitting.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg">Fig. 11</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg">Fig. 12</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg">Figure 11. A stump with bony prominence and scars cannot tolerate the elastic bandage, but has no difficulty with Removable Rigid Dressing.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg">Figure 12. A one handed patient, either due to hemiplegia or upper limb amputation, can use the system easily.</a> <h3>Making A New Cast</h3> The below-knee cast is changed whenever the residual limb has shrunk to the point at which too many tube socks are being used, usually about 10-14 ply of socks. The total number of casts needed depends on the speed of progressive shrinkage. Frequently three or four casts are required before the patient is ready to be fitted for a preparatory prosthesis. <h3>R.R.D. Compared To IPSF</h3> Both the R.R.D. and the thigh high rigid dressing provide immobilization of soft tissue, prevention of trauma, and prevention of edema. However, being removable, the R.R.D. allows frequent limb observation without a need for cast-cutting and cast-reapplication as needed in a thigh high rigid dressing. More importantly, it permits frequent addition of tube socks for fast shrinkage. Because space is provided between bony prominences and the plaster, adding tube socks will produce compression force to soft tissues, but will not cause pressure sores (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg">Fig. 4</a>). If there is excessive pressure over an area, the cast can be softened from outside with a hammer, then pushed from inside for relief. Being removable, the R.R.D. has been very useful in monitoring the limb's response to weight bearing exercise. This facilitates progressive weight bearing within the safe tolerance range. Both undesirable skin breakdown from excessive weight bearing activity and hesitation in application of early graded weight bearing stress are minimized. <h3>R.R.D. Compared To The Shrinker</h3> The residual limb shrinker is an effective method for shrinkage, except for the danger of excessive pressure over bony areas or thin grafted skin. It does not protect the limb from unexpected falling, nor does it allow weight bearing exercise. The compression force can be adjusted by sewing the shrinker periodically rather than by adding socks as with the R.R.D. <h3>R.R.D. Compared To The Elastic Bandage</h3> The elastic bandage is not only difficult to apply for the staff and the elderly below-knee amputees,<a></a> but also is so unreliable that it frequently causes skin breakdown and distal edema (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg">Fig. 2 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3</a>). It cannot protect the limb from trauma due to accidental falling. With the R.R.D., it is much easier for the patient to don and doff as well as adjust the compression, accommodate progressive shrinkage,<a></a> and perform weight bearing exercise. Since the adoption of the R.R.D. at this medical center, the problems of skin breakdown and distal edema, commonly seen in the past from elastic bandaging, have been completely eliminated (Fig. 13). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-14.jpg">Figure 13. One of the first patients achieved 15-ply shrinkage in 7 days and spontaneous healing of the right pretibial sore caused by an elastic bandage.</a> <h3>R.R.D. For Delayed Wound Healing</h3> Delayed wound healing is not a contraindication for using the R.R.D. or a preparatory prosthesis. The R.R.D. is a useful means to facilitate wound healing, because the system reduces edema and tissue tension. The size of the open wound can be reduced and the edges of the wound can be brought closer together. With frequent debridement of the necrotic tissue and adding socks for shrinkage, often a big open wound can be healed without surgery (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg">Figure 14. Removable Rigid Dressing facilitated shrinkage of the limb (upper left) and the open wound. By frequent debridement and prosthetic fitting (upper right), the wound completely healed without skin graft (lower left).</a> <h3>Scotchcast™ Preparatory Prosthesis</h3> When the patient is able to tolerate full weight bearing in the R.R.D. and the residual limb is no longer bulbous, a Scotchcast™ preparatory prosthesis can be fit for early gait training and further shrinkage.<a></a> The advantages of the Scotchcast™ preparatory prosthesis are its moderately light weight, comfortable fitting, rare need for realignment, and reduction of fabricating time. This is achieved by, 1) direct formation of the socket on the residual limb with special pressure relief techniques, 2) use of a wool sock lining as the soft interface, and 3) precise semi-dynamic alignment of the prosthesis. Since the Scotchcast™ prosthesis can be fabricated within 1 1/2 hours during the patient's initial visit, the delivery of this prosthetic service is very efficient and cost effective. <h3>Conclusion</h3> The Removable Rigid Dressing has proved to be a very reliable means of preprosthetic management of the below knee amputee at this institution and others for the past nine years. It has proven to shorten the time from amputation to the initial preparatory prosthesis; is shown to be equal to or superior to all other means of preprosthetic stump management; features easy application; simple donning and doffing by the patient; progressive stump shrinkage by adding socks under the cast; gives protection through its rigidity for the not yet healed stump; ease in wound inspection; and allows early weight or pressure bearing to be started, thus conditioning the soft tissues for the first prosthesis. The R.R.D. has no contraindications other than application to a residual limb with a deep wound infection that requires surgical intervention. <h3>Acknowledgments</h3> The authors wish to express their appreciation to Henry B. Betts, M.D., Robert Keagy, M.D., Nasim Rana, M.D. and Dudley Childress, Ph.D., for their support in the development and demonstration of this technique. References: <ol> <li>Burgess, E.M. and Romano, R.L., "The Management of Lower Extremity Amputees Using Immediate Postsurgical Prostheses," Clin. Orthop., 57, 1968, pp. 137-146.</li> <li>Burgess, E.M., Romano, R.L., and Zettl, J.H., "The Management of Lower Extremity Amputations," Technical Report TR10-6, Prosthetic and Sensory Aids Service, Departments of Medicine and Surgery, Veterans Administration, Washington, D.C., 1969.</li> <li>Kay, H.W. and Newman, J.D., "Relative Incidence of New Amputations: Statistical Comparisons of 6,000 New Amputations," Orthotics and Prosthetics, Vol. 29, No. 3, 1975.</li> <li>Mooney, V., Harvey, J.P., Jr., Mcbride, E., and Snelson, R., "Comparison of Postoperative Stump Management: Plaster vs. Soft Dressings," Journal of Bone and Joint Surgery, 53-A, March, 1971, pp. 241-249.</li> <li>Mueller, M.J., "Comparison of Removable Rigid Dressing and Elastic Bandages in Preprosthetic Management of Patients with Below-knee Amputations," Physical Therapy, 62, 1982, pp. 1438-1441.</li> <li>Wu, Y. and Flanigan, D.P., "Rehabilitation of the Lower-Extremity Amputee with Emphasis on a Removable Below-Knee Rigid Dressing," pp. 435-453, and "Gangrene and Severe Ischemia of the Lower Extremities," edited by John J. Bergan, M.D. and S.T. James Yao, M.D., Grune and Stratton, New York, 1978.</li> <li>Wu, Y., Keagy, R.D., Krick, H.J., Stratigos, J.S., and Betts, H.B., "An Innovative Removable Rigid Dressing Technique for Below-the knee Amputation," Journal of Bone Joint Surgery, 61A, 1979, pp. 724-729.</li> <li>Wu, Y., Brncick, M.D., Krick, H.J., Putnam, T.D., and Stratigos, J.S., "Scotchcast™ P.V.C. Interim Prosthesis for Below-knee Amputees," Bulletin of Prosthetics Research, BPR 10-36, Fall, 1981.</li> <li>Parhad, A., Gervis, B., and Wu, Y., "From The Clinic: The Rigid Dressing; Pre-prosthetic Ambulation for the Below-knee Amputee, Amer. Corr. Ther. J., 37, 1983, pp. 66-89.</li> <li>Gervis, B., Parhad, A., and Wu, Y., "From The Clinic: Fabrication of the Removable Rigid Dressing and Supracondylar Cuff for the Below-knee Amputee," Amer. Corr. Ther. J., 35, 1982, pp. 126-133.</li> <li>Wu, Y., Krick, H.J., and Sankey, J.A., "Postoperative and Prosthetic Management of Below-knee Amputee with Removable Rigid Dressing and Scotchcast™ Preparatory Prosthesis." Proceedings of 8th annual Conference of Rehabilitation Engineering Society of North America, 1985, pp. 370-372.</li> </ol> Harold Krick, CP. Rehabilitation Institute of Chicago, 345 E. Superior Avenue, Chicago, Illinois 60611. Yeongchi Wu, M.D. Rehabilitation Institute of Chicago, 345 E. Superior Avenue, Chicago, Illinois 60611. <div style="width: 400px;"></div> Page Number(s) 33 - 44 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg Figure 7 FIGURE 7 (a,b,c) http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg FIGURE 7 (d,e,f) http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource Removable Rigid Dressing for Below-knee Amputees Creator An entity primarily responsible for making the resource Yeongchi Wu, M.D. * Harold Krick, CP. * https://staging.drfop.org/files/original/bb9083f1dffd396d8d2fdd08e6d8d92f.pdf 4437d79d4106d3a832f83ce13ad09060 https://staging.drfop.org/files/original/93ef94d1e76c7566ffd5e0cd3fd47a23.jpg 91c1fb1425a1479c970fb202a50dec30 https://staging.drfop.org/files/original/1a059f50c301f249f166e460aa740858.jpg 74b2a7e6a5c644519542d95255dc1238 https://staging.drfop.org/files/original/8a139363d6c58b7e3e0ff9d49d858a81.jpg 51bc170e7320050042ce526c6f20dabe https://staging.drfop.org/files/original/cdb356107ada6b1ea68967babe581532.jpg c4402901f82db70afb93dca3a42a2a60 https://staging.drfop.org/files/original/59c914c60ab4d16fb04bda07ccbd378c.jpg ae5f4cac5a35b970f247fa7de8af1756 https://staging.drfop.org/files/original/49877aa5e486f4fbd0e9c86b7ad03e00.jpg 7cd593c79e4e402647fd02c82b7f6de1 https://staging.drfop.org/files/original/fd0348f41099b48f8accd80df9cef917.jpg da2998cc2add3944a32f709035daf6b2 https://staging.drfop.org/files/original/4c182a73a83689bcc70f8ca67b4aa9b3.jpg 183189efded27bc2ae8440b420391b8c https://staging.drfop.org/files/original/678c4be09e85d9f222ba39be3c07b78e.jpg e04ffb7a53e03ff24b366fc957fc0649 https://staging.drfop.org/files/original/1e08a87d4324f10714555dfeeccf9204.jpg 206bd0b2a46e92e0afdbbd69f5fd774c https://staging.drfop.org/files/original/6888edf3d448611749dc5f86f0ac757f.jpg d1d50555428df3818b34fbe6eda2c845 https://staging.drfop.org/files/original/433672fd8b805de0e90ae09bb2925f86.jpg 63590aacfabe97cf4d3d968d0162f82e https://staging.drfop.org/files/original/829d7bed15bcb7438d6f5bc5d6747ec0.jpg 4809d4e59ac5f80bf9392cdf39ecd869 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_020.pdf Text Any textual data included in the document <h2>The Design a<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg"></a>nd Testing of a Gradient Pressure Sock for Control of Edema</h2> <h5>Martha Field, M.S. <a style="text-decoration: none;">*</a> Joseph Zettl, CP. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Since the fit of a prosthesis on a residual limb influences skin condition, gait, comfort, and even whether or not the prosthesis will be worn, the stability of the limb size is critical. Even in a whole leg, prolonged standing without the 'pumping' action of the leg muscles leaves a poorly supported column of blood within the veins. "The amputated limb has virtually no muscle contraction to aid venous return."<a></a> External pressure, when well applied, does facilitate venous return, reduces hemo-stasis, and provides comfort. Pressure must be sufficient to offset the increased hydrostatic pressure of trauma, standing, or straining and yet not interfere with arterial flow.<a></a> Poorly applied pressure may be injurious. Various investigators have charted the wide range of pressures obtained by elastic wrap and have cautioned against the harmful effects that could result from this edema control method.<a></a> Isherwood states that "elastic wrap bandaging is unreliable and dangerous in terms of pressure and pressure distribution,"<a></a> because pressure can become so great from too tight a wrap that a tourniquet effect results. The use of tubular elastic bandaging results in more predictable and less pressure fluctuation, and requires considerably less skill in application. Especially for below-knee edema problems, Compressogrip<a style="text-decoration: none;">*</a> and similar products, including the Puddifoot method,<a></a> have proven to be effective, inexpensive, easy to apply, and well liked. However, as early as 1961, Beninson recognized that, "Pressure gradient dressings can, in some instances, be used following surgery to hasten healing prior to application of the supports."<a></a> In 1971, Mooney, et al., stated that their study revealed postoperative residual limb care using plaster shell or plaster with pylon resulted in more successful prosthetic fittings than those using soft dressings.<a></a> In 1975, Isherwood defined the requirements of a good dressing by stating that "as intracapillary pressure varies with dependency, the ideal bandage should provide a graded pressure which is maximum at the most dependent distal point, decreasing proximally."<a></a> Shaping the residual limb is also recognized as a function of a shrinker sock. Available shrinker socks generally lack the shaping capacity, particularly at the distal end. Our objective, therefore, was to make a shrinker sock which would shape the distal end, have gradient pressure, and be accepted by wearers. This sock would not only accomplish the task of reducing post-amputation edema, but would also control fluids which might recur as the result of illness, injury, or any number of conditions. When any edema is uncontrolled, the tendency is not to wear the prosthesis. In defining the size and shape of the residual limb, two studies were helpful. In the July, 1983 Journal of the American Geriatrics Society, Dr. Clark, et al., described ideal limb characteristics including length below knee (6-8 inches) and above knee (8-10 inches) and shape (cylindrical).<a></a> A Swedish study actually measured 58 below-knee amputations. They found that 66 percent of the residual limbs were conical, 28 percent cylindrical, one percent bulbous, and five percent were other. The length in the supine position from the knee joint, i.e. the anterior rim of the medial condyle to the most distal part of the soft tissues at the end of the residual limb, was six inches (8 to 20 cm.).<a></a> No average measurement has been found in the literature for above-knee residual limbs. This lack of information about residual limb measurements may result from the fact that, in spite of what researchers have said, wrapping has been the most universal method of residual limb reduction. It may be that prosthetists feel no two limbs are identical and each needs to be treated individually. Nevertheless, with cooperation and knowledge, general parameters can be established for socks which will exert the desired graded pressure over a limited measurement range so that standard sizes of socks can be readily available. Although the benefits of using pressure as a prophylactic aid to reduce edema after amputation, or whenever edema develops in a mature stump, have been recognized for centuries, no precise definition of the amount of pressure to be used has been created. Part of the reason is that each researcher has used a different instrument for measurement, and although each instrument can be calibrated to a manometer, certain features of each instrument result in un-comparable readings.<a></a> Much of the research on using pressure to alleviate pain and ulcers in cases of deep venous insufficiency supports much higher mmHg readings than those indicated by the fairly limited research on wrapping and tubular elastic bandaging pressures. Our request for information on instruments being used to obtain the pressures printed on packaging of various companies making pressure garments only revealed the use of the Kompritest II (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg">Fig. 1</a>). We secured that instrument and found it gave readings 15-20 mmHg higher than the CTC 250 we had been using (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg">Fig. 2</a>). We pursued this with Midwest Research Institute<a style="text-decoration: none;">*</a> and received the following explanation: <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg">Figure 1. Kompritest II for measurement of pressure values of elastic stockings.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg">Figure 2. CTC 250 Digital Pressure Gauge.</a> <blockquote> Both devices accurately measure pressure imposed upon their respecting sensing elements. When placed under an elastic fabric, the devices produce different readings because the Kompritest II (K-II) device distends the elastic fibers surrounding the bulge of its inflated bladder and thus produces a local increase in pressure over the measurement site. This local pressure increase observed using the K-II accounts for the difference between values produced by the two devices, and suggests that the CTC device is the more accurate of the two for measuring the pressures exerted by elastic fabric.<a></a> </blockquote> Although some instruments have misrepresented pressures on the high side and some researchers have advocated unusually low pressures,<a></a> a 1985 study by Hendricks and Swallow used stockings "designed to exert graded compression from 24 mmHg pressure at the ankle to 16 mmHg pressure at the calf." They admit that "the optimal amount of compression at the ankle and calf necessary to heal and prevent statis leg ulcers is not known at this time." Their explanation of the value of external compression therapy is that "it compresses the superficial veins and prevents extravasation of fluid into the subcutaneous tissues . . .," thus reducing "swelling of the leg as measured by total leg volume and by lower extremity circumference measurements."<a></a> The study by Varghese, et al., obtained similar results with similar pressure readings using the CTC instrument. To date, capillary and anteriolar blood pressure have not been related for the purpose of establishing pressure values that would reduce edema; nor has the difference between new or mature residual limbs been studied. Different pressure readings have been observed over bony areas versus fleshy areas.22 <h3>Procedures</h3> Since our aim was to develop a sock which would be fashioned to give greater pressure distally, less pressure proximally, and have a rounded toe to shape the distal end, the flat, V-bed type machine was employed. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg">Fig. 3</a> is a close up of the carriage and the needle bed where needles are picked up or dropped according to machine programming so that wid-enings or narrowings (fashionings) can be made. All standard prosthetic socks are full-fashion knit in this way, with gradual wid-enings up both sides of the sock. To give even greater rounding, a new widening for the toe was programmed. On circular machines, as used for most currently available shrinkers, widening can only be achieved by loosening the knitting tension. Knitting a rounded toe on a circular machine is not possible. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg">Figure 3. Needle bed of knitting machine where widenings and narrowings can be made.</a> The yarn to be used for this sock needed firmness in its stretch so that the desired pressures could be obtained. Softness, strength, and washability were also considered important. A corespun yarn was selected, with Lycra spandex being the core and Avril rayon being the covering. Attempts were made to obtain postoperative edemic residual limb measurements from various facilities. Not enough measurements were obtained to make any generalizations. Therefore, our knowledge was combined with that of the Knit-Rite production manager to formulate an experimental size range (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-04.jpg">Table 1</a>). Specifications were made for the knitting machines so that the desired pressures would be obtained when tested over a steel cylinder (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg">Fig. 4</a>) at the Fits Circumference measurements. Heavy pressure was defined at the top of the effective range, i.e. 25-30 mmHg for the distal pressure and 15-20 mmHg for the proximal pressure. The recognition that some patients could not tolerate heavy pressure, and that some researchers suggested less pressure for nighttime wear, led to the development of a sock having distal pressure in the 15-20 mmHg range and proximal pressure in the 10-15 mmHg range. Socks were identified with color stitching at the top: green for heavy pressure and gray for medium pressure. The increase in pressure caused by the increased stretch over the range was measured to be no greater than the allowed variance. Shrinker socks were sent to many prosthetists who indicated that they would use them and return evaluation forms. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg">Figure 4. Testing cylinder with pressure sensing device in position.</a> <h3>Results</h3> Forty-five evaluations were returned representing 43 patients. All but three of these evaluations were for below-knee amputees (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-06.jpg">Table 2</a>). Of the 42 below-knee evaluations, 17 had toe measurements ranging in circumference from eight inches to 11 inches; 18 had toe measurements ranging from 11 1/8 inches to 13 5/8 inches; four had toe measurements ranging from l4 1/2 inches to 16 inches; and three did not give measurements (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg">Table 3</a>). The significance of grouping the measurements in this way was so they would correspond with the size range we had developed for testing purposes. A smaller toe circumference measurement was encountered than had been anticipated, but the actual toe sizing ranges could be compared with the experimental toe sizing ranges in the narrow, medium, and wide. Top measurements were ranged as they corresponded with toe measurements in each size (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg">Table 3</a>). Note, the actual tester range of top circumference measurements was both larger and smaller than the experimental sizing range for the narrow and the regular, but was only smaller for the wide (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg">Table 1 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg">Table 3</a>). Pressure measurements were again taken which defined ranges of each size as reported for the wearers. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg">Fig. 5</a> shows pressure measurements of heavy shrinker socks at circumferences one inch from the distal end. These pressures should relate to pressures exerted on those fitted with the narrow, the medium, and the wide as indicated by the rectangles. Our KU study indicated laboratory pressure measurements over steel cylinders are approximately ten percent higher than pressure measured on patients, or control volunteers making these pressures in agreement with our criteria, if the larger circumference in each specified Fits Circumference range is the cut off point; therefore, if 11 inches is the larger suggested circumference, 11 1/8 circumference inches would be fit with the next size unless greater pressure is desired. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg">Figure 5. MmHg of pressure exerted by heavy shrinker sock on inch from distal end.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg">Fig. 6</a> shows pressure measurements of heavy shrinker socks at circumferences six to eight inches from the distal end. These pressures should relate to pressures exerted on those fitted with the narrow, the medium, and the wide as defined by the rectangles. These pressures are less than the distal end pressures. However, particularly in the narrow size, some readings were at the 20 to 25 mmHg level. Since some wearers' residual limbs were exceeding the suggested range in top circumference measurement and were obtaining greater proximal pressure than might be desired, patterns were made using the measurements given for each limb. These were grouped by shape. As a result of comparing these shapes and listening to comments from several facilities, a double tapered shrinker was developed. Comparison to the regular taper is shown in <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg">Fig. 7</a> where the dotted lines represent the regular tapered sock and the three toe lengths represent the 10, 12, and 14 inch sock lengths. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg">Figure 6. MmHg of pressure exerted by heavy shrinker sock six to eight inches from distal end.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg">Figure 7. Scale of regular and double taper.</a> When knitted, the regular taper and double taper can be compared as in <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg">Fig. 8</a>. The toe is the first consideration for fit using the Fits Circumference range as the guide. Then, if the top circumference exceeds the recommended limit of the regular range, a double taper should be ordered or at least considered. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg">Figure 8. Comparison of regular and double taper shrinker sock (14 inch length).</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg">Fig. 9</a> shows pressure measurements of medium pressure shrinker socks at circumferences one inch from the distal end. These pressures should relate to pressures exerted on those fitted with the narow, the medium, and the wide as indicated by the rectangles. These pressures met our criteria for a sock with medium pressure of 15 to 20 mmHg. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.jpg">Fig. 10</a> shows pressure measurements of medium pressure shrinker socks at circumferences six inches to eight inches from the distal end. These pressures should relate to pressures exerted on those fitted with the narrow, the medium, and the wide as defined by the rectangles. These pressures were lower than our criteria when circumferences were less than our sizing guide. This was not considered to be a problem unless a lack of pressure caused slippage. Where circumferences were more than our sizing guide, the pressures of the narrow exceeded our criteria as did those of the heavy shrinker sock. As for the heavy shrinker sock, when the top circumference exceeds the Fits Circumference recommendation, the double taper is recommended to get the advantages of gradient pressure. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg">Figure 9. MmHg of pressure exerted by medium pressure shrinker sock one inch from distal end.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.jpg">Figure 10. MmHg of pressure exerted by medium pressure shrinker sock six to eight inches from distal end.</a> Evaluation forms revealed that both green top, heavy compression socks, and gray top, medium compression socks, were used for day and night wear. Four testers used two socks: heavy compression for daytime wear and medium compression for nighttime wear. Seventy percent of the testers wearing the heavy compression felt the tops stayed up adequately; 65 percent of the testers wearing the medium compression socks felt the tops stayed up adequately. Night-time was the most difficult time. To one tester who complained in detail about the roll down, we sent him a shrinker with a turned down zigzagged stitched top. He liked this top, but it was not pursued for fear the doubled top would cause greater pressure prox-imally. Some trials indicated the shrinker should come up proximally past the patella and that if it comes a little higher, it is less likely to roll. All but one of the testers using the heavy compression felt that the shrinker was improving the shape, decreasing the edema, and/or maintaining the limb. One tester, who felt the heavy pressure was not adequate, used both heavy and medium socks at the same time and still felt the need for greater pressure. The prosthetist noted this was a young man with a high pain level and a drive to get back on his legs. Sixty-four percent of the testers using the medium compression felt the shrinker was maintaining the limb's size and shape. Thirty-five percent of the respondents felt the pressure of the medium compression sock was not sufficient. Most of the amputees using the experimental shrinker socks were new patients who lost a leg because of vascular disease, usually diabetes. Any undue pressure over the residual limb serves as an excuse to take the shrinker off; therefore, medium pressure may help to start the process of controlling edema so that heavy pressure will eventually be tolerated as needed. Some of the shrinkers were worn over Ace® bandaging and some comments were made about using Ace® bandaging some of the time. Prosthetists' comments revealed that the experimental shrinkers were effective in shaping the distal end, hugging the anatomy, and giving good overall suspension. The distal end support was positive as long as the patients applied the shrinker firmly. Some residual limbs are very bulbous initially following surgery. This depends on the patient's physique, the surgical technique use, and the amount of edema. Previous experience indicates a bulbous residual limb will, in time (six to 12 weeks post-surgery), become slowly cylindrical, and a cylindrical amputation will become cone-shaped. Thirty percent of the wearers said they had not washed their shrinker sock which may have meant that they were wearing it continuously. Five percent did not answer the question. Of the 65 percent who did wash their shrinker, none mentioned any washing problems. In answer to the question, "Is the sock easy to apply", 100 percent of the testers said, "Yes." One said, "Very." In answer to the question, "Is the sock comfortable?," all but one tester replied positively. This one tester was having some orientation problems. Other comments were "Feels good," "Feels great, except at first when a little tender." <h3>Conclusions</h3> Evaluation forms for a new below-knee shrinker sock revealed it was comfortable, easy to put on, stayed up on most but not all wearers, gave desired shrinking and shaping in the heavy compression, and some shaping and residual limb maintenance for 65 percent of the medium compression wearers. When pressure was greater and the sock was fitted longer, proximally past the patella, roll down was less of a concern. Analysis of residual limb measurements and pressure measurements determined that both the heavy and the medium compression shrinker socks did exert greater pressure distally than proximally, and that wider circumferences than those recommended at six or more inches from the distal end could be accommodated by the double tapered sock. This study did not offer the opportunity to study above-knee shrinkers, but they are being custom made in order to gain knowledge of fit and support. The same fabric used in the below-knee shrinkers can be cut and sewn to make above-knee socks. To meet the needs of shrinking stumps, below-knee shrinkers can be altered with a sewing machine stitch if the sock is not to be used for walking. If the sock is to be used for weight bearing, it can be returned to be altered with a flat seam according to specified markings, or a smaller size can be fitted. <h3>Acknowledgments</h3> We are especially indebted to the prosthetists from the various facilities who did most of the reporting for the testers. Without their help, this report would not have been possible. We also wish to thank William B. Smith, CO, President, and Larry Pierce, Production Manager, of Knit-Rite, Inc.. Without their product, knitting knowledge, and encouragement, no sock would ever have been made. References: <ol> <li>Beninson, Joseph, M.D., "Six Years of Pressure Gradient Therapy," Angiology, Volume 12, No. 1, January, 1961, pp. 38-45.</li> <li>Bauer & Black, Elastic Stocking Compression in the Therapy of Varicose Veins, Chicago, Il., 1956, pp. 4-14.</li> <li>Chavatzas, Dimetrios, and Jamieson Crawford, "A Simple Method for Approximate Measurement of Skin Blood-Pressure," The Lancet, April 20, 1974, pp. 711-712.</li> <li>Clark, Gary S., M.D.; Barbara Blue, R.N.; and John B. Bearer, RPT, "Rehabilitation of the Elderly Amputee," Journal of the American Geriatrics Society, Volume 31, No. 7, July, 1983, pp. 439-447.</li> <li>Cohen, Havey D., Ph.D., Letter to Knit-Rite, Inc. on "Equipment Evaluation Service," November 14, 1984, p. 1.</li> <li>Hendricks, William M,, M.D. and Roger T. Swallow, B.A., "Management of Statis Leg Ulcers with Unna's Boots Versus Elastic Support Stockings," Journal of the American Academy of Dermatology, Volume 12, No. 1, January, 1985, pp. 90-98.</li> <li>Hera, J. Alan, M.D.; Antonio M. Sotlo, M.D.; Peter S. Kaufman, Ph.D.; and Stephen M. Weiss, Ph.D., "Cardiovascular Instrumentation," Proceedings of the Working Conference on Applicability of New Technology to Biobehavioral Research, March 16-19, 1982, pp. 207-217.</li> <li>Horner, J., R.N.; L.C. Loruth; and A.N. Nicolaides; "A Pressure Profile for Elastic Stockings," British Medical Journal, March 22, 1980, pp. 818-821.</li> <li>Husni, Elias A., M.D.; Jose O.C. Xemenes, M.D.; and Frederick G. Hamilton, M.D., "Pressure Bandaging of the Lower Extremity," Journal of the American Medical Association, Volume 206, No. 12, December 16, 1986, pp. 2715-2718.</li> <li>Isherwood, P.A.; J.C. Robertson; and A. Rossi, "Pressure Measurements Beneath Below-Knee Amputation Stump Bandages: Elastic Bandaging, the Puddifoot Dressing and a Pneumatic Bandaging Technique Compared," British Journal of Surgery, Volume 62, 1975, pp. 982-986.</li> <li>Johnson, George, Jr., M.D.; Cynthia Kupper, R.N.; David J. Farrar, Ph.D.; and Roger Swallow, "Graded Compression Stockings," Archives of Surgery, Volume 117, January, 1982, pp. 69-72.</li> <li>Makin, G.S.; F.B. Mayes; and A.M. Holroyd, "Studies on the Effect of 'Tubigrip' on Flow in the Deep Veins of the Calf," British Journal of Surgery, Volume 56, No. 5, May, 1969, pp. 369-372.</li> <li>Manella, K.J., "Comparing the Effectiveness of Elastic Bandages and Shrinker Socks for Lower Extremity Amputees," Physical Therapy, Volume 61, No. 3, pp. 334-337.</li> <li>Mooney, Vert, M.D.; J. Paul Harvey, M.D.; Elizabeth McBride, M.D.; and Roy Snelson, C.P.O., "Comparison of Post Operative Stump Management: Plaster Vs. Soft Dressings," The Journal of Bone and Joint Surgery, Volume 53-A, No. 2, March, 1971, pp. 241-248.</li> <li>Puddifoot, P.C.; P.C. Weaver; and Sheila A. Marshall, "A Method of Supportive Bandaging for Amputation Stumps," British Journal of Surgery, Volume 60, No. 9, September, 1973, pp. 729-731.</li> <li>Renstrom, Per, The Below-Knee Amputee, University of Goteborg, Sweden, 1981, p. 18.</li> <li>Sigg, K., M.D., "Compression with Pressure Bandages and Elastic Stockings for Prophylaxis and Therapy of Venous Disorders of the Leg," Fortschritte Der Medizin, No. 15, August 15, 1963, pp. 601-606.</li> <li>Spiro, M.; V.C. Roberts; and J.B. Richards, "Effect of Externally Applied Pressure on Femoral Vein Blood Flow," British Medical Journal, Volume 1, March, 1970, pp. 719-723.</li> <li>Swallow, Ramsey; and Roger Swallow, "How to Use Tester to Measure Compression Force of Support Hosiery," Knitting Times, November 22, 1976, p. 55.</li> <li>Van Pijkeren, Teun; Marinus Naeff, M.D.; and Him Hok Kwee, Ph.D., "A New Method for the Measurement of Normal Pressure Between Amputation Residual Limb and Socket," Bulletin of Prosthetic Research, Volume 17, No 1, Spring, 1980, pp. 31-34.</li> <li>Varghese, George, M.D.; Peter Hindle, M.D.; Serge Zilber, Ph.D.; Judith Perry, RPT; and John B. Redford, M.D., "Pressure Applied by Elastic Prosthetic Bandages: A Comparative Study," Orthotics and Prosthetics, Volume 35, No. 4, December, 1981, p. 34.</li> </ol> Footnote Midwest Research Institute is a professional not-for-profit corporation doing contract research for business, industry, government, individuals and groups. Footnote Available from Knit-Rite, Inc. Joseph Zettl, CP. Joseph Zettl, CP., is President of the American Artificial Limb Co., Inc., 1400 East Pike Street, Seattle, WA 98122. Martha Field, M.S. Martha Field, M.S., is Manager of Research and Development for Knit-Rite, Inc., 2020 Grand Avenue, Kansas City, MO 64141. Page Number(s) 20 - 32 Year 1987 Volume 11 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg Figure 4 TABLE I http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-04.jpg Figure 5 FIGURE 4 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg Figure 6 TABLE II http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-06.jpg Figure 7 TABLE III http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 5 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg Figure 9 FIGURE 6 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg Figure 10 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg Figure 11 FIGURE 8 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg Figure 12 FIGURE 9 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg Figure 13 FIGURE 10 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Design and Testing of a Gradient Pressure Sock for Control of Edema Creator An entity primarily responsible for making the resource Martha Field, M.S. * Joseph Zettl, CP. * https://staging.drfop.org/files/original/5e9f050c02d96432d8f104ec812ace8c.pdf da0d38d9a804a332fd9a3207062a9f1a https://staging.drfop.org/files/original/08e07425408bf41c87dc2c93b224fb5b.jpg 5c092b58ef2060d68e7424b84d6116a0 https://staging.drfop.org/files/original/e346dec2bedf92a857e59abd1ffd7248.jpg 7ee5ff43fa419c57bc4fd8cc6391d463 https://staging.drfop.org/files/original/f61adfb1b17552120e234743993ec28c.jpg ab766cfcc2786236a2c9260ce284e2f4 https://staging.drfop.org/files/original/273c55454cc1bf885d5d972065422824.jpg 2bd9f6a2c4b4d4dc4605e3164b28a1a4 https://staging.drfop.org/files/original/d7748887e1fa845160bc8a5ed9a0b605.jpg a6a917a2af2d7d7b9c2aaf4fe33859dc https://staging.drfop.org/files/original/66af61cdb008228dfacfa6384bb43a35.jpg 4526ad7811f6fb0b5ab5e82c5898c111 https://staging.drfop.org/files/original/ec901e8f405550f48f40e16d73cb2668.jpg f6a4b8e029d8a483756ef3093ef5b526 https://staging.drfop.org/files/original/4f6d845321f89277e90d05be3717d8c6.jpg 1b032cda8b3d4109ce6eb11f5a7f1bff https://staging.drfop.org/files/original/8f7da8912d661f332b7e1a1bf78d597d.jpg 674e1d743a9075daacadf8b4dc82e328 https://staging.drfop.org/files/original/259e168640efa7a9e4790687b54c8fe3.jpg f2644041c4e2f5558269baa90c20d8ca https://staging.drfop.org/files/original/0e7f28c6e5f7b709866175e5ccdf4771.jpg a9c7feb31eff0f0a1e47b133085f51fb https://staging.drfop.org/files/original/117acbf788a7d3c1a7c6e8475739c1ed.jpg 415a50b0631ed70cc4f1c6e34ead3306 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_011.pdf Text Any textual data included in the document <h2>A Variable Volume Socket for Below-knee Prostheses</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration: none;">*</a> C. Michael Schuch, C.P.O. <a style="text-decoration: none;">*</a> Robert O. Nitschke, C.P.O. <a style="text-decoration: none;">*</a></h5> The benefits concerning control of edema by fitting the lower limb amputee as soon as the stitches are removed are well documented,<a></a> yet for a number of reasons, mostly economic, the majority of new amputees are not treated in this manner. As a result, most patients present for their first prosthesis with an edematous residual limb that can be expected to shrink even when it has been wrapped properly with an elastic bandage or with a shrinker sock. Proper management of these patients has usually required the fabrication of several provisional sockets in successively smaller sizes until the soft tissues have reached a point where no further reduction is to be expected. Besides the expense involved in this procedure, a truly proper fit occurs only for a very short period after each new provisional socket is provided, a condition which is bound to have an effect on the activity of the newly fitted patient. Thus, a socket that can be adjusted to accommodate the gradual change in residual limb volume is desirable. <h3>History</h3> Attempts to provide adjustable socket volume are found more commonly at the above-knee level.<a></a> The Irons, et al.<a></a> socket design has evolved to become available as a non-custom fitted, prefabricated socket system, manufactured and distributed by Orthomedics<a></a> and United States Manufacturing Company.<a></a> To quote Mooney,<a></a> a co-author of the paper by Irons, et al.,<a></a> "For the above-knee stump, the design constraints are simpler in that the residual limb usually presents no significant bony contours and adequate soft tissue covers all bony elements. On this basis, the fabrication of a lightweight above knee prosthesis with an adjustable socket is a relatively simple problem." Referring again to the Irons, et al.<a></a> study, Dr. Mooney7 states that, "a significantly higher percentage of amputees became functional users due to the availability of the adjustable above-knee prosthesis than would have been expected by previous experience if they had waited for the maturation time to be considered for a conventional socket. The average time to fitting with a conventional socket in the past was about six months. In this group, using earlier fit of adjustable sockets, which were also lightweight, a higher percentage of patients became functional users." The only volume adjustable below-knee socket system reported on to date is by Mooney, et al.<a></a> from the University of Texas at Dallas, who report early gratifying results with use of this system. However, it is an off-the-shelf item, which inherently presents fitting problems. As opposed to the above-knee limb, the below-knee limb requires more exacting contours of fit due to prominent bony contours, and relatively less soft tissue. In addition, the below-knee amputee often presents with adherent scar tissue in the suture areas. For these reasons, most will agree that a custom fit is mandatory at the below-knee level. An interesting fact can be noted in all of the designs cited: ease of volume adjustments were concentrated in the proximal aspect of the socket as opposed to the distal aspect, where the greatest reduction in volume occurs. <h3>Goals And Design Criteria</h3> After reviewing existing designs in which the volume of the socket can be adjusted, and considering the use of materials and techniques now available, a set of criteria was established for a custom fitted variable volume below-knee socket as follows: 1) the socket would be custom fitted to the individual patient; 2) existing prosthetic molding, modification, and fabrication techniques would be used as appropriate; 3) the volume would be controlled equally or selectively between proximal and distal parts of the residual limb; 4) normal prosthetic cosmesis would be possible and practical; and 5) the finished prosthesis would be light, but durable. The original, primary purpose of the project was to design a socket for use as a preparatory prosthesis, and thus avoid the need for several socket changes before stabilization occurs. However, it appears that the design that has resulted may also be very appropriate for use over extended periods where fluctuation in limb volume is difficult to control, or where the shear stresses normally encountered with present day socket designs present a problem. Because of the two-piece design (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg">Fig. 1</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg">Fig. 2</a>), it is possible to don and doff the prosthesis without subjecting the skin of the residual limb to shearing forces, and thus should be considered when it is desirable to avoid shear on the limb. Additionally, the two-piece construction should add a measure of suspension if this element is considered in the individual design. <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg">Figure 1. Exploded schematic view of the variable volume socket showing major components.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg">Figure 2. Schematic showing relationship of the major components of the variable volume socket.</a> We are confident that the concept is valid and useful. What follows here is, we hope, sufficient information for an experienced prosthetist to try the concept. The materials and dimensions given are those that have been found to work in our still limited experience, but are by no means considered to be the best. Our original method for controlling volume, by use of two conventional hose clamps, is described here, because we have yet to locate a commercially available adjustment buckle that is suitable. We made some progress in designing a buckle especially for this purpose, but have not pursued the idea since the hose clamps can be made to work satisfactorily. However, there is probably a place for a more convenient method of controlling the circumferential dimensions. <h3>Casting And Modifying The Positive Model</h3> As stated in the design criteria, this socket system is intended to make use of existing prosthetic molding, modification, and fabrication techniques. We recommend use of the casting procedure described by Fillauer<a></a> in which an impression of the anterior portion of the limb is made first, using plaster splints to capture the bony definition before enclosing the remainder of the residual limb with plaster. Model modification should be carried out in normal function. We also recommend the use of a transparent diagnostic socket and algination procedure as described by Schuch and Lucy,<a></a> before proceeding with pouring the final positive model and fabrication of the socket. Fabrication of the Socket <ol> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-03.jpg">Step 1 </a> Place the positive model in a vise horizontally with the anterior section facing up. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-04.jpg">Step 2 & 3</a> Over the positive model, form a Pelite™ liner for the anterior half of the socket. After heating a proper size sheet of Pelite™, a piece of latex rubber can be used to form the Pelite™ around the cast model. </li> <li> Trim the Pelite™ liner so that it extends posteriorly slightly past the midline, dividing the anterior-posterior halves of the model. Skive all edges that will be inside the socket. Remove the Pelite™ liner from the cast in preparation for the next step. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-05.jpg">Steps 4 and 5</a> Rotate the model in the vise 180° so that the posterior surface is up. </li> <li> Using conventional drape molding techniques, vacuum form a piece of 1/8 inch polyethylene (or Surlyn®) around the model, posterior side up so the seam is on the anterior side. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-06.jpg">Step 6</a> Trim the polyethylene to form a posterior socket shell that extends anteriorly just past the midline and "underlaps" the Pelite™ anterior liner by about 3/8-1/2 inch. Again, skive all edges that will be inside the socket. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-07.jpg">Step 7</a> With the Pelite™ anterior liner and the polyethylene posterior shell in place on the model, pull a thin sheath of nylon over both to hold them in place. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-08.jpg">Step 8</a> On the posterior aspect of the model, glue a 1/4 inch diameter rope to form the cutout for the posterior volume control panel. Prepare for lamination in the usual manner. For use as a temporary design prosthesis, we use Otto Bock<a></a> modular endoskeletal components and laminate the 4R42 component (socket adaptor with pyramid and lamination anchor) directly into the socket. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-09.jpg">Step 9</a> Before beginning the lamination procedure, cut two polyethylene strips 1/16 inch thick by 9/16 inch wide by the circumference, plus 1/2 inch of the cast model at the levels shown. The strips are placed in the lamination layup and are removed after the lamination sets up to form channels for the volume control straps. Layup for the lamination is as follows: <blockquote> 1 layer of 1/2 oz. dacron felt 1 nylon stockinette the 4R42 component (if used) I.P.O.S.<a></a> glass matting over the lamination anchors of the 4R42 component and over the medial, lateral, and posterior aspects of the layup 1 nylon stockinette; the two polyethylene strips cut earlier are placed at the appropriate levels; 1 nylon stockinette 2 nyglass stockinettes; laminate with 80:20 mixtures of acrylic resin </blockquote> </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-10.jpg">Steps 10, 11, and 12</a> When the laminate has set and cured, cut out the window over the rope and trim as shown. </li> <li> Using a pair of needle nose pliers, pull out the two polyethylene strips imbedded in the lamination. This leaves a clean, hidden track for guiding the pull of the control straps. </li> <li> Cut out an area about 1 1/2 inches along each control strap track in the anterior-lateral area of the socket, to allow for exposure of the adjustable part of the control strap. </li> <li> Make up control straps of 1/2 inch da-cron tape and two to three inches of the hose clamps. </li> <li> Put the socket system back on the cast model for determination of the initial volume setting. Insert the dacron straps through the tracks and speedy rivet the hose clamp section so that the hex head of the clamp is exposed in the slots cut in step 12 above (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg">Figure 3. Photograph of laminated outer socket prior to mounting on adjustable leg. A foam block is shown here but this practice has been superceded by use of the Otto Bock 4R42 component which is laminated into the distal end of the outer socket.</a></li> <li> Attach the pylon and foot and align in the conventional way (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg">Figure 4. Variable volume socket mounted on an adjustable leg.</a></li> </ol> <h3>Clinical Experience</h3> To date, seven variable volume below-knee sockets have been fitted on six carefully chosen amputees. Five of these patients were new amputees and the variable volume socket prosthesis was their first prosthesis. One of these five had an extremely edematous limb due to a recent infection, and required two successive variable volume sockets before being fitted with a definitive conventional P.T.B, prosthesis. The remaining patient was a young amputee, three years post-amputation, who was having difficulty maintaining consistency in limb volume. The variable volume socket proved to be very useful in managing this patient. Evaluation was basically simple and subjective. The clinic team discussed and recorded any problems that arose with the socket design and documented that atrophy was accommodated by the variable volume socket. In all cases, maintenance of socket fit was made possible by decreasing socket volume as atrophy of the residue limb took place. At no point was comfort compromised by a reduction of socket volume. In addition to the patients fitted at the University of Virginia; trial fittings were made by Mr. Nitschke in the courses of development at Leimkuehler, Inc. in Cleveland, Ohio, American Orthotic and Prosthetic Laboratory, Inc. of Columbus, Ohio, and Rochester Orthopedic Laboratories, Inc. in Rochester, NY where we were given much help and encouragement. In addition, Karl Fillauer, CPO of Fillauer Orthopedic, Inc. in Knoxville, Tennessee has fit two patients and Robert Gooch, CP and John Michael, CPO of Duke University have fit one patient, all of whom are currently being followed. <h3>Summary And Conclusion</h3> Rationale, design criteria, and fabrication techniques for an adjustable volume below-knee socket have been discussed and described. Successful fittings with the system have been noted. It is felt that this system can meet a need by providing new amputees with a durable, cosmetic, and reasonably long lasting preparatory prosthesis that accommodates the familiar problem of residual limb volume shrinkage. <h3>Acknowledgments</h3> This work was made possible by support from the Veterans Administration Rehabilitation Research and Development Service. We are also grateful for the help and encouragement provided by Messrs. Jon Leimkuehler, CPO, Peter Ockenfels, CPO, Karl Fillauer, CPO, Carlton Fillauer, CPO, Robert Klebba, Robert Gooch, CP, John Michael, CPO, and Dr. Frank Clippinger. References: <ol> <li>Brownsey, ZZ; Fillauer, ZZ: "Temporary Prosthesis with Adjustable Socket," Physical Therapy, 47:12:December, 1967, pp. 1129-1131</li> <li>Fernie, Geoff, R. and Pamela J. Holiday, "Volume Fluctuations in the Residual Limbs of Lower Limb Amputees," Archives of Physical Medicine and Rehabilitation, 63:4:April, 1982, pp. 162-165.</li> <li>Fillauer, Carlton, "A Patella-Tendon-Bearing Socket with a Detachable Media Brim," Orthotics and Prosthetics, 25:4:December 1971, pp. 25</li> <li>Irons, G., V. Mooney, S. Putnam, M. Quigley, "A Lightweight Above Knee Prosthesis With an Adjustable Socket, Orthotics and Prosthetics, 31:1:March 1977, pp. 3-15.</li> <li>Malone, J. et al, "Rehabilitation for Lower Extremity Amputation," Archives of Surgery, 116:1:January 1981, pp. 93-98.</li> <li>Malone, J. et al., "Therapeutic and Economic Impact of a Moderate Amputation Program," Annals of Surgery, 189:6:June 1979, pp. 798-802.</li> <li>Mooney, V., B. McClellan, D. Cummings, P. Smith, "Early Fitting of the Below Knee Amputee," Orthopedics, 8:2:February 1985, pp. 199-202.</li> <li><a href="cpo/1986_03_101.asp">Schuch, C. Michael, and Tony Lucy, "Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets," Clinical Prosthetics and Orthotics, 10:3:Summer 1986, pp. 101-104.</a></li> <li>Orthomedics, Inc., 2950 East Imperial Highway, Brea, California 92621.</li> <li>Otto Bock Orthopedic Industry, Inc., 4130 Highway 55, Minneapolis, Minnesota 55422.</li> <li>United States Manufacturing Company, 180 North San Gabriel Blvd., Pasadena, California 91107.</li> <li>I.P.O.S., U.S.A., 155 Portage Road, Lewiston, New York 14092.</li> </ol> *Robert O. Nitschke, C.P.O. Robert Nitschke is a consultant and lives in Rochester, NY. *C. Michael Schuch, C.P.O. Department of Orthopedics and Rehabilitation at the University of Virginia. *A. Bennett Wilson, Jr. Department of Orthopedics and Rehabilitation at the University of Virginia. <div style="width: 400px;"> </div> Page Number(s) 11 - 19 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg Figure 3 STEP 1 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-03.jpg Figure 4 STEP 2 &3 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-04.jpg Figure 5 STEP 4&5 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-05.jpg Figure 6 STEP 6 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-06.jpg Figure 7 STEP 7 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-07.jpg Figure 8 STEP 8 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-08.jpg Figure 9 STEP 9 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-09.jpg Figure 10 STEP 10,11&12 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-10.jpg Figure 11 FIGURE 3 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg Figure 12 FIGURE 4 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Variable Volume Socket for Below-knee Prostheses Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * C. Michael Schuch, C.P.O. * Robert O. Nitschke, C.P.O. * https://staging.drfop.org/files/original/134d9851f6fd34f10b98fac119946d9b.pdf c9a03496075767605fc06bd5d6ac4780 https://staging.drfop.org/files/original/fea6766a6495664f5260b51cbff436da.jpg 2e5dfdcbd0b96f663f5470b95ebe80a0 https://staging.drfop.org/files/original/b0db79c79f26f20be00e643367cdaa15.jpg 33873f40f357926954a3ccc9907a4e72 https://staging.drfop.org/files/original/3a7f8361eb473cf4b078c9f8d8c050a5.jpg 0ce7d7a42e382acb91b859f476cc606c https://staging.drfop.org/files/original/ca3ca8e14a2047103f815a282222d402.jpg 0606d742b82c86d87ae8e3750f3f4ce5 https://staging.drfop.org/files/original/ba4b3555b1b4d3697712c9583451c279.jpg 4dd8248ec379a7a364390de2dd9e4097 https://staging.drfop.org/files/original/0a4be97418198a9f496239b0614dbc9f.jpg 0ece3b4b41b32030ebfd864956ad1720 https://staging.drfop.org/files/original/b5afeb1c4d62e046282c3d489417b9be.jpg c67123038b2fd3fd5c451d5fa83d1552 https://staging.drfop.org/files/original/819880245c9711ba14636f81f2b4dfbb.jpg 32a971bc21c5714eaf7d010fd9ebf314 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_005.pdf Text Any textual data included in the document <h2>The Stat Limb: A Prosthesis for Immediate Postoperative Fitting of AK and BK Amputations</h2> <h5>Joseph CM. Sheehan, M.D. <a style="text-decoration: none;">*</a> Michael J. Quigley, C.P.O. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> Postoperative care of amputation wounds varies significantly ranging from simple daily dressings to rigid immobilization. These variations make it difficult for the occasional surgeon to judge the virtues of each method from available literature. A basic prefabricated plastic supportive structure is described here to simplify the use of an immediate postoperative prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg">Fig. 1)</a>. <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg">Figure 1. The Stat Limb is a prefabricated high density polyethylene shell that can be applied in less than ten minutes in the operating room.</a> Although immediate post surgical fittings (IPSF) were in common use 20 years ago, they are used only in isolated areas today. The reasons for the decline of IPSF were both educational and logistical. Most amputations today are done by general and vascular surgeons who are not trained in IPSF principles or rehabilitation, and who do not have a working relationship with a prosthetist. Secondly, to use the conventional IPSF technique as taught by Weiss and Burgess, a prosthetist needs to be available at surgery with a number of special socks, attachment plates, tubes, padding materials and the associated tools needed to apply the prosthesis. Scheduling the prosthetist caused logistical problems, so physicians began to simply apply a rigid dressing in surgery and call the prosthetist in a week or so later to apply a shrinker. A preparatory prosthesis is not usually prescribed until three to four weeks post-surgery. <h3>Advantages Of Early Mobilization</h3> The postoperative disease problems of the amputee are typical of any long term illness encountered in medical practice. Thinking solely of the amputated limb is a grave mistake, not only for the mental health of the patient, but also for the surgical wound itself. Early mobilization after surgery is a necessity in preventing bowel, bladder and cardiopulmonary complications. The post-amputated patient is usually a high risk patient. Often, severe diabetes with restricted cardiopulmonary reserve is a common associated medical problem. Small pulmonary emboli cause major cardiac changes, and bladder/bowel stasis of recumbency may lead to recurrent septicemias. Each day of postoperative immobilization adds a significant risk to ultimate survival. First or second day mobilization into the standing position is a necessity to reduce basilar atelectasis, reduce the residual urine volume in the bladder, and allow feces to move into the rectum for evacuation. Even without the psychological and balance effect of a second limb, the process of getting a weak postoperative patient to stand on the unaffected leg alone is next to impossible. However, a rigid locked knee above a "weightless" prosthesis gives the patient more stability than when they had a painful necrotic leg before surgery. It is possible to mobilize a patient within 24 hours post-surgically or to at least have the patient stand and transfer to a commode or wheelchair using a limb, even though they have been bedridden entirely for many weeks preoperatively. Minimal ambulation in therapy from the second day onwards is important. The wound risk involved with minimal weight bearing and the brief stance phase on the amputated leg is outweighed by all the general advantages to the patient for ultimate survival. The Stat Limb was designed to allow even the surgeon doing an occasional amputation to apply an immediate postoperative prosthesis himself following surgery. The Stat Limb comes in one size that fits both right and left legs, eliminating the requirement for inventory. The patient receives all the advantages of a rigid dressing, with the added advantages of early weight bearing. The psychological boost given to a patient who wakes up following surgery with two feet under the covers cannot be easily measured, but is definitely a positive factor. In addition, the medical team working with the patient (physician, nurse, therapist, etc.) automatically become rehabilitation oriented. The patient is no longer laying in bed week after week waiting for his new leg. Early ambulation is safe and is encouraged as early as one day postoperatively. The lack of knee flexion in the prosthesis poses no particular problem to the patient during walking, and the extremely light prosthesis allows the patient to move the leg around easily in the sitting and supine positions. Patients who have worn the Stat Limb make the transfer to a preparatory prosthesis very easily; they already know how to walk and are not afraid to place weight on the residual limb. <h3>Application Procedure</h3> The major advantages of the Stat Limb immediate postoperative fitting are as follows: <ol> <li> a rigid dressing, </li> <li> the knee fixed in hyperextension, </li> <li> rapid application of the prosthesis while the patient is under anesthesia, </li> <li> light weight due to the structural strength at the periphery of the prosthesis, and </li> <li> modification of the limb as rehabilitation continues. </li> </ol> Rigid Dressing The application of a rigid protective dressing is important to the survival of a poorly perfused limb. By surrounding the limb in a soft, heat-insulated environment, free of shearing forces, the limb is maintained at near 37 degrees centigrade, which is optimal for almost all physiological functions of wound healing, tissue resistance, and arteriolar dilation, and gives the surgery its best chance of success. Daily opening of the wound by tearing off adherent, coagulated dressings is not only painful, but rarely indicated unless for observation of unexplained pyrexias or blood loss. The dressing is nothing other than a gauze dressing over the wound site, to allow for any drainage which might occur, followed by multiple layers of cotton, giving a total of about two centimeters of thickness of cotton from groin to the distal end. A thin layer of fiberglass casting material is then applied to provide a rigid outer layer, preventing knee flexion and maintaining the residual limb shape, and protecting the wound (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg">Fig. 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3jpg">Fig. 3</a>). If plaster is used for the rigid dressing, it must be allowed to dry 24 hours before the Stat Limb is applied. At no stage is compression ever applied in the application of the rigid dressing. The speed of limb application is important in the critically ill, and with prior experience of one or two applications, it should be successfully applied in less than eight minutes (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg">Figure 2. A simple dressing creates pressure between the skin and bone and forces the weight of the gastrosolei flap to pull on the wound against the amputated distal tibia.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3.jpg">Figure 3. The rigid dressing maintains the knee in extension.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg">Figure 4. Left, a bulbous residual limb after compression wrap. Right, a cylindrical residual limb after rigid dressing.</a> Stat Limb Application Following the application of the rigid dressing, the Stat Limb is applied. The Stat Limb is designed to fit both left and right legs and can be cut to fit around the rigid dressing in nearly all cases. The desired length of the Stat Limb is approximated by either measuring the sound side, or by laying the Stat Limb next to the patient and marking the section to be cut off. The top edge of the Stat Limb should be trimmed a few inches short of the top of the rigid dressing (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg">Figure 5. The rigid dressing consists of a gauze bandage over the wound, about two centimeters thickness of cast padding, and two layers of fiberglass casting tape to mid-thigh. The Stat Limb should be one centimeter shorter than the sound side, and the knee cast in extension.</a> Six vertical cuts are then made in the Stat Limb to allow it to form around the rigid dressing (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg">Fig. 6</a>). Alignment is approximated while wrapping the Stat Limb onto the rigid dressing. The Stat Limb should be about a half inch shorter than the sound limb to allow toe clearance with an extended knee (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg">Fig. 7</a>). Toe out, foot in-set and out-set, and the anterior-posterior positioning of the foot should be held in a normal position as the casting material sets (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg">Figure 6. A scissors or cast saw is used to cut off excess length and multivalve the Stat Limb. Six longitudinal cuts are recommended. The cuts may have to extend past the end of the rigid dressing if a bulbous end is present.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg">Figure 7. For most applications, the vertical cuts can stop two centimeters from the distal end of the rigid dressing, and the proximal edge of the Stat Limb should be a few centimeters distal to the rigid dressings upper edge. A drain hole can be punctured through the Stat Limb, allowing removal in 24-48 hours.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg">Figure 8. A double layer of fiberglass material is used to fasten the Stat Limb to the rigid dressing. All of the vertical slits should be covered. For heavy duty users, reinforce the ankle area with casting material as well. Normal toe-out and foot positioning should be maintained while the casting material sets.</a> Knee in Extension Keeping the knee in extension, or locking it in about two degrees of hyperextension, makes the knee stable at the tibiofemoral joint. Subsequently, the quadriceps, hamstrings, and gastrocnemius are reflexly relaxed. Pain and associated spasms are reduced. The reduction of spasm of the gastrocnemius reduces the stress placed upon the distal myodesis and, indirectly, on the wound itself. With the knee in extension, the distal residual limb can be molded to prevent posterior migration of the long posterior flap. In extension, limb application is easier and it is easier to judge valgus, varus, rotation, and length of the limb. Application under anesthesia is justifiable because the patient is relaxed and this avoids fighting with a flexed knee joint four days later. Lightweight Due to Exoskeletal Construction Using the mechanical principles of the square area of inertia, the prosthetic material and the intended forces acting through the prosthesis are distributed to the periphery. This allows the use of a minimum amount of material while gaining the maximum strength to the prosthesis. A semi-pliable thermoplastic of high density polyethylene is used to give toughness to the prosthesis, to reduce the chance of any brittle failures, and to allow for cold forming of the prosthesis around the rigid dressing. <h3>Modification As Rehabilitation Continues</h3> As the patient's healing improves and rehabilitation continues, the thigh length rigid dressing is changed for a padded P.T.B, socket, also made of fiberglass cast material and attached to the limb. Depending on the strength of the quadriceps and hamstrings, the suspension is either a supracondylar strap or a simple single axis hinge from a knee orthosis; this usually occurs at the end of the second week. At the end of the seventh week, the residual limb is usually mature enough for a standard P.T.B, prosthesis. In a similar manner, the prefabricated limb can be used with less complexity for an above-knee prosthesis. A non slip sole material should always be worn when a patient is using the Stat Limb, as the plastic foot section is very slippery. A hospital slipper can be used as can elastoplast adhesive tape. On some occasions, buckling of the plastic at the ankle has occurred. This is usually a sign that the patient has become either very active or is wearing the prosthesis for a longer time than for which it was designed. Reinforce the ankle and foot with fiberglass tape during the original application process if it is felt that the patient will be a heavy user. The same Stat Limb module can be used for cast changes. However, it is important to cut off the cast carefully to prevent damage to the Stat Limb. It is not recommended to reuse the Stat Limb on other patients since it is designed for limited use. The earlier a prosthesis is applied, the more successful and pain free is the final fitting. The problems encountered in the use of any system have to be recognized, but it is difficult to scientifically explain why a minimally weighted limb can impede wound healing. If the prosthesis is not applied to the patient for a few days, we note the rate of progress is retarded. This is detrimental to the functional recovery of wound healing and the entire patient. <h3>Case History</h3> Although over 1,000 Stat Limbs have been used to date, one case history will be presented to illustrate the benefits of the Stat Limb in a community hospital setting. Patient A.B. is an 80 year old woman who had a right below-knee amputation, secondary to diabetic gangrene, two years ago. She was fit with a Stat Limb immediately and began weight bearing in physical therapy two days later. A cast change was made 12 days postoperatively when the stitches were removed. The Stat Limb was reapplied and the patient was discharged home with a walker and wheelchair. Two weeks later, a second cast change was made and measurements were also taken for a preparatory prosthesis. The following week, the Stat Limb was removed and the patient was fitted with her prosthesis. She walked six full lengths of the parallel bars without hesitation. One year later, the same patient lost her left leg below the knee and was immediately fit with a Stat Limb. Within two weeks she was home with a walker using a definitive right below-knee prosthesis and her Stat Limb. Without the availability of the Stat Limb in this case, this patient would have been wheelchair bound for weeks, the time needed for physical therapy would be lengthened, and many activities of daily living would have required assistance. <h3>Summary</h3> With the decline in use of immediate postsurgical fitting of prostheses, most amputees do not walk for several weeks post-surgically. The Stat Limb is designed for easy application by even the occasional surgeon and allows weight bearing within days following surgery. The Stat Limb does not provide the answer to every amputation. Each patient is entirely different from another in any series, and many other factors must be taken into account, including the initial pathology, age, cooperation of the patient, availability of nursing and physical therapy care, and other associated problems. The Stat Limb does remove most of the logistical and educational problems that are associated with IPSF, and should allow many new amputees to benefit from early weight bearing and walking. *Michael J. Quigley, C.P.O. Michael J. Quigley, CPO is President of Oakbrook Orthopedic Services, Ltd., 1 South 132 Summit Avenue, Oakbrook Terrace, Illinois 60181. *Joseph CM. Sheehan, M.D. Dr. Joseph CM. Sheehan is Associate Clinical Professor for Orthopedic Surgery and Rehabilitation at Loyola University in Chicago, Illinois. He is also Attending Surgeon at Marianjoy Rehabilitation Center in Wheaton, Illinois. Page Number(s) 5 - 10 Year 1987 Volume 11 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Stat Limb: A Prosthesis for Immediate Postoperative Fitting of AK and BK Amputations Creator An entity primarily responsible for making the resource Joseph CM. Sheehan, M.D. * Michael J. Quigley, C.P.O. * https://staging.drfop.org/files/original/39661617c0a9eba6b610fe42b024ce94.pdf 80938ab1a7c2213a21e860229c9f5c1c https://staging.drfop.org/files/original/d2190975fcf22aaf4d36cd1f1486eadc.jpg 52102233724241493879e8180f7fe559 https://staging.drfop.org/files/original/c229382fb9182331c340914d8f7e4521.jpg 9c97aed7e57f467d273fe1b5df97c576 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_001.pdf Text Any textual data included in the document <h2>Preparatory Prosthetics</h2> <h5>Bruce P. McClellan, C.P.O. <a style="text-decoration: none;">*</a> Donald R. Cummings, CP. <a style="text-decoration: none;">*</a></h5> The use of preparatory prostheses has for some time been a widely accepted methodology for the immediate or early management of the amputated limb. Burgess, et al., first introduced and popularized the immediate postoperative fitting procedure back in the late 60's.<a></a> Since that time, the use of early weight bearing prostheses has become the norm in fitting centers around the country and indeed in other parts of the world. This paper will deal primarily with preparatory prostheses as they relate to the below-knee amputee. The rationale for such devices will be emphasized in a generalized fashion, as opposed to presenting a different array of commercially available systems or components. The word "preparatory" denotes that these prostheses are used to prepare the amputated limb for definitive fitting with a prosthesis. Within this context, the scope of prostheses which may be considered preparatory in nature ranges from immediate postoperative fitting to the laminated socket with pylon and S ACH foot. In between these two ends of the spectrum are such devices as the pneumatic air cast and Wu early fitting prosthesis. All of these devices have the major purpose of either controlling postoperative swelling or promoting the inevitable atrophy of muscles which were transected during surgery. <h3>Short Term Versus Long Term Devices</h3> The differences between prostheses used for immediate or very early fitting and those used for long term are worth noting. We will clarify the terms "temporary" and "intermediate" to distinguish between the two types of devices. The term "temporary" will be used to describe those prostheses which are intended for relatively short usage; they are applied soon after amputation, and usually are applied directly to the patient using plaster or a plaster substitute. "Intermediate" describes those prostheses which are intended for relatively long-term use; they are generally applied following the use of a temporary prosthesis and are fabricated from plastic over a positive model instead of being formed directly over the patient. <h3>Temporary Prostheses</h3> A temporary prosthesis is primarily used to control postoperative edema and is often the initial step in the residual limb maturation process. But the temporary prosthesis has many additional functions, one of which is early mobilization of the patient. This is especially critical to the physiological well-being of elderly patients. The less time the generally debilitated patient is confined to a bed or a wheelchair, the better the chances for overall recovery and successful long-term prosthetic use.<a></a> Indeed, the early mobilization of any patient can shorten the hospital stay and, therefore, save the patient and the insurance company the costs of increased hospitalization. Another benefit of the temporary prosthesis is the psychological lift it can give the new amputee by reducing phantom pain and permitting early ambulation. Temporary fitting may also help offset some of the anxiety the patient experiences after an amputation. <h3>Temporary Design Concepts</h3> A temporary prosthesis is essentially a rigid dressing with a foot and pylon attached (<a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg">Fig. 1</a>). It is a total contact system, encapsulating the amputated limb, including the patella, and extending to the mid-thigh. The knee is maintained in five to ten degrees of flexion. Suspension is by total contact, with some purchase over the adductor tubercle of the femur, and by a waist belt incorporated into the cast. Padding is provided for the distal end and bony prominences. <a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg">Figure 1. Temporary below-knee prosthesis.</a> The standard mid-thigh height of the temporary prosthesis serves some definite purposes. This design assists in sharing weight bearing over a larger surface area, which reduces the load on the amputation site itself. The amputee can also ambulate with less risk of traumatizing the residual limb. Encapsulating the knee also helps prevent knee flexion contractures, which are a very real threat to successful rehabilitation. In spite of the well-documented benefits of early fitting, all too often patients are sent home in an Ace® wrap to languish in a wheelchair for a period of weeks until their "stump toughens up enough" to be fitted with a prosthesis. This is the scenario that results in the elderly patient appearing for prosthetic fitting with hip and knee flexion contractures and an edematous residual limb. Although the knee is fully encapsulated in the traditional temporary prosthesis, knee contractures are rare; partially because the cast is usually changed at weekly or biweekly intervals over the period of use. To enhance knee motion, the patient should be encouraged to flex and extend the knee through its range of motion at the time of each cast change. Intermittent weight bearing in the prosthesis also prevents a knee contracture, much as it does in the case of a long leg weight bearing case used in fracture management. The non-removable nature of the temporary prosthesis has the advantage of continuous control of the tissues. When left to the patient to control via an Ace® wrap or shrinker, the limb is often wrapped intermittently or not at all. Rigid dressings have proven in most cases to be far superior to elastic wrappings in reducing the limb's soft tissue volume, especially in conjunction with controlled weight bearing.<a></a> The inclusion of a waist belt, or billet, is essential in maintaining suspension in this type of system. As the residual limb shrinks, the prosthesis will piston on the limb if not supported by this auxiliary suspension. The pylon system is equally important with respect to the success of the temporary prosthesis. Although the patient walks with a stiff knee, appropriate alignment is essential for single limb stance stability. <h3>Intermediate Prostheses</h3> The primary role of the intermediate prosthesis is to act as a preparatory device to reduce the limb to a definitive fitting status. It is generally fit when the postoperative swelling and distal edema have been reduced to a point where the bulbous end can be introduced into a socket. This prosthesis acts as the interim step between the temporary and definitive, thus the term "intermediate." The intermediate differs significantly from a temporary in that it is removable and allows free flexion of the knee. Residual limb shrinkage is accommodated by prosthetic socks as opposed to cast changes. Aside from the obvious advantages of full range of motion and free access to the residual limb, the intermediate prosthesis allows the patient to learn appropriate sock ply management prior to being fitted with a permanent prosthesis. The length of time a patient wears his intermediate prosthesis varies from person to person. Body type, cause of amputation, level of activity, and other considerations all play a part in how rapidly a residual limb will mature to a definitive fitting status. The duration of use can be anywhere from two months to six months, or longer. A general guideline which may be used to determine whether a limb has "plateaued" with regard to shrinkage is when weight bearing and wearing time have stabilized, and the patient has gone approximately three weeks without adding any additional plys of socks. <h3>Intermediate Design Concepts</h3> The design of the intermediate socket is generally consistent with the standard PTB or TSB configuration (<a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.jpg">Fig. 2</a>). A soft liner may or may not be incorporated in the system. In either case, it is appropriate to fit the socket to the patient with as few ply of socks as possible. A one ply or even a nylon sheath fit is preferable in light of the fact that shrinkage, and thus the need for additional plys, is inevitable. As with the temporary, dynamic alignment plays an important role. This importance is now magnified by the fact that the patient is ambulating in essentially the same manner as he will in his definitive prosthesis. Again, it is recommended that the patient be fit with some sort of waist belt suspension to minimize relative motion between the socket and limb as shrinkage continues. <a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.jpg">Figure 2. Intermediate below-knee prosthesis.</a> <h3>Gait Training</h3> At the time of fitting of the intermediate prosthesis, gait training becomes most significant. This is one of the great advantages of preparatory prostheses: the patient can be monitored and guided by a physical therapist in regard to an appropriate gait pattern while a prosthetist can periodically make alignment modifications as the patient becomes a more proficient ambulator. This advantage is lost, of course, in some of the commercially available systems, which do not allow for fairly precise alignment adjustability. <h3>The Forgotten Limb</h3> One of the least considered aspects of the benefits of preparatory fitting is the contralateral leg. Not only does the preparatory device make it easier for the amputee to maintain his balance, it also allows him to share his weight partially on the prosthesis instead of totally on his remaining limb. In the case of the diabetic or peripheral vascular disease patient, this can be critical, as the remaining leg is usually at risk as well. Any additional trauma, such as prolonged single limb body support or hopping, should be avoided. Preparatory prostheses make this weight sharing possible, and thus prevents overuse or trauma to the remaining leg and foot. It is clear that the role of preparatory prostheses and the management of the new amputee is a necessary and essential component in reaching the fullest rehabilitation potential of the patient.<a></a> The encroachment of non-traditional providers into the prosthetic arena, especially with regard to early fittings, poses a real threat to the realization of these patients' full potentials. It is critical that the prosthetist understand and appreciate the important role of preparatory prostheses in the total regimen of medical and prosthetic care. Success with preparatory fittings depends upon competent management by all members of the rehabilitation team. Temporary and intermediate systems must be applied and managed competently by the prosthetist. Weight bearing, gait training, and residual limb atrophy must be monitored carefully. The term "preparatory" implies that such systems are designed to achieve specific desirable objectives. In this case, the objectives are the maturation of the residual limb and optimum patient readiness for definitive fitting. Comprehensive patient management with preparatory systems produces many advantages, including the provision of maximum early function, improved evaluation of the patient's long-term needs, and reduction of rehabilitation time and expense.<a></a> References: <ol> <li>Burgess, E.M., M.D., "Amputation Surgery and Post-Operative Care," In Bonjeree, Sikhar Nath (ed)., Rehabilitation Management of Amputees, Baltimore/London; Williams & Wilkins, 1982.</li> <li>Burgess, E.M., "Post-Operative Management," Atlas of Limb Prosthetics, St. Louis, The C.V. Mosby Company, 1981.</li> <li>Burgess, E.M. and Zettl, J.H., The Management of Lower Extremity Amputations, Washington, D.C., U.S. Government Printing Office, 1969.</li> <li>Friedmann, Lawrence W., The Surgical Rehabilitation of the Amputee, Springfield, Charles C. Thomas, 1978.</li> <li>Mooney, Vert, M.D., McClellan, Bruce, C.P.O., Cummings, Donald, B.S., and Smith, Patty, R.P.T., "Early Fitting of the Below Knee Amputee," Orthopedics, 8:2, February, 1985, pp. 199-202.</li> </ol> *Donald R. Cummings, CP. Donald R. Cummings, CP., is Chief Prosthetist at Prosthetic-Orthotic Associates of North Texas, Inc. in Lewisville, Texas. *Bruce P. McClellan, C.P.O. Bruce P. McClellan, C.P.O., is Director of Orthotics and Prosthetics at the Dallas Rehabilitation Institute in Dallas, Texas. Page Number(s) 1 - 4 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_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 Preparatory Prosthetics Creator An entity primarily responsible for making the resource Bruce P. McClellan, C.P.O. * Donald R. Cummings, CP. *