12 20 371 https://staging.drfop.org/files/original/bfcefefb32a201912fdc868f0f0cc04e.pdf 0148ecdd9b99d82897c6b1c95fb4d6cd Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_03_001.pdf Text Any textual data included in the document <h2>To Check Out Or Not To? That Is The Question</h2> <h5>Kurt Marschall, CP&nbsp;</h5> <p>It is now over twenty-five years since the introduction of intensive short-term courses in prosthetics and orthotics at New York University, Northwestern, and the University of California at Los Angeles. These condensed courses have benefitted every practitioner, not only in his practical approach to patient management, but also in his inter-relationship with his peers through a unified and common language that we call "nomenclature." In countless cases, these formal educational courses have served as a springboard to successful completion of the certification examination.</p> <p>It was the Veterans Administration which at that time took the primary responsibility of disseminating and funding prosthetic research programs. Their Clinic Team approach became very popular, leading to the simultaneous education of physicians, therapists and prosthetists/orthotists. Undoubtedly, this close relationship of the three disciplines, working together for one common goal, namely, the rehabilitation of the disabled, has narrowed a gap that formerly was all too visible. I feel it has also helped to lift the field of prosthetics and orthotics out of the dark age, out of its sole "craftsmanship concept" into the more comprehensive classification of "professionalism"—all in all, an appropriate tribute that was long overdue.</p> <p>Every prosthetist/orthotist, having successfully completed these short-term courses, came out a better person, a better clinician. The physician and therapist, by the same token, gained insight into our field as never before. Now all three disciplines in their deliberations at clinic meetings spoke at the same level through a unified language, and intelligent solutions were arrived at by understanding the underlying problems.</p> <p>A by-product of this progressive and noteworthy approach was the respect the prosthetic/orthotic practitioner gained from the medical and paramedical professions, once his continued striving for excellence in performance and elevation of standards was realized by them. This respect, however, was not attained very easily. In our quest for sharing the knowledge and insight into our field with the physician and therapist, we also committed a monumental mistake—making them experts in the fitting, alignment and fabrication of every prosthetic/orthotic device there is. Without realizing it at the time, we gave into their hands a powerful tool, even further, a most powerful weapon —<em>the check-out sheet!!!</em></p> <p>There, in black and white, we developed a questionnaire telling them exactly how to pick a device apart, piece by piece, making them the sole, omnipotent judge of whether to pass or fail it. By setting up this systematic method of examining our devices we have admitted that one cannot trust our professional judgment or technical expertise. I know of no other group in the health care profession that has so mindlessly relinquished its professional prerogatives and intricate understanding of a subject to another discipline, with certainly less knowledge of the particular subject, for its scrutiny. Even today, after 25 years of continuous upgrading, we sheepishly subject ourselves to this procedure. This permits even a therapist fresh out of school, but equipped with a check-out sheet, to suddenly become powerful and to be feared for his or her "judgment" when check-out day rolls around. Countless man-hours and precious components and materials have been wasted when physician and therapist could not see eye-to-eye with the prosthetist/orthotist on alignment, fitting and finishing procedures. A device often had to be altered, sometimes even done over entirely, for rather trivial reasons, not to mention the immense damage inflicted on the patient-prosthetist/orthotist relationship when these so-called "problems" were hashed out in the open, for everyone to hear, rather than in a more private setting.</p> <p>There is no doubt in my mind that the level of education and the competence of every prosthetist/orthotist has risen tremendously in the last two and one-half decades, especially for one who takes advantage of the continued education process. He is a better person than he was 25 years ago, and his knowledge of the subject, "Prosthetics and Orthotics," is vastly greater than that of a physician or therapist. He is a professional who will, without complaint, work his way around a poorly-amputated limb that may not be to his liking for fitting purposes and come up with a functional prosthetic device without asking the surgeon for a revision. He will produce an adequate prosthetic device despite flexion contractures and edema, due to insufficient exercise and lack of proper stump-wrapping.</p> <p>Nobody denies the need for a check-out after a prosthetic/orthotic device has been completed. But yesterday's check-out sheet should be scrapped in its entirety —the sooner the better—and replaced with one consisting of only three questions:</p> <ol> <li>Is the prosthesis/orthosis as prescribed?</li> <li>Is the patient comfortable?</li> <li>Is the prosthesis/orthosis functional?</li> </ol> <p>The above criteria should more than satisfy any physician or therapist.</p> <p>The decision as to pleasing cosmetic appearance, insofar as possible, should be left to the patient.</p> <p>The decision on whether or not accepted standards and principles have been met in the fitting, alignment and fabrication of the device, should be entirely that of the prosthetist/orthotist.</p> <p>The field of prosthetics and orthotics has come of age; so have its practitioners. The check-out sheet has not kept pace with changing times and should be abolished in its present form.</p> Page Number(s) 1 - 2 Year 1979 Volume 3 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource To Check Out Or Not To? 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_030.pdf Text Any textual data included in the document <h2>Two-Stage Cast-taking Procedure for PTS Prosthesis</h2> <h5>Kurt Marschall, CP&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Proper cast-taking and accurate measurements of a patient's remaining extremity, combined with careful evaluation and modification of the positive mold, are the most important steps in the fabrication and fitting of any prosthetic-orthotic device. Success or failure in prosthetic-orthotic fitting is directly related to the cast taken and the modifications incorporated in the positive mold.</p> <p>It is my firm belief that the person taking the cast should also be the one to modify it. Ideally, the modification of any master mold should be accomplished as soon after cast-taking as possible. The reasons are obvious. It makes it possible to recall the characteristics of the patient's extremity and to pay special attention to particular landmarks and problem spots that have been identified. Long delays will only serve to wipe out the memory of these characteristics. Granted, the caseload in some facilities does not permit this ideal situation of an immediate cast-modification procedure. Therefore, it should be the aim that the cast-taker produce a cast that can be easily understood and interpreted by the person modifying it. In the case of the PTS cast, landmarks should be well identified, circumference and length measurements should be accurate and special consideration or conditions should be carefully recorded. These are preconditions for proper cast modification and subsequent fabrication of a superior fitting socket, and form the foundation of any successful below knee fitting procedure.</p> <p>It is now well over twenty years since I first introduced, together with my colleague and partner, Robert Nitschke, CP, the American concept of the PTS prosthesis in Palm Springs, California. It now enjoys a widespread acceptance in the field of prosthetics and has become an integral part of the prosthetic armamentarium.</p> <p>Since then, deviations from the original PTS concept, dictated by physiological reasons, geographic location or climactic conditions have been introduced. The Fillauer removable medial wedge,<a></a> as well as the removable medial brim version,<a></a> are such a case in point. The supracondylar fitting with the anterior portion of the socket cut distal to the midpatella level, which thus sacrifices intimate contact with the quadriceps, should also be mentioned.</p> <p>All of these different techniques have their place. They work well, if, as a prerequisite to socket fabrication, a cast of superior quality and accurate cast modification can be supplied.</p> <p>Twenty years ago, we advocated a one step cast-taking technique, necessitating the use of a cast cutter in the posterior portion of the medial and lateral hamstrings for cast removal. The noise of the cast cutter, accompanied by some heat development when the blade oscillates through the cast, proved to be quite troublesome and sometimes frightening, especially to children and geriatrics. For these reasons we have employed for many years now a two-stage casting procedure in our facilities that produces a cast of superior quality with built-in characteristics that are easily identifiable in our positive molds prior to modification.</p> <h3>MEASURING AND CASTING PROCEDURE</h3> <ol> <li> <p>Materials and tools necessary for cast-taking procedure (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg"><b>Fig. 1</b></a>):<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg"><strong>Figure 1. Materials and tools necessary for PTS prosthesis cast-taking procedure.</strong></a></p> <blockquote> <p>2 light cast socks<br />1" elastic belt and 2 holding clamps<br />PTS caliper<br />A-P tension clamp<br />Bandage scissor<br />Goniometer<br />Modified Ritz stick<br />Orthoflex plaster bandage, 4"<br />Regular plaster of Paris bandages, 4", extra fast setting<br />Revere rubber bands, size 33 or equivalent<br />Otto Bock separation gel (Gipsisoliercreme) or vaseline</p> </blockquote> </li> <li> <p>After positioning patient properly and comfortably on table, examine and palpate extremity carefully. Record findings on measurement sheet. Apply two light cast socks over patient's extremity and identify with indelible pencil all pertinent landmarks and bony protuberances (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg"><strong>Fig. 2</strong></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg"><strong>Figure 2. Identify all landmarks and bony protuberances.</strong></a></p> <ol> <li> <p>Record circumference at three levels: mid-patellar tendon, mid-portion and around distal end of extremity.</p> </li> <li> <p>Record length of amputated extremity with modified Ritz stick (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg"><b>Fig. 3</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg"><strong>Figure 3. Record length of extremity with modified Rita stick.</strong></a></p> </li> <li> <p>Record M-L dimension with PTS caliper at widest margin of knee (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg"><strong>Figure 4. M-L dimension at the widest margin</strong></a></li> <li> <p>Record M-L dimension above the medial and lateral femoral condyles (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg"><b>Fig. 5</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg"><strong>Figure 5. M-L dimension above medial and lateral femoral condyles.</strong></a></p> </li> <li> <p>Record A-P dimension with knee relaxed and slightly flexed. The amount of flexion depends on the length of the remaining extremity. Seven-10 degrees is usually sufficient for medium sized amputations. Shorter ones may require more flextion (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg"><b>Fig. 6</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg"><strong>Figure 6. A-P dimension with knee relaxed and slightly flexed.</strong></a></p> </li> </ol> </li> <li> <p>Wrap the amputated extremity with Ortho-flex bandage starting at distal end and terminating at the mid-patella level. Reinforce with regular, extra fast setting plaster of Paris bandage, and identify with thuimbs the patellar-tendon bridge (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-07.jpg"><b>Fig. 7</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-08.jpg"><b>Fig. 8</b></a>).</p> </li> <li> <p>With plaster of Paris cast still soft and moldable, apply A-P tension clamp (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg"><b>Fig. 9</b></a>). This makes it possible to shape the cast with both hands while it hardens, thus keeping later cast modifications to a minimum (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-10.jpg"><b>Fig. 10</b></a>). Please note clamp and hand-induced characteristics of hardened first stage of mold (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-11.jpg"><b>Fig. 11</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg"><strong>Figure 9. Apply A-P tension clamp.</strong></a></p> </li> <li> <p>Use Otto Bock separating gel or vaseline and apply a thin layer to the proximal 1 1/2" of the superior portion of the cast (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-12.jpg"><b>Fig. 12</b></a>). Measure out six layers of 4" regular, extra fast setting plaster of Paris bandage or splints, sufficient in length to reach slightly past medial and lateral hamstrings (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-13.jpg"><b>Fig. 13</b></a>). Apply to patient's extremity, overlapping first stage cast by at least one inch and extending over the patella and covering quadriceps tendon by one inch. Use six inch wide splints if necessary. Apply two thin rubber bands to superior edge of wings (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg"><b>Fig. 14</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg"><strong>Figure 14. Apply two rubberbands to superior edge of wings.&nbsp;</strong></a></li> <li> <p>Place thumbs in the indentations of the mid-patellar tendon bridge and use the index and middle fingers of both hands to apply sufficient pressure to reach the depth of the recorded narrow M-L dimension just superior to the femoral condyles. The fingers should always straddle the ilio-tibial band on the lateral side (<b>Fig. 15</b>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-15.jpg"><strong>Figure 15. Apply sufficient pressure to reach the depth of the recorded narrow M-L dimension.&nbsp;</strong></a></li> <li> <p>After the second stage of the cast has set enough to hold finger impressions in place, remove the rubber bands and mark juncture between first and second stage with indelible pencil (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg"><b>Fig. 16</b></a>). Remove second stage by carefully lossening and lifting medial and lateral wings free (<b>Fig. 17</b>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg"><strong>Figure 16. Mark juncture between first and second stage.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-17.jpg"><strong>Figure 17. Carefully loosen and lift medial and lateral wings free</strong></a></p> </li> <li> <p>Reflect the top cast sock distally. Let patient's musculature relax completely. While pulling the bottom cast sock proximal, slowly remove first stage (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg"><b>Fig. 18</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg"><strong>Figure 18. Slowly remove first stage while pulling the bottom cast sock proximal.</strong></a><br /> <p>Cut off excess cast sock adhering to first stage (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg"><b>Fig. 19</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg"><strong>Figure 19. Cut off excess cast sock adhering to first stage.</strong></a></li> <li> <p>Join both stages together again by matching the separation marks exactly (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg"><b>Fig. 20</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg"><strong>Figure 20. Join both stages together, matching the separate marks exactly.</strong></a><br /> <p>While holding both stages securely together with the left hand, place plaster of Paris bandage about the juncture and wrap all the way to the top of cast.</p> </li> <li> <p>The negative wrap should display all landmarks clearly (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg"><b>Fig. 21</b></a>). Check for correct flexion angle. Negative cast can now be filled.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg"><strong>Figure 21. The negative wrap should display all landmarks clearly</strong></a></li> </ol> <p>During the cast-taking procedure, I make it a point to involve the patient by explaining each and every step. I use proper nomenclature and anatomical description of the remaining extremity. We should remember that each patient has gone through a very traumatic, cosmetically and functionally destructive surgical procedure. His or her spirits need to be lifted and encouraged. Most patients appreciate an intimate involvement in their prosthetic rehabilitation. Some of them even retain the knowledge gained during their cast and fitting procedures and answer subsequent questions on a sophisticated level. Treatment of your patient as a human being, rather than as a number among many makes being in this profession such an outstanding experience.</p> <h3>Conclusion</h3> <p>The importance of a good cast-taking technique has been stressed. Ideally, the positive mold should be modified by the cast-taker. In the absence of such a luxury, the cast modifier, with the aid of the measurements and the recording of special considerations, should be able to readily understand the characteristics that have been built into the cast. Proper cast modification will contribute immeasurably to good socket fit and superior function and performance by the amputee.</p> <p>Where the above guidelines have not been followed, an inferior socket fit will result. In such a case, the cast-taking procedure should be repeated and a new socket should be fabricated. Successfully fitting 10 to 20 patients in a row does not make any of us an infallible super-prosthetist. Every once in a while we all have to admit defeat due to oversight of basic principles or failure to adhere to prescribed guidelines and procedures. These infrequent failures will keep us on our toes and make us humble again. But, admitting defeat or failure and correcting it without a moment's hesitation, will make you, in the eyes of your peers, in the eyes of your physician, but foremost, in the eyes of your patient, the better practitioner.</p> <p><b>References:</b></p> <ol> <li>Marschael, K. and Nitschke, R., "Principles of the Patellar Tendon Supracondylar Prostheses," <i>Orthopedic Appliance Journal</i>, Vol. 21, No. 1, March, 1967, pp. 33-38.</li> <li>Fillauer, C., "Supracondylar Wedge Suspension of the PTB Prostheses," <i>Orthotics and Prosthetics</i>, Vol. 22, No. 2, June, 1968, pp. 39-44.</li> <li>Fillauer, C., "A Patellar-Tendon-Bearing Socket with a Detachable Medial Brim," <i>Orthotics and Prosthetics</i>, Vol. 25, No. 4, December, 1971, pp. 26-34.</li> </ol> <div style="width: 400px;"><em><b>*Kurt Marschall, CP </b> Kurt Marschall, CPO is President of Empire Orthopedic Laboratories, a division of Rochester Orthopedic Laboratories, Inc., 249 East Adams Street, Syracuse, New York 13202.</em><br /><br /><br /></div> Page Number(s) 30 - 34 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg Figure 19 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg Figure 20 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg Figure 21 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Two-Stage Cast-taking Procedure for PTS Prosthesis Creator An entity primarily responsible for making the resource Kurt Marschall, CP * https://staging.drfop.org/files/original/8bb8e9e8755bb707d94843a7f67c3c83.pdf 2d1e1c9eb5739153c629b229aba1573c https://staging.drfop.org/files/original/0aa3c65a77880b3f215c6a379f41ebdf.jpeg 4e53ce2cb0da74c0306d918dbcbf3600 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_03_003.pdf Text Any textual data included in the document <h2>Comment</h2> <h5>Lawrence W. Friedman, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><b></b><strong><a href="/files/original/0aa3c65a77880b3f215c6a379f41ebdf.jpeg">Photo</a>: Lawrence W. Friedmann, M.D.</strong></p> <p>Dear Sir:</p> <p>I have just been reading <a href="https://staging.drfop.org/items/show/179433">Volume II, Number 4, 1978</a> of the NEWSLETTER. While I have a lot to say on immediate postsurgical fittings, whose major problem I fear is the inaccurate name since very few people really fit a prosthesis immediately post-surgically, I think that the part of the NEWSLETTER that deserves the most comment is the reprint of the article "<a href="https://staging.drfop.org/items/show/179433">Prostheses, Pain and Sequelae of Amputation as Seen by the Amputee</a>" from Prosthetics and Orthotics International.</p> <p>There appears to me to be little doubt that the complaints of the amputees are accurate. There is not only poor fitting and poor fabrication, but a tremendous absence of knowledge on what is correct on the part of the medical profession, the amputees, and, unfortunately, sometimes even the prosthetists. We must recognize the fact that many doctors "prescribe" an artificial limb with instructions to the prosthetist to "give the patient a prosthesis" or, if they want to be very accurate, "give the patient an above-knee prosthesis". This leaves the entire prescription, fabrication and sometimes training of the amputee on the prosthesis to the prosthetist, who does the best he can, but is not adequately trained to take over the entire responsibility for the care of the patient. It is the exact equivalent of a doctor "prescribing" a medication for a patient and saying "give heart medicine".</p> <p>Most of the doctors doing amputation have little or no interest in the aftercare of the amputee once the wound is healed. For that reason, the amputee is required to be responsible for his own care and must seek out amputee clinics in which adequate prescription, checkout and training can be given to assure that adequate prosthetic fabrication has been achieved. The average general or vascular surgeon cannot be assumed to have been able to keep up with the latest in prosthetic components, fitting and training. While research is important, we are not, at the present, delivering the standard of care which we could have delivered twenty-five years ago had every amputee the access to an amputee clinic team.</p> <p>It is obvious that the amputees questioned are suggesting checkout procedures, such as x-rays, to measure the accuracy of prosthetic fit which have been available to us and have been used for decades. Unfortunately, it is the "consumer" who determines what is produced in the market place. In my view, the amputees must band together and insist on getting adequate service. When they do so, the competitive market place will give them what they need.</p> <p>In some areas, there is a problem because there are very few prosthetists and the amputee is, to some extent, at the mercy at that individual. With modern transportation however, any dissatisfied amputee should be able to get to a knowledgeable amputee team for adequate care. I know that there are many problems. In a neighboring state I know that the orthopedic surgeons have inhibited any competitor from coming into the state to challenge what everyone admits is an inadequate prosthetist-orthotist because they like that individual as a person, even though they know that the devices produced are grossly inadequate. While this is beneficial to the individual prosthetist-orthotist, it is to the detriment of his patients.</p> <p>Part of the problem is that each amputee is concerned with his own welfare, and when his needs are satisfied to a tolerable level, he tends not to band together with his fellows for their common good. This decreases their effectiveness in demanding optimal care. Rehabilitation is a process in which a patient is made responsible for his own well-being. In this regard, we may have made amputees feel so independent that they have lost sight of the power of communal action.</p> <p>Perhaps the NEWSLETTER format should be duplicated for the amputees as well as for those of us serving the amputees, so that the amputee himself could know what is going on and what devices and techniques are available to him should he need them. Certainly a list of the formal clinics and services would be of help.</p> <p>While there is much discussion of the advantages and disadvantages of different socket designs and other prosthetic components, it appears to me that these are, to some extent, academic discussions, since even the plug fit socket can be made comfortable for the majority of above-knee amputees, provided it is properly fabricated for the individual. What is needed is to improve the state of prosthetic delivery, even more than the state of the prosthetic art. The situation in prosthetics is the same as the situaiton in general medicine, in which in many places in this country what has been known in the medical literature is not getting to the individual patient.</p> <p>As far as upper extremity amputees go, the professor is much more satisfied with the appearance of the cosmetic hand cover than are the amputees themselves. I believe that I have the opportunity in this region to see." some of the most cosmetic hand covers available. They are, despite all our efforts, still inadequate and rejected by the great majority of amputees. As far as myo-electric hands are concerned, all of my patients want them. Most of them use them for a period of a few months and then discard them, except for rare use as a cosmetic hand, since they are so poorly functional as well as delicate. I believe it is important to prescribe one, if the patient demands a myo-electric hand, because he will never be satisfied of its mediocre function, until he has the opportunity to try it. I think the professor needs to be aware of many of its limitations. We, perhaps, get carried away too often by our favoritism for our own development.</p> <p>I believe further discussion on this point would be of help to the amputee community and also to the medical community in its broader sense, to give us a proper perspective of where our problems are.</p> <p>Best wishes for a happy and productive year.</p> <p style="margin-left: 50%;"><i>Lawrence W. Friedmann, M.D.</i></p> <br /> <div style="width: 400px;"></div> <em><b>Lawrence W. Friedman, M.D.<br /></b>Chairman of the Department of Rehabilitation Medicine at the Nassau County , Medical Center in East Meadow, New York.<br /></em><b><br /></b> Page Number(s) 3 - 4 Year 1979 Volume 3 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete. Figure 1 http://www.oandplibrary.org/cpo/images/1979_03_003/1979_03_003-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Comment Creator An entity primarily responsible for making the resource Lawrence W. Friedman, M.D. * https://staging.drfop.org/files/original/a266195253e839079dde8975e42d8087.pdf c594dc2a840e8199425e981f66117aec https://staging.drfop.org/files/original/7f05ccb8586557cc7b0183cdafe725aa.jpg 63616a4cd1eb71d495e9a1972785cec8 https://staging.drfop.org/files/original/34baa4d0c9f50173d122a1fc9f03237c.jpg 17ba15b4ce63bb3be5f4808d51a3ea39 https://staging.drfop.org/files/original/1c09d56923228c1e807060fe9577bb4b.jpg c44f04d953c3e6e8897a4cd1e4634223 https://staging.drfop.org/files/original/2cc047309ed120bc63aa3b83a308d3fb.jpg 725142c35120be7cfc9eeda3881c00aa https://staging.drfop.org/files/original/616d272e127cadd9ddfd4dfa00a6ada9.jpg aecf21517233b63d0e773199af09d87e https://staging.drfop.org/files/original/d91b0ee4dc2e5f1b5d29d240c9cc5019.jpg e4c5b9f5516409a4f2feb3f7440c342e https://staging.drfop.org/files/original/ab13b0cc1721ab18b7969a2d89777bff.jpg 6dda6cc8254a02d70975f70817cf72de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_025.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 25 - 29 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Artificial Arm Checkout Procedures</h2> <h5>Lester Carlye, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>The story of civilization's slow but steady march of progress from the days of the Roman Empire, through the Industrial Age, and into the present Technological Age is the story of measurements. The standardization of such common units as the inch and the foot required thousands of years, but once that was accomplished, it paved the way for an almost unbelievably rapid technological advance. One need only compare the developments that have occurred since the metric system was devised in 1793 with those of all the preceding centuries. Replacement of the craftsman's personal art with clearly understood, standard methods has enhanced the lives of all of us my making simple necessities, as well as more luxurious items, available in more adequate quantities and at more reasonable prices.</p> <p>Just as mankind in general profited from measurement standardization, so can those who have lost a limb or limbs and those who devote themselves to replacing lost members. Every person concerned with the manufacture and fitting of a prosthesis-whether he be a prothetist, amputee, trainer, or representative of the paying agency-has felt the need for some set of standards to determine the worth of the prosthesis. Development of such a "yardstick of performance" was just as necessary to the advancement of the prosthetics industry as was the standardization of the inch to the Industrial Age. The so-called "checkout procedures" provide the prosthetist and other members of the clinic team with an invaluable tool for measuring the biomechanical effectiveness of all upper-extremity prostheses. Such questions as "Does this prosthesis fit as well as your last one?" or "Can you work it?" receive only a vague, often uncertain, answer, but such criteria are too often accepted as a measure of performance. One of the first steps in establishing a set of standards is to determine which variable factors can be measured accurately. In upper-extremity prosthetics, some of the measurable factors are ranges of motion with and without the prosthesis, control-system efficiencies, forces necessary to flex the forearm, live-lift of the forearm, socket stability, movement of the terminal device when locking the elbow, plus several others. Once the factors are determined, a test program must be set up and carried out. The results of such a test must first be analyzed, then a trial set of standards must be established, and finally the standards must be laboratory-tested on as great a number of amputee subjects as possible.</p> <p>To this end, a test station was established, and 29 amputees, selected at random from a mailing list, were tested. Approximately 30 tests were applied to these amputees and their prostheses. By combining the test data with research and practical experience, a preliminary set of liberal standards was drawn up. The standards were then applied to more than 70 amputees during the two-year existence of the Case Study Program at the University of California at Los Angeles. Certain modifications and refinements in the tests were made until the procedure attained present form.</p> <p>One of the prime requirements in establishing the tests was that their application be kept simple, with respect both to the equipment and to the procedures to be followed. Sufficient accuracy of measurement can be obtained with a ruler and a spring scale, and the test standards are liberal enough to allow minor inaccuracies without rejecting the prosthesis. The most important concern is, first, that all tests be applied in a similar manner and, second, that the results be compared to a universally acceptable standard.</p> <p>The tests and standards may be conveniently listed in three groups: general tests, applicable to all types of prostheses; tests for below-elbow prostheses; and tests for above-elbow prostheses.<a style="text-decoration:none;">*</a></p> <p>All tests should be performed with the amputee wearing his prosthesis. In the case of a bilateral amputee, each side should be tested separately, but the amputee should have almost complete independence of action on each side while wearing both prostheses.</p> <h3>General Tests</h3> <h4>Test No.1-Compression Fit and Comfort</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Push the prosthesis onto the stump while the wearer resists the push (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Test for compression fit and comfort. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should feel no undue discomfort or pain when the prosthesis is forced onto the stump.</p> <h4>Test No. 2-Tension Stability</h4> <p><i>Test</i>: Straighten the prosthesis at the side (<b>Fig. 2</b>). Hook the scale over the terminal device and apply a force of 50 lb. straight down. (A force of 30 lb. is sufficient for children.) Standard: The prosthesis should not slip more than 1 in. in relation to the stump, and no part of the prosthesis or harness should fail when a 50-lb. distal load is applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Test for tension stability. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 3-Hook-Opening Facility (Normal Use)</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Have the wearer actively operate the terminal device.</p> <p><i>Standard</i>: The wearer should be able to obtain full range of terminal-device operation actively with the forearm flexed to 90 deg.</p> <h4>Test No.4-Hook-Opening Facility (At Mouth And Perineum)</h4> <p><i>Test</i>: Flex the forearm so the terminal device is near the mouth (lock if AE). Have the wearer actively operate the terminal device. Repeat this procedure with the terminal device near the perineum.</p> <p><i>Standard</i>: The wearer should be able to obtain at least 70 percent of full range of terminal-device operation actively at the mouth and perineum.</p> <h4>Test No. 5-Control-System Efficiency</h4> <p><i>Test</i>: a) Disconnect the control cable from the terminal device, and attach the scale to hook-operating lever or hand-operating cable (<b>Fig. 3</b>a). Place a 3/4-in. block between the fingers and pull until the block slips out of a voluntary-opening hook or until the fingers of a voluntary-closing hook or hand just close on the block. Note the force at this instant.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Test for control-system efficiency. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>b) Reconnect the control cable to the terminal device, and apply the scale to the T-bar. or terminal, at the other end of the control cable. Pull along the line of the harness unti. the block slips or the fingers touch, as before (<b>Fig. 3</b>b). Note the force at the instant this occurs.</p> <p>c) Multiply the force measured at the terminal device by 100. Then divide by the fora measured at the cable terminal as in the following formula:</p> <blockquote><p>Efficiency = (Force measured at terminal devices X 100)/(Force measured at cable terminal)</p> </blockquote> <p><i>Standard</i>: The control-system efficiency should be at least 70 percent.</p> <h3>Below-Elbow and Below-Elbow Biceps-Cineplasty Tests</h3> <p>All of the following tests apply to the conventional below-elbow prosthesis and to the below-elbow biceps-cineplasty prosthesis.</p> <h4>Test No. 1-Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm flexion with and without the prosthesis.</p> <p><i>Standard</i>: Active flexion with the prosthesis on should be as great as active flexion without the prosthesis.</p> <h4>Test No. 2-Forearm Rotation<a style="text-decoration:none;">*</a></h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm rotation (extreme pronation the extreme supination) with and without the prosthesis (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Test for forearm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: Active rotation with the pros-thesis on should be at least half that obtained without the prosthesis.</p> <h3>Above-Elbow and Shoulder-Disarticulation Tests</h3> <p>All of the following tests apply to the above-elbow prosthesis, and most of them apply to the shoulder-disarticulation prosthesis. Those which do not apply to the shoulder-disarticulation case are marked with an asterisk.</p> <h4>Test No. 1-Ranges Of Stump Motion*</h4> <p><i>Test</i>: Have the amputee straighten the prosthesis and lock the elbow. Then move his stump and prosthesis through the maximum ranges of flexion, extension, elevation, and rotation.</p> <p><i>Standard</i>: The amputee should be able to satisfy the following minimum requirements while wearing the prosthesis: flexion, 90 deg.; extension, 30 deg.; elevation, 90 deg.; rotation, 45 deg.</p> <h4>Test No. 2-Range of Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum active range of prosthetic forearm flexion with the maximum manual range. Note the amount of initial forearm flexion built into the prosthesis.</p> <p><i>Standard</i>: The amputee should be able to flex actively to 135 deg. of forearm flexion, no more than 10 deg. of which should be due to initial flexion.</p> <h4>Test No. 3-Humeral Flexion Required to Flex Forearm*</h4> <p><i>Test</i>: Have the amputee flex the prosthetic forearm actively through its entire range using humeral flexion, and note the degrees of flexion of the humerus required to do so.</p> <p><i>Standard</i>: Humeral flexion required to flex the prosthetic forearm fully should not exceed 45 deg.</p> <h4>Test No. 4-Force Required to Flex Forearm</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Insert the spring scale through the cable attachment, and flex the forearm to 90 deg. while holding the socket stationary. Pull along the normal line of the cable until further flexion of the forearm just starts, and note the force.</p> <p><i>Standard</i>: The force required to start flexion of the forearm from 90 deg. should not exceed 10 lb.</p> <h4>Test No. 5-Live-Lift</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Hook the spring scale over the prosthesis at a distance of 12 in. from the elbow pivot using a leather strap if necessary (<b>Fig. 5</b>). Flex the forearm to 90 deg., and have the amputee actively resist while applying a straight-down pull on the scale. Note the scale reading when the amputee can no longer completely resist the pull and the forearm slips below 90 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Test for live-lift. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should be able to resist actively a downward force of at least 3 lb. located 12 in. from the elbow center when the forearm is flexed to 90 deg.</p> <h4>Test No. 6-Involuntary Operation of the Elbow Lock*</h4> <p><i>Test</i>: Face the amputee and have him abduct the prosthesis 60 deg. Note whether or not the elbow lock operates. Then have him walk a short distance swinging the prosthesis in a normal manner, and note whether the elbow lock operates involuntarily or not.</p> <p><i>Standard</i>: The elbow lock should not operate involuntarily when the prosthesis is abducted 60 deg. nor during normal walking. In addition, a natural-appearing arm swing should be exhibited while walking.</p> <h4>Test No. 7-Movement of Terminal Device When Locking Elbow*</h4> <p><i>Test</i>: Have the amputee actively flex the forearm to 90 deg. Then have him actively lock the elbow. Note the movement of the terminal device as the elbow is locked.</p> <p><i>Standard</i>: The terminal device should not move more than 6 in. during active operation of the elbow lock when the forearm is flexed to 90 deg. (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Test for motion of terminal device when locking elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 8-Socket Stability During Arm Rotation*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Have the amputee abduct the prosthesis 60 deg. and rotate his stump and prosthesis. Note any slippage of the socket about the stump.</p> <p><i>Standard</i>: The amputee should be able to control the prosthesis during arm rotation, and there should be no slippage of the socket about the stump (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Test for socket stability during arm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 9-Stability of Socket Against Torque*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Hook the scale over the prosthesis at a distance of 12 in. from the elbow center, using a leather strap if necessary. Have the amputee resist while pull is applied, first laterally, then medially, on the socket with a force of 2 lb. Note any slippage of the socket about the stump, or of the turntable, which may occur.</p> <p><i>Standard</i>: The amputee should be able to resist both lateral and medial pulls of 2 lb. located 12 in. from the elbow center, and the turntable should not turn with this force.</p> <h3>Conclusion</h3> <p>That the test procedure has reached a sufficient degree of refinement to be used successfully in the field is evidenced by its widespread adoption. Such agencies as the United States Veterans Administration, the State Departments of Vocational Rehabilitation of California and Illinois, and others include fulfillment of the standards as a contract stipulation. It must, however, be borne in mind that these test procedures are not to be considered as the final answer. Additions, revisions, and general improvements constitute a never-ending project in the field of prosthetics evaluation.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">This test need not be applied when the stump is only half the normal forearm length or less.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">These tests and standards may not apply in cases where atrophy, bone blocks, loss of muscles, and the like are in evidence.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Lester Carlye, M.E. </b></td></tr><tr><td class="clsTextSmall">Engineer, Artificial Limbs Project, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-007.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 Artificial Arm Checkout Procedures Creator An entity primarily responsible for making the resource Lester Carlye, M.E. * https://staging.drfop.org/files/original/6d21fba44b4c02b4c004bf63e1f63831.pdf cfe971bc146b39e11e97c79118b1a01c https://staging.drfop.org/files/original/b6e1c2c759ed57d301d37d5ab4b5dac1.jpg 1c533dccdbe487d7d7d5d410dad1110b https://staging.drfop.org/files/original/c4a8c9195afad4e3ca03898f003dee7a.jpg daa3d984879549cbfc42159eb222089a https://staging.drfop.org/files/original/9f6daaddd1106d9cbe983c2033775d25.jpg becab7587312a262eb82597586a55b32 https://staging.drfop.org/files/original/362bb85952cc606295a9d63a6b958884.jpg bc9f5510398c4a397e38835cfa659c6b https://staging.drfop.org/files/original/3df3d00f10722335a631d5d506bce3e9.jpg 1438d406cb4650e0b21cc5cd159ab4d4 https://staging.drfop.org/files/original/3c515a6e746ee9da332077965f79f130.jpg eeaa58e7d94c89adda2a30a56fce67e6 https://staging.drfop.org/files/original/c14f2585925462148b4dc438c9c27a32.jpg d44e67466a5e9abea7791e13cea64868 https://staging.drfop.org/files/original/f76954679dfd8b87f5df527a3c7d892b.jpg 7ac7d32a7aec4d1aec8fd653c346fbc1 https://staging.drfop.org/files/original/1993fdd6c16310f6c51fb0a4ac52babe.jpg 3404b478edcf7b6daea295ec18b64db0 https://staging.drfop.org/files/original/5699bab2e0bc22f0d0c338f1fe253c49.jpg dd7be1022a55d231aecf0c0506683d10 https://staging.drfop.org/files/original/7edc77d5b01a38b55dc8a930df01f1a9.jpg d1de7bf09a288dccc2a1dbaa6f857c5e https://staging.drfop.org/files/original/19b07e847745ca927903c374fcdd08b3.jpg 329601d54d376428eddccdf1c99743e2 https://staging.drfop.org/files/original/35cb88c8107f12d1e13e4f66aeb734d0.jpg 50819e7dac33551723a15d6e26c1d066 https://staging.drfop.org/files/original/1cb6915c5fcaae6c2d352544442ba21e.jpg 0bcc34a21662a964b18d6bcb72c0e2ed https://staging.drfop.org/files/original/4ac29010338a64c8712eb4fcef376384.jpg ae72774766d287aff0fe5353562f75a3 https://staging.drfop.org/files/original/e7e2686a60c6518befb80b03771e5f80.jpg 9f8d304788a8729cacce1bfeb40979a6 https://staging.drfop.org/files/original/affd9f9bd75a9a20f20ca57f8be4e3c3.jpg 4a1273b17bd7fa3518107c0cfa7fe4de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_026.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 26 - 33 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_026.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_026.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Special Equipment and Aids for the Young Bilateral Upper-Extremity Amputee</h2> <h5>Liesl Friedmann, O.T.R. <a style="text-decoration:none;">*</a><br /></h5> <p>Considerable information is available concerning the treatment philosophy, prosthetic prescription, and training of the child with a unilateral upper-limb deficiency<a></a>. However, there are few published data on adapted equipment for the child with a bilateral upper-extremity deficit. To help remedy this lack, this article presents a brief discussion of the current treatment philosophy at the Institute of Physical Medicine and Rehabilitation in the New York University Medical Center and describes some of the adapted equipment and training procedures that have been found useful for children with congenital bilateral upper-limb deficiencies.</p> <p>The presentation is essentially confined to children fitted with conventional prostheses. Experience with unilateral and a few bilateral amelic children at the Institute of Physical Medicine and Rehabilitation has led to the conclusion that these patients obtain inadequate benefit from conventional fitting and might do better with externally powered prostheses. However, these prostheses pose their own unique training problems which are not considered here.</p> <p>Bilateral Fitting Recommended The child is fitted as soon as he sits independently. If there are lower-limb deficiencies or other conditions which delay the achievement of sitting balance, assistive devices and training programs are used to facilitate this accomplishment.</p> <p>It is believed that all children with bilateral upper-limb deficiencies should be fitted bilaterally at the outset for the following reasons:</p> <ol> <li>To encourage the performance of bimanual activities and, hopefully, to assist in the development of an appropriate body concept by providing bilateral extremities of equal length.</li><li>To aid balance and prevent scoliosis.</li><li>To increase prosthetic tolerance.</li><li>To prepare for later bilateral prehensile function.</li><li>To promote eye-hand control of the prostheses.</li></ol> <p>The considerations listed above outweigh the disadvantages of lack of sensory input from the covered stumps. Since the prostheses are not worn full time by any of these children, ample sensory stimulation of the deficient limbs can be achieved.</p> <h3>Training Considerations</h3> <p>In the training program, the longer stump is developed as the dominant member unless the child shows a strong preference for the shorter limb. If both sides are equal in length, the child's preference is determined by observation.</p> <p>If the child has lower extremities which can assist in the performance of activities of daily living, use of the feet is encouraged, with loafer-type shoes recommended for easy removal.<a></a> However, exclusive use of the feet should be discouraged. Pedal skills should be used to assist prosthetic function or in emergencies when the prostheses are not available. Thus, the feet should be used primarily for activities that cannot be performed with prostheses, although strict rules cannot be applied. The degree to which the lower extremities are used must be a matter of judgment based on the individual case. It should be remembered, however, that if the child becomes too dependent on his lower extremities he will have to learn to reduce foot usage when he reaches the age of social consciousness.</p> <h3>Fitting Modifications</h3> <p>In general, the same standard fitting procedures are used for the bilateral limb-deficient child as are used for the unilateral patient with the following modifications:</p> <ol> <li>A 12P hook is fitted immediately but is not activated . Passive mitts are not used.</li><li>During the passive phase of training (inactive terminal device), a figure-eight harness is used, with a chest strap connecting the two axilla loops added for retention. To prevent the harness from riding up in the back, a vertical strap from the cross of the figure-eight is attached to a waist belt.</li><li>The usual developmental sequence in a child's perception of the prehensile function of a hook is well known<a></a>. In bilateral amputees, the developmental sequence is the same, but is sometimes extended over a longer period. The therapist will usually be able to detect the child's readiness for cable attachment and active use by noting the typical signs of frustration arising from inability to function independently; for example, a sudden, sustained increase in crying, temper tantrums, refusal to wear the prostheses, and similar otherwise unexplainable manifestations. Occasionally, the child will verbalize the desire to do things independently without the prostheses. A reasonable attention span is an imperative requisite.</li><li>When the child reaches the age of four or five years, bilateral wrist-flexion units are provided.</li><li>For the very young above-elbow amputee, friction-lock elbow units, which have recently become available, are useful.</li></ol> <h3>Training Procedures</h3> <p>Patients with bilateral limb deficiencies below the mid-humeral level present less of a fitting and training problem than bilateral amelic patients. Nevertheless, they still require specialized training. It is recommended that they be taught the use of one hook at a time and learn pre-positioning of the terminal device by use of the opposite hook, the knee, elbow, chin, or any available hard surface. Training in changing the position of wrist-flexion units by pushing against a hard surface or the opposite prosthesis needs to be given. These patients must also learn to don and remove their prostheses <a></a> and perform the activities of daily living.</p> <h3>Assistive Devices</h3> <p>The pattern of the training program in the New York University Medical Center follows the developmental scale of the normal child as far as possible.<a></a> However, it must be remembered that the "child amputee" will eventually become a teen-ager and then an adult. Thus both the physical and psychological aspects of growth should be taken into account in special training programs.</p> <p>Most of the special training devices used by adults for independence in activities of daily living can also be used by the young teenager. However, since training must start at a very early age if independence is to be obtained, devices specifically designed for the very young child must be used initially. The items described in this article are some that have been developed for the patients at the Institute of Physical Medicine and Rehabilitation.</p> <h3>Self-Feeding Aids</h3> <p>The first level of activity training is self-feeding. A swivel spoon<a style="text-decoration:none;">*</a> possibly with a flat, built-up handle to prevent slipping (<b>Fig. 1</b>) is useful. Initially, the therapist places the spoon into the hook. Later, the child learns to pick up the spoon from the rim of the plate or from the table without assistance. Usually, the child can push the food against the rim of a bowl or against a plateguard. At about four years of age, the child is introduced to the use of a "pusher," a utensil (<b>Fig. 2</b>) commonly used by normal children in Europe. The pusher has been found to be a good pre-knife-and-fork feeding aid. The pusher, which can be made from a flattened and re-shaped teaspoon, is placed behind the "thumb" of the hook on the nondominant side by the therapist. At this stage it is also likely that the child will be able to use a regular teaspoon with a flat handle, bent at an angle which is a compromise between that needed for scooping and the angle needed to get the food to the mouth without spilling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Straight spoons. The one on the right illustrates a method of building up the handle to prevent slipping when grasped by a prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Top, metal pusher formed from flattened spoon. Bottom, spoon flattened to make pusher. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At six to seven years of age, knife-and-fork usage can be started (<b>Fig. 3</b> and <b>Fig. 4</b>). At first, both utensils are placed behind the "thumbs" by the therapist, but with practice the child learns to do this independently. Bilateral wrist-flexion units are very useful for proper positioning of the utensils as they are maneuvered for insertion into the terminal devices and then for cutting. To prevent plate movement, it is frequenth" helpful at this stage to use a damp, flat foam-rubber sponge, wet paper towel, or adhesive foam rubber attached to the bottom of the plate. Correct table height is important in reducing shoulder abduction during eating. With the prostheses in complete abduction, the elbows should barely touch the table.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Use of knife and fork for cutting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Use of knife and fork for peas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When teaching drinking with a cup, a plastic, flat-handled cup<a style="text-decoration:none;">*</a> should be used initially. If necessary to prevent spilling when the cup is placed on the table, a lid (<b>Fig. 5</b>) may be provided. At this stage, the child can grasp and release actively but has not yet learned to pre-position the hook. This must be done by the therapist. When the child is able to preposition the hook (three to four years of age), a regular plastic or paper cup can be introduced. Such cups must be held by the upper rim from above (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cup equipped with cover to avoid spilling. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Plastic cup held at rim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the public schools of New York City, children are provided soup and a sandwich for lunch. These items are most difficult to handle with a prosthesis. Soup should be sipped from the cup or through a straw, but the child cannot control his prosthesis well enough to prevent mutilation of a sandwich. At the Institute of Physical Medicine and Rehabilitation, a sandwich holder has been devised which is used successfully by some children. The teacher or a parent must insert the sandwich, but the child can then eat it from the holder (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Sandwich holder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Dressing Aids and Adapted Clothing</h4> <p>The amount and type of dressing activities performed by the bilateral upper-extremity amputee vary greatly from one child to the next. For these patients the combined use of feet and teeth may be required.</p> <p>To don his prostheses the child must first put on his stump socks and then maintain them in position as he maneuvers his stumps into the sockets. This feat is not very difficult for the bilateral below-elbow amputee, but if one or both of the limbs are deficient above the elbows, the socks tend to fall off. Others<a></a> have described a bilateral stump sock which is useful. At the Institute of Physical Medicine and Rehabilitation, a connecting piece has been added to this bilateral stump sock to protect the back and axillary skin from irritation (<b>Fig. 8</b>). There is no commercial source for this item at present.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Bilateral stump socks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Adolescent girls frequently find a front-opening brassiere useful. The standard item can be easily converted into a front-opening type by sewing up the back, opening the front and fastening it with a long Velcro strap and D-ring (<b>Fig. 9</b>). To close the top, a supplementary smaller strap with Velcro or a large hook on an elastic strap may be used. Sleeveless dresses split below the waist and with an open back are helpful.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Front-opening brassiere. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major training problem is toileting, which is particularly difficult for females. If a female child does not have normal lower extremities or at least toes able to function sufficiently in grasping clothing or toilet paper at the proper body level, life-long dependency in this function may have to be accepted. In using bilateral upper-extremity prostheses for assistance in toileting, it is a problem to get the prostheses close enough to the body to adjust the underpants while wearing a dress, even with elbow turntables and bilateral wrist-flexion units.</p> <p>Some children have successfully used modified underpants which do not have to be removed. The crotch of the undergarment is split and refinished with binding (<b>Fig. 10</b>). The opening should close when the child is in the erect position. When the patient sits on the toilet seat, with the trunk flexed on the thighs and the lower limbs abducted, the opening is sufficiently wide to prevent soiling of the garment. With practice, the use of toilet paper can usually be mastered without special devices. Sometimes, however, the solution of this problem requires the development of special reaching devices which are highly individualized. Female patients usually find tampons much superior to sanitary napkins.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Modified underpants. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Schoolwork Aids</h3> <p>For the bilateral amputee to function effectively in school, adaptation of equipment is required in many activities. For example, cutting with scissors is an impossible task with the standard item. <b>Fig. 11</b> illustrates a simple and very satisfactory adaptation in which one handle of the child's scissors is embedded in a small piece of wood 1-1/2 in. X 1 in. X 1/2). The lower handle of the scissors is placed in a groove made with an X-acto knife and held in place with plastic wood. When the scissors are positioned in the wood block, the tip should touch the table. The axis of the two blades should not be tight and the blades should fall open with ease. The child holds the upper handle of the scissors with the hook tines pointing downward. As the handle of the scissors is pulled up and down, the block of wood rides flat on the table surface. In learning to use the adapted scissors, the child should start with straight lines on paper and then include gentle curves and corners and, finally, complex figures. Such scissors are effective only with paper; cloth cutting requires the use of electric scissors (<b>Fig. 12</b>). For cutting thread on a sewing project, a seam ripper is verv useful (<b>Fig. 13</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Scissors with one handle embedded in wood. Plastic wood holds the handle in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Electric scissors. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Seam ripper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Writing can be facilitated by the use of a clipboard or attaching the paper to the table with masking tape, rather than letting the child struggle to hold the paper steady with his non-dominant prosthesis. Chalk holders which prevent the chalk from breaking and improve blackboard writing efficiency are available commercially<a></a>. A pencil holder has also been described<a></a>. A simpler crayon-holding device has been used for very young patients at the Institute of Physical Medicine and Rehabilitation (<b>Fig. 14</b>). This holder consists of a wood block (6 in. X 2 in. X 2 in.) with a series of holes drilled at angles to enable the child to withdraw and reinsert the cravon without having to pre-position the crayon. Unless the child presses down very hard, the crayon will not slip from the hook. If a thin layer of foam rubber is glued to the bottom of the wood block, it will not slip on the table. Some older children cannot use their other hook to insert a pencil behind the ''thumb" for stability. When clamped to the edge of the table, a simple block of wood with a single deep hole (<b>Fig. 15</b>) is effective in holding the pencil so that it may be properly grasped. In time, the child learns to pick up and position the pencil without special devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Crayon holder fashioned from wooden block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Pencil holder clamped to edge of tray. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Sewing and Knitting Aids</h3> <p>It is possible for a bilateral upper-extremity amputee to learn knitting and sewing. One needle with the knitting on it can be inserted in a vise (<b>Fig. 16</b>), while the other needle is held behind the "thumb" in the dominant prosthesis. The wool is laced around the needle by the nondominant hook. Thick needles and wool should be used. Sewing can be made easier by use of a frame mounted on a pivot with ball bearings (<b>Fig. 17</b>). Many four- and five-year-old children enjoy sewing cards or doing simple cross-stitch work. This is an excellent activity for training the child to achieve minimal opening of one hook at a time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Small vise used to hold knitting needle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Frame to hold sewing card, mounted on ball bearings to swing freely on pivot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Constant Modification Necessary It is hoped that other therapists will find these suggestions useful and that they will report special devices that they have used successfully. Finally, it should be emphasized that, although a variety of assistive devices, including the feet, are used by young children with bilateral upper-extremity deficiencies in performing the activities of daily living, the problem changes as the child grows older. The physical growth and social consciousness characteristic of the teen-ager may preclude the use of techniques that were acceptable in the younger child. Constant alertness to the need for modification of techniques is required to meet the changing physical and psychosocial needs of the developing child.</p> <p><b>References:</b></p> <ol> <li>Calef, P. L., A pencil holder for the bilateral upper-extremity amputee fitted unilaterally, Inter-Clinic Information Bulletin, September 1964, pp. 15-16.</li> <li>Deutsche Vereinigung fur die Rehabilitation Behinderter (Heidelberg-Schlierbach), Information on measures for rehabilitation of children with dysmelia, 1962.</li> <li>Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Inter-Clinic Information Bulletin, April 1965, pp. 7-16.</li> <li>Jentschura, G., E. Marquardt, and M. Rudel, Behandlung und Versorgung bei Fehlbildungen und Amputationen der oberen Extremitaet, George Thieme Verlag, Stuttgart, 1963.</li> <li>Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</li> <li>University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Calef, P. L., A pencil holder for the bilateral upper-extremity amputee fitted unilaterally, Inter-Clinic Information Bulletin, September 1964, pp. 15-16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Baby Cup, KT5, with flat double handle and lock lid (50 cents); Kayware Corp., 2731 North Crawford Ave., Chicago, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Sta-Lcvel Baby Training Spoon ($1.00); Price Industries, Ltd., 815 East Talmadge Ave., Akron, Ohio.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Jentschura, G., E. Marquardt, and M. Rudel, Behandlung und Versorgung bei Fehlbildungen und Amputationen der oberen Extremitaet, George Thieme Verlag, Stuttgart, 1963.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Liesl Friedmann, O.T.R. </b></td></tr><tr><td class="clsTextSmall">Therapist-in-Charge, Children's Division, Institute of Physical Medicine and Rehabilitation, New York University Medical Center, 400 East 34th St., New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_026/autum65-53.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_02_026/autum65-54.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_02_026/autum65-55.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_02_026/autum65-56.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_02_026/autum65-57.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_02_026/autum65-58.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_02_026/autum65-59.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_02_026/autum65-60.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_02_026/autum65-61.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_02_026/autum65-62.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_02_026/autum65-63.jpg Figure 12 http://www.oandplibrary.org/al/images/1965_02_026/autum65-64.jpg Figure 13 http://www.oandplibrary.org/al/images/1965_02_026/autum65-65.jpg Figure 14 http://www.oandplibrary.org/al/images/1965_02_026/autum65-66.jpg Figure 15 http://www.oandplibrary.org/al/images/1965_02_026/autum65-67.jpg Figure 16 http://www.oandplibrary.org/al/images/1965_02_026/autum65-68.jpg Figure 17 http://www.oandplibrary.org/al/images/1965_02_026/autum65-69.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 Special Equipment and Aids for the Young Bilateral Upper-Extremity Amputee Creator An entity primarily responsible for making the resource Liesl Friedmann, O.T.R. * 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.&nbsp;<a style="text-decoration: none;">*</a><br />Linda McHugh, R.P.T.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>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.</p> <h3>Patient Distribution</h3> <p>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.</p> <p>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.</p> <h3>Protocol</h3> <p>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.</p> <p>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:</p> <ol> <li> <p>Parents and child will watch a video prepared by the hospital showing the fitting and training process for the Reciprocal Gait Orthosis.</p> </li> <li> <p>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.</p> </li> <li> <p>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)&nbsp;donning and doffing of the orthosis.</p> </li> </ol> <p>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.</p> <p>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.</p> <p>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.</p> <h3>Fitting Problems</h3> <p>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"><b>Fig. 1</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.jpg"><b>Fig. 2</b></a>). Our intention is to enable the child to exhibit effective ambulation and then to consider joint releases when possible.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg"><strong>Figure 1. Front view of patient showing extensive pre-existing contractures and shoe wedging to accommodate the contractures.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.jpg"><strong>Figure 2. Lateral view.</strong></a><br /> <p>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.</p> <h3>Early Intervention</h3> <p>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.</p> <h3>Results</h3> <p>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.</p> <h3>Conclusion</h3> <p>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.</p> <p><b>References:</b></p> <ol> <li>Douglas, R., P. Larson, R. Ambrosia, and R. McCall, "The LSU Reciprocation-Gait Orthosis," <i>Orthopedics</i>, 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," <i>Orthopedics</i>, 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," <i>ACPOC</i>, April, 1985.</a></li> </ol> <p><em><b>*Linda McHugh, R.P.T. </b> Linda McHugh, R.P.T. is also with Shriners Hospital for Crippled Children.</em></p> <p><em><b>*Lou Ekus, C.P.O. </b> Lou Ekus, C.P.O. is Director of Orthotics and Prosthetics at Shriners Hospital for Crippled Children, 516 Carew Street, Springfield, Massachusetts 01104.</em></p> <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/3737624fef3a56640de26ee5e3002198.pdf 15dcba40ce0ee64a88813bdb9436da11 https://staging.drfop.org/files/original/90b09bc05fe9f54eac7fb5d364a84b1c.jpeg bf517f01325ef5bfd382d9f9221d3ade https://staging.drfop.org/files/original/f21dd604b9586a00f2668ad4a7c12771.jpg 6fb57a7aca27799becfcbf804eeb70ed Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_01_006.pdf Text Any textual data included in the document <h2>Cross-Diagonal Closure Of Pelvic And Spinal Appliances</h2> <h5>Louis Ekus, CO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The pelvic region with its numerous bony prominences, subcutaneous structures, and varied contours, has long been a useful site for the stabilization of many different orthoses and prostheses. The Milwaukee orthosis, body jackets, prostheses for hemipelvectomy and hip disarticulation amputees, to name a few, often maintain high internal forces as components of complex three-point pressure systems. Due to the nature of these devices, the internal forces are often quite different on the patient's opposing sides. Most practitioners are already aware that when the differences in the forces from right to left sides becomes large enough, relative motion of the two sides of the appliance becomes a difficult problem. This motion, in the superior or inferior direction in the frontal plane, causes skin breakdown, irritations, torsional stress on the devices and, thus, provides less than optimal function. In hip disarticulation and hemipelvectomy prostheses, "pumping" can be attributed to a great extent to the lack of the closures to maintain effective apposition of the two sides of the socket. The cross-diagonal closure is one way of dealing with this undesirable movement effectively.</p> <p>When the attachment points of closure straps are placed horizontally across from one another, as in conventional practice, the long axis of the straps is perpendicular to the direction of the relative movement between the two sides. A large amount of this motion can then occur with little increase in the distance between these points. This fact, in addition to the high degree of compression and migration of the tissue in the pelvic region, contributes greatly to the problem. In this case, the unwanted action can take place due to a lack of increased tension on the closure straps at the onset of the motion. However, if the points are placed so that the long axis of the straps will <i>not</i> be perpendicular to the direction of movement, the distance change between these points per unit of motion is much greater.<a style="text-decoration: none;">*</a> This will cause a rapidly increasing tension on the straps, hence restricting additional movement.</p> <p>Each strap in the cross will restrict translation in one direction; motion in the other direction will bring the attachment points closer together, and the strap will loosen. Application of the cross introduces a strap for the limitation of motion in both directions (<a href="/files/original/90b09bc05fe9f54eac7fb5d364a84b1c.jpeg"><b>Fig. 1</b></a>).</p> <p>When applied to prostheses, a visible difference in the amount of relative motion possible could be noted between the conventional closure and the cross-diagonal closure (<a href="/files/original/f21dd604b9586a00f2668ad4a7c12771.jpg"><b>Fig. 2</b></a>). The appliances with the crossed type were no more difficult to don and doff than the corresponding conventional types. This closure is presented here because of the similarities in the pelvic sections of both prostheses and orthoses along with the similarities in the problems that accompany each. The cross-diagonal closure may be utilized as an important new method of optimizing increased effectiveness and patient comfort.</p> <b>Footnote</b> This physical phenomenon is explained trigonometrically by the fact that the difference in the sine functions of a one degree (1°) change (0° to 1°) near the horizontal is much larger than the difference in the sine function of a one degree (1°) change near the vertical (89° to 90°).<br /> <div style="width: 400px;"><br /><em><b>*Louis Ekus, CO </b> Currently medical student at the School of Medicine, Universidad del Noreste, Tampico, Mexico; formerly a staff orthotist, Institute of Rehabilitation Medicine, New York University Medical Center.</em></div> <div style="width: 400px;"><br /><br /></div> Page Number(s) 6 - 6 Year 1981 Volume 5 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1981_01_006/1981_01_006-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1981_01_006/1981_01_006-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Cross-Diagonal Closure Of Pelvic And Spinal Appliances Creator An entity primarily responsible for making the resource Louis Ekus, CO * https://staging.drfop.org/files/original/fa104bc2df9d1eb8a2e3fcfe1be372dc.pdf 3cac7ed2272aa4b36cb461ab73d777af https://staging.drfop.org/files/original/03c6dab500bcc8abcf2064a69651e3fb.jpg 78f6ebbe4d49f0e3d87c4a2431800fec https://staging.drfop.org/files/original/ef57e986fd642949abac655e0ddfbb48.jpg f228ca3d4b1bb1b07a591f5647f82f55 https://staging.drfop.org/files/original/6f3713a26a2d78a1af84b3371b05ee26.jpg 4cbdb84cf8ff35a7778b82dbb1364778 https://staging.drfop.org/files/original/984d8d4e3f3b4d44a11796f074d966bc.jpg fd661aac55fb812af0850e8319a6494b https://staging.drfop.org/files/original/a0e1497de95803eedb7c9bae27189933.jpg 86578a267fce21bebb761d96df09ad56 https://staging.drfop.org/files/original/ac40bae7d01bf2c9df78320ef938a453.jpeg 121965bd03be3afd015cb87750d6b2f5 https://staging.drfop.org/files/original/6ac0309f920adb45f06a6d73b90dbb23.jpeg 822b8149c492fcc9a1b2e8791f80a98d https://staging.drfop.org/files/original/ad272a01fb6edf60c48e85a6111e0d64.jpeg 28953020850578f0557a831f57db00da Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_03_003.pdf Text Any textual data included in the document <h2>An Ankle-Foot Orthosis Providing Mediolateral Stabilization While Allowing Free Plantar and Dorsiflexion of the Foot</h2> <h5>Lucia Klemmt, CO&nbsp;<br />Fritz Klemmt&nbsp;</h5> <p>The development of an ankle-foot orthosis (AFO) providing mediolateral stabilization while allowing free plantar and dorsiflexion of the foot was prompted by a patient (W. F.) seen some months ago, who was wearing a posterior solid ankle-foot orthosis (PSAFO). However, rather than providing ankle stability, it was ineffective and an irritant during stance. W. F. was unhappy with it, and discouraged.</p> <p>In evaluating his condition, he was found to have good plantar and dorsiflexion, but suffered from mediolateral ankle instability. He was shown a conventional AFO with a metal stirrup and metal uprights, demonstrating the mediolateral protection the orthosis provides, while allowing free motion at the ankle. The fact that it was less cosmetic than a plastic orthosis did not concern the patient, if it allowed him to walk normally again and not with a stiff ankle. But considering his physician's preference for plastic over a metal orthosis, with its advantages, e.g., free choice of shoes, better appearance, etc., it occurred to us to combine mediolateral protection of the ankle with free ankle plantarflexion and dorsiflexion in a plastic orthosis.</p> <p>This idea was realized by incorporating an ankle joint similar to that used in fracture bracing in a PSAFO (<a href="/files/original/03c6dab500bcc8abcf2064a69651e3fb.jpg"><b>Fig. 1</b></a>). From a plaster mold of the patient's limb, a PSAFO was fabricated with an anterior section for added tibial support. The distal aspect of the calf section was trimmed to clear the Achilles tendon. The proximal edge of the footplate was trimmed so as to include the malleoli (<a href="/files/original/ef57e986fd642949abac655e0ddfbb48.jpg"><b>Fig. 2</b></a>). A contoured bar was riveted to the lateral aspect of the posterior calf portion and joined with the footplate over the malleoli, creating a pivot point allowing, rotation necessary for flexion or extension (<a href="/files/original/6f3713a26a2d78a1af84b3371b05ee26.jpg"><b>Fig. 3</b></a>). Two velcro straps provided an intimate fit around the limb. The patient was pleased with the function and support provided by this orthosis.</p> <p>The second patient fitted with this type of orthosis (R. R.) had a similar ankle problem. A slight change in the design was made. A separate ankle joint as with W. F.'s orthosis was not used. Rather, the proximal edges of the footplate were extended to the proximal aspect of the malleoli. The distal edges of the posterior calf section were then made to overlap the malleoli portions of the foot plate (<a href="/files/original/984d8d4e3f3b4d44a11796f074d966bc.jpg"><b>Fig. 4a</b></a> and <a href="/files/original/a0e1497de95803eedb7c9bae27189933.jpg"><b>Fig. 4b</b></a>). This joint system works smoothly and is more cosmetic, although it requires a little more work. R. R. was delighted with the orthosis since he can wear it with regular Oxfords or boots (<a href="/files/original/ac40bae7d01bf2c9df78320ef938a453.jpeg"><b>Fig. 5</b></a> and <a href="/files/original/6ac0309f920adb45f06a6d73b90dbb23.jpeg"><b>Fig. 6</b></a>).</p> A third patient (P. B.) with a similar problem of ankle instability was fitted with the same type of orthosis made for R. R., but eliminating the anterior portion. This patient, too, was happy with the freedom of motion it allowed (<a href="/files/original/ad272a01fb6edf60c48e85a6111e0d64.jpeg"><b>Fig. 7</b></a>).<br /><br />In these three cases, free plantar and dorsiflexion were allowed while mediolateral ankle stability was achieved. Though it involves extra work and time during fabrication of this type of ankle joint on a posterior solid ankle foot orthosis, the security of the ankle on weight bearing, the freedom of movement while walking, and the satisfaction of the patients wearing the orthosis are achievements justifying the extra effort and expense. Page Number(s) 3 - 5 Year 1980 Volume 4 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-3.jpg Figure 4 FIGURE 4A http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-4.jpg FIGURE 4B http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-5.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-7.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Ankle-Foot Orthosis Providing Mediolateral Stabilization While Allowing Free Plantar and Dorsiflexion of the Foot Creator An entity primarily responsible for making the resource Lucia Klemmt, CO  Fritz Klemmt  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.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>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.</p> <p>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.</p> <p>Mechanical knee joints are only a single component of a very complex system (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg"><b>Fig. 1</b></a> and <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg"><b>Fig. 2</b></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.</p> <strong><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.</strong><br /><br /><strong><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.</strong><br /> <h3>Free Knee Joints</h3> <p>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.</p> <p>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.</p> <h3>Offset Knee Joint</h3> <p>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.</p> <p>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.</p> <p>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.</p> <h3>Locked Knee Joints</h3> <p>A locked knee joint (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg"><b>Fig. 1</b></a> and <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg"><b>Fig. 2</b></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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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"><b>Fig. 1</b></a>). Incorporation of knee joints into laminated and thermo-formed KAFOs (<a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg"><b>Fig. 2</b></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.</p> <p>The Lower Extremity Telescoping Orthosis (LETOR) (<a href="/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg"><b>Fig. 3</b></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.</p> <strong><a href="/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg">Figure 3</a>. LETOR-Posterior telescoping rod bridges the knee and prevents knee flexion.</strong><br /> <p>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.</p> <h3>Conclusion</h3> <p>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.</p> <p>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.</p> <p>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"><b>Fig. 4</b></a>). This has been used with limited success in selected pediatric paraplegic patients.</p> <strong><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.</strong><br /> <p>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.</p> <p><b>References:</b></p> <ol> <li>Anderson, E.G., and J.T. Henshaw, "The Design and Prescription of Above Knee Orthosis." <i>Orthotics and Prosthetics</i>, 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." <i>Clinical Prosthetics and Orthotics</i>, 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." <i>Orthotics and Prosthetics</i>, Vol. 40, No. 1, Spring, 1986, pp. 43-50.</li> <li>Condie, D., C. Pritham, A.B. Wilson, III, and M. Stills, <i>Lower-Limb Orthotics, A Manual</i>, First Edition, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, PA.</li> <li>Foster, R., and J. Milani, "The Genucentric Knee Orthosis-A New Concept." <i>Orthotics and Prosthetics</i>, Vol. 33, No. 2, June, 1979, pp. 31-44.</li> <li>Glancy, J., and R.E. Lindseth, "The Polypropylene Solid Ankle Orthosis." <i>Orthotics and Prosthetics</i>, 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." <i>Prosthetics and Orthotics International</i>, Vol. 8, No. 2, August, 1984, pp. 114-116.</li> <li>Pritham, C, and M. Stills, "Knee Cylinder," <i>Orthotics and Prosthetics</i>, 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," <i>Orthotics and Prosthetics</i>, Vol. 31, No. 3, September, 1977, pp. 9-25.</li> <li>Stills, M., "Lower Limb Orthotics." Report: <i>The Current Status of Prosthetics and Orthotics and Trends for Future Research and Development</i>, University of Miami, April 1-3, 1977.</li> </ol> <em><b>*M.L. Stills, CO. </b> 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.<br /><br /><br /></em> 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/a35cfabdeded6efeb701fabb13e0203a.pdf 1c6c0d675c28db96ad766418ff443a9b https://staging.drfop.org/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg 14d5744670f9a9f1540367bb959c02c2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_01_001.pdf Text Any textual data included in the document <h2>Transfer of Rehabilitation Research and Development Results into Clinical Practice</h2> <h5><a href="/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg">Margaret Giannini, M.D.&nbsp;*</a></h5> <p><i>For more than thirty years, Dr. Margaret Giannini has been a pioneer in creating programs for the diagnosis, treatment, education, rights and affairs of the mentally retarded, developmentally disabled and the handicapped.</i></p> <p><i>In 1950, Dr. Giannini founded and directed the Mental Retardation Institute at New York College. In 1980, she accepted a Presidential appointment as the first Director of the National Institute of Handicapped Research, a branch of the U.S. Department of Education. In April, 1981, Dr. Giannini took over the position of Director for the VA Rehabilitation Research and Development Service (Rehab R&amp;D).</i></p> <p><i>In addition to these positions, Dr. Giannini is past-president of the American Association on Mental Deficiency and past-president of the American Association of University Affiliate Progams, two of the most influential organizations concerned with the mentally and physically handicapped.</i></p> <p><i>Dr. Giannini is the recipient of many awards from varying organizations in recognition of her professional and humanitarian services and achievements. She also has authored and co-authored numerous publications; presented many lectures, papers, keynote addresses; and participated in panel discussions and workshops throughout the world.</i></p> <p>The Veterans Administration, Rehabilitation Research and Development Service (Rehab R&amp;D) funds approximately 100 projects a year aimed at developing new methods or improving existing techniques for assisting disabled veterans. The program was created by a Congressional mandate, U.S.C. 38, Sec. 4101, (c)(1) and (2), which directs that the VA "carry out a program of medical research including prosthetics research. Prosthetics research should include research and testing in the field of prosthetic, orthotic and/or orthopedic appliances and sensory devices."</p> <p>A review of Rehab R&amp;D scientific and engineering accomplishments provides insight into the VA/Rehab R&amp;D technology-transfer programs. Some of the recent and ongoing research conducted under this sponsorship includes: maxillofacial restorations—to include use of biomaterials and their clinical applications; development and evaluation of robotic aids for the severely disabled; seat cushions for the paralyzed to prevent decubitus ulcers; functional electrical stimulation (FES) systems for upper extremity control; physiological effects of FES on paralyzed muscles; walking restored in a paralyzed man using FES; a motion-guiding load-bearing external frame for the knee; possible myoelectric controlled above-knee prosthesis; oprimum prosthetic foot characteristics for the dysvascular below-knee amputee.</p> <p><b>Image: Dr. Giannini</b></p> <p>In addition to sponsoring such research in the past, Rehab R&amp;D has established a program concerned with the transfer of research into clinical practice. This program consists of the following six parts:</p> <ol> <li> <p>Establishing clinically relevant research priorities.</p> </li> <li> <p>Insuring that the significant research encompasses clinically relevant factors.</p> </li> <li> <p>Dissemination of research findings to the scientific community.</p> </li> <li> <p>Evaluation of research results for suitability for transfer to clinical settings.</p> </li> <li> <p>Support to private industry to make new devices and equipment commercially available.</p> </li> <li> <p>Dissemination of new methods to clinical practitioners.</p> </li> </ol> <p>Each of these is examined at length in the remainder of this paper.</p> <h3>Establishing Clinically Relevant Research Priorities</h3> <p>In the past, the VA had only general research priorities for award of Rehab R&amp;D funds. Oftentimes researchers focused proposals on esoteric topics which were of little or no clinical significance while major clinical issues went unaddressed. To remedy this situation, a series of workshops were held with consumers and clinical leaders to develop priorities for research on clinically significant issues.</p> <p>Many of the workshops sponsored by RESNA and the VA have been published. Workshop topics have included sensory aids, functional electrical stimulation, and prosthetics/amputation. Rehab R&amp;D also has participated in meetings of the International Standards Organization (ISO) which established specific priorities within the areas of prosthetics/amputation, spinal cord injury (including wheelchairs), and sensory aids. Rehab R&amp;D now has a policy of soliciting and approving funding for only those proposals which fall within these priorities.</p> <h3>Ensuring that Research Addresses Relevant Clinical Issues</h3> <p>There is a vast distance between research and clinical application of methods and devices. Rehab R&amp;D has the responsibility not only to fund research, but also to initiate and support the development of the clinical methods necessary for effective application. For example, the outstanding work done by Ernest Burgess, M.D., in Seattle, and others on immediate postoperative fitting requires new and complex clinical procedures. A necessary step in promoting clinical application of this method has been the development of a clinical procedures manual and the training of practitioners and patients.</p> <h3>Dissemination of Research Findings</h3> <p>The new VA <i><i></i>Journal of Rehabilitation R&amp;D</i> replaces the earlier <i>Bulletin of Prosthetics Research</i> with a number of major changes. Aimed at the entire scientific community, and charged with following the highest standards of scientific quality, the <i>Journal of Rehabilitation R&amp;D</i> is designed to offer an interdisciplinary vehicle for publication of technical materials which can most directly reach rehabilitation professionals. In addition to the <i>Journal</i>, the first edition of a new annual publication <i>Rehabilitation R&amp;D Progress Reports</i>, is now in press. This publication is aimed at providing a comprehensive overview of research and development now in progress both in the United States and internationally. One of the publication's functions will be to serve as a guide to sources of information within the areas of Rehab R&amp;D priorities.</p> <p>Rehab R&amp;D, in the planning stage of developing, will work in coordination with professional organizations in the field to facilitate the translation of scientific results into technical clinical information of direct relevance to practicing clinicians.</p> <h3>Evaluation of Research Results</h3> <p>The Chief Medical Director of the VA has given approval to establish the Development and Evaluation Program (DEP) for the evaluation of research and development findings to determine their suitability for adoption into clinical practice. The program is designed to stimulate, evaluate, and acquire and disseminate information, including the development of educational guidelines and technical manuals.</p> <p>The educational guidelines will be coordinated between the Continuing Education Resources Service and the Prosthetics and Sensory Aids Service (PSAS). Thus, both the people who will prescribe and/or use these new devices, techniques, or concepts, will be trained. Rehab R&amp;D will not actually provide the training, but it will provide the data and/or research scientists as instructors for the training program. This Rehab R&amp;D program is currently limited to devices specifically developed in VA or other federally funded R&amp;D projects.</p> <p>Rigorous evaluation will provide objective and comprehensive information to the key decision makers related to clinical adoption. Information will be provided to funding agencies—including the VA—which must formally approve reimbursement of the devices or use of procedures in clinical practice; to industry so they can decide whether to add the devices to their commercial lines; and to clinicians who must decide on how to apply the new methods or devices. VA responsibility for evaluation will be shared cooperatively between Rehab R&amp;D on new research, and by the VA's Prosthetics and Sensory Aids Service on devices which are already commercially available, but have not been previously evaluated.</p> <h3>Support to Private Industry to Make New Devices Commercially Available</h3> <p>No matter how good research and engineering results are, they are of no value unless they become available to clinicians. Many useful devices which have resulted from research are not commercially available. To overcome this gap, discussions have been held with industrial leaders who have offered advice on the nature of the rehabilitation market, which is just one impediment. Based upon the input of these industrial leaders, commercial availability is being attacked on two fronts.</p> <p>First, an interagency agreement with the Department of Commerce has been developed to assist small minority business firms in tooling-up for offering new products as a part of their commercial lines. Specifically, the interagency agreement provides for the study of marketing and development methods to fully utilize the research and development of new devices for the disabled. The purpose of this interagency agreement is to utilize existing programs in the Minority Business Development Agency (MBDA) and stimulate marketing for devices that result from VA-sponsored R&amp;D.</p> <p>The National Commission of Technology Transfer, of the Department of Commerce, is in the process of offering funding in order to:</p> <ul> <li> <p>plan for an international conference on making prosthetic and orthotic devices and sensory aids readily available to the handicapped population;</p> </li> <li> <p>identify and develop potential markets and financing for such devices;</p> </li> <li> <p>examine the use of microcomputers and other high technology areas;</p> </li> <li> <p>examine the impediments to obtaining funding for high-technology products; and,</p> </li> <li> <p>develop a process that leads to the commercialization of technology researched and developed by the VA, with emphasis on providing access to these markets for minority entrepreneurs.</p> </li> </ul> <p>Arrangements have been made to encourage private industry to adopt the results of individual research products which are judged to have particular merit. As a result of these efforts, the Johns Hopkins Manipulator will soon be commercially available. Other negotiations are continuing. To facilitate this process, VA Rehab R&amp;D has assisted in the creation of a National Commission for Technology Transfer, which is concerned with making research results commercially available to handicapped people.</p> <h3>New Directions</h3> <p>Future plans by VA Rehab R&amp;D to assist in the transfer of technology from research to clinical practice are as follows:</p> <ul> <li> <p>Continued publication of the <i>Journal of Rehabilitation R&amp;D</i> and the <i>R&amp;D Progress Reports</i>;</p> </li> <li> <p>Publication and distribution of papers on subjects potentially relevant to future clinical practice (e.g. training manual for use of robotic systems for the severely disabled);</p> </li> <li> <p>Design and implementation of a formal research program, based at the Office of Technology Transfer, to evaluate and improve the transfer of technology, including:</p> <ol> <li> <p>The collection of clinical practice data from VA facilities to give a chronological picture of the gap between state-of-the-art devices and actual clinical practice;</p> </li> <li> <p>A series of consumer surveys to determine their needs and to uncover problems or frustrations with existing rehabilitation procedures and equipment; and,</p> </li> <li> <p>A series of surveys among clinical practitioners to collect data on clinical needs, problems and priorities.</p> </li> </ol> </li> <li> <p>A periodical and/or a technical communication in existing periodicals for clinicians, designed in cooperation with PSAS, the Academy, AOPA, AAOS, Paralyzed Veterans of America, Disabled American Veterans, National Institute of Handicapped Research, and other organizations to further enrich the transfer of new research findings to clinicians in a format tailored to their practical needs. In the long run, a computerized reference system may be developed;</p> </li> <li> <p>Seminars on selected topics between recognized clinical leaders and senior researchers who have achieved scientific breakthroughs relevant to clinical practice; and,</p> </li> <li> <p>Access to national and international scientific and clinical literature.</p> </li> </ul> <p>These thrusts are ambitious and will take time, but they convey the depth of Rehab R&amp;D commitment to technology transfer.</p> <em><b>*<a href="/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg">Margaret Giannini, M.D</a>. </b> A native of New York, Dr. Giannini is married to Louis J. Salerno, M.D. and has raised four sons. Dr. Giannini is scheduled to speak at the Academy Annual Meeting in Orlando on January 26, 1984.</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 1 - 3 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_001/1984_01_001-1.jpg 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 Transfer of Rehabilitation Research and Development Results into Clinical Practice Creator An entity primarily responsible for making the resource Margaret Giannini, M.D. * 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.&nbsp;<a style="text-decoration: none;">*</a><br />Joseph Zettl, CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>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.</p> <p>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.</p> <p>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></p> <p>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.</p> <p>In defining the size and shape of the residual limb, two studies were helpful. In the July, 1983 <i>Journal of the American Geriatrics Society</i>, 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.</p> <p>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.</p> <p>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"><b>Fig. 1</b></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"><b>Fig. 2</b></a>). We pursued this with Midwest Research Institute<a style="text-decoration: none;">*</a> and received the following explanation:</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg"><strong>Figure 1. Kompritest II for measurement of pressure values of elastic stockings.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg"><strong>Figure 2. CTC 250 Digital Pressure Gauge.</strong></a><br /> <blockquote> <p>Both devices accurately measure pressure imposed upon their respecting sensing elements.</p> <p>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></p> </blockquote> <p>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</p> <h3>Procedures</h3> <p>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"><b>Fig. 3</b></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.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg"><strong>Figure 3. Needle bed of knitting machine where widenings and narrowings can be made.</strong></a><br /> <p>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.</p> <p>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"><b>Table 1</b></a>).</p> <p>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"><b>Fig. 4</b></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.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg"><strong>Figure 4. Testing cylinder with pressure sensing device in position.</strong></a><br /> <h3>Results</h3> <p>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"><b>Table 2</b></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"><b>Table 3</b></a>).</p> <p>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"><b>Table 3</b></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"><b>Table 1</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg"><b>Table 3</b></a>).</p> <p>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"><b>Fig. 5</b></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.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg"><strong>Figure 5. MmHg of pressure exerted by heavy shrinker sock on inch from distal end.</strong></a><br /> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg"><b>Fig. 6</b></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"><b>Fig. 7</b></a> where the dotted lines represent the regular tapered sock and the three toe lengths represent the 10, 12, and 14 inch sock lengths.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg"><strong>Figure 6. MmHg of pressure exerted by heavy shrinker sock six to eight inches from distal end.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg"><strong>Figure 7. Scale of regular and double taper.</strong></a><br /> <p>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"><b>Fig. 8</b></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.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg"><strong>Figure 8. Comparison of regular and double taper shrinker sock (14 inch length).</strong></a><br /> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg"><b>Fig. 9</b></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"><b>Fig. 10</b></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.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg"><strong>Figure 9. MmHg of pressure exerted by medium pressure shrinker sock one inch from distal end.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.jpg"><strong>Figure 10. MmHg of pressure exerted by medium pressure shrinker sock six to eight inches from distal end.</strong></a><br /> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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."</p> <h3>Conclusions</h3> <p>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.</p> <p>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.</p> <h3>Acknowledgments</h3> <p>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.</p> <p><b>References:</b></p> <ol> <li>Beninson, Joseph, M.D., "Six Years of Pressure Gradient Therapy," <i>Angiology</i>, Volume 12, No. 1, January, 1961, pp. 38-45.</li> <li>Bauer &amp; Black, <i>Elastic Stocking Compression in the Therapy of Varicose Veins</i>, Chicago, Il., 1956, pp. 4-14.</li> <li>Chavatzas, Dimetrios, and Jamieson Crawford, "A Simple Method for Approximate Measurement of Skin Blood-Pressure," <i>The Lancet</i>, 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," <i>Journal of the American Geriatrics Society</i>, 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," <i>Journal of the American Academy of Dermatology</i>, 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," <i><i></i>Proceedings of the Working Conference on Applicability of New Technology to Biobehavioral Research</i>, 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," <i>British Medical Journal</i>, 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," <i>Journal of the American Medical Association</i>, 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," <i>British Journal of Surgery</i>, 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," <i>Archives of Surgery</i>, 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," <i>British Journal of Surgery</i>, 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," <i>Physical Therapy,</i> 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," <i>The Journal of Bone and Joint Surgery</i>, 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," <i>British Journal of Surgery</i>, Volume 60, No. 9, September, 1973, pp. 729-731.</li> <li>Renstrom, Per, <i>The Below-Knee Amputee</i>, 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," <i>Fortschritte Der Medizin</i>, 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," <i>British Medical Journal</i>, 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," <i>Knitting Times</i>, 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," <i>Bulletin of Prosthetic Research</i>, 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," <i>Orthotics and Prosthetics</i>, Volume 35, No. 4, December, 1981, p. 34.</li> </ol> <b>Footnote</b> Midwest Research Institute is a professional not-for-profit corporation doing contract research for business, industry, government, individuals and groups.<br /><br /><b>Footnote</b> Available from Knit-Rite, Inc.<br /><br /><b>Joseph Zettl, CP. </b> Joseph Zettl, CP., is President of the American Artificial Limb Co., Inc., 1400 East Pike Street, Seattle, WA 98122.<br /><br /><b>Martha Field, M.S. </b> Martha Field, M.S., is Manager of Research and Development for Knit-Rite, Inc., 2020 Grand Avenue, Kansas City, MO 64141. <p style="width: 400px;"></p> 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/a7159063fb302b4a250573acb23abb85.pdf aa6c07bf41a25532666dc158ce0efc4b https://staging.drfop.org/files/original/c42f998e614f8cd33a557b45a09d067d.jpg 252589ddc51f2a80b7358f6974149b31 https://staging.drfop.org/files/original/8d6cfd7f8cac05cec1a7453dc79b69bd.jpg 4d64a6d4509dc6980e238a1a502d6547 https://staging.drfop.org/files/original/e6c5c23d894b219b103d507658c2b0ac.jpg 6e9ac58868a4f5e82d8a903c755fea21 https://staging.drfop.org/files/original/e91306e674a1c8947e9630148ddffd96.jpg ccb3e8403102657e330cce7186b530cc https://staging.drfop.org/files/original/68227ba109352f07e3866a1f452796c9.jpg 039bf222e5524b1352c7ab1b0ffd41a6 https://staging.drfop.org/files/original/19c1aad96069fabe0758187e646d1228.jpg e471fbdbef1ed11c58c71eff500781ba https://staging.drfop.org/files/original/2f07aa534dbd1584512f9c90809230d2.jpg 3570573c6cfd62aecaafbde8fbefc4ea https://staging.drfop.org/files/original/1a1fe4a37edcbe75d90b6ad73b8d0d4e.jpg c6ddc6b5a6d87db0bf2007ef5d8638b6 https://staging.drfop.org/files/original/75a33a9d6d5d0849ce7c12868685f1f9.jpg 1971a4230bd4ec28af875304f23a2cf6 https://staging.drfop.org/files/original/2617ce55fd29a20968da7d3e13766774.jpg 07a4a8a190d0f78932851483890b3b5d https://staging.drfop.org/files/original/c4d84385c58581f6533ec9d4e71f4fdc.jpg 30755fd905f1bc5e9d75566a928e222a https://staging.drfop.org/files/original/f6cffdc0a882bdda54350168a2222b6d.jpg a25624d88c7dadd9d6fa60f533badf24 https://staging.drfop.org/files/original/97eeaf86cf996280b7c14b0c5986553e.jpg 8268c26f3339dea97ccd44cdaba968a2 https://staging.drfop.org/files/original/015afe62ead49a74fb3a6f4162d7dc17.jpg cc0ba22ce6d1dbfee4a7d9bb8d429894 https://staging.drfop.org/files/original/9b82fe61ad066b08870be2171f256b77.jpg 36eccb8e1aac51332d921c634ede86be https://staging.drfop.org/files/original/e9359d5db4d7aafa657acee425a392c9.jpg 5b2005fd8445657c7504c01fe7a6773b https://staging.drfop.org/files/original/eec578b1c7b89a572f2f806882dda2fe.jpg ec67913ae1770d508da25e93c69258d2 https://staging.drfop.org/files/original/f69e7b05d484398ec53b97b665e4f948.jpg ac554dd86efbc1142de95f1fbca637b2 https://staging.drfop.org/files/original/fc43c4b25852b8cefa8ce6d8cccbb2cb.jpg 55676a5ab998ab1a06d8f6ea61c38fec DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_004.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 4 - 40 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience with Prosthetic Problems of Upper Extremity Amputees</h2> <h5>Marvin S. Gottlieb, M.A. <a style="text-decoration:none;">*</a><br />Robert L. Mazet, JR., M.D. <a style="text-decoration:none;">*</a><br />Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br />Marian P. Winston, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>The history of the upper extremity prosthetics program up to 1954 has been outlined in a previous article in this journal<a></a>. From 1950 to the present, the upper extremity research group established in the Department of Engineering, University of California at Los Angeles, has processed some 300 arm amputees: 72 during the Case Study Program<a></a>, an overlapping 250 during the 12 schools at the Prosthetics Training Center<a></a>, a small group of adult research amputees, and 104 children seen at the Child Amputee Prosthetics Project<a></a> prior to July 1, 1956. From the adult cases we have selected 23 of special interest to summarize in this article.</p> <p>First presented are five cases that responded well to standard methods, the purpose being to establish a baseline for comparison with the problem cases. Cases aided by the development of special equipment and by training in its use are grouped in one section because of the interrelationship between fitting, correct equipment, and amputee training. Under the heading of special equipment come the prototypes of several devices now standard in the armamentarium and also some modifications that remain unique to the individual wearer.<a style="text-decoration:none;">*</a> Cases aided by medical and biomechanical treatment are grouped together, again because of the interrelationship involved.</p> <p>Although some three fourths of all arm amputees encountered in the program have become consistent users of functional prostheses, we have chosen to present unsolved problems in nearly half of the case histories given here. The reason, obviously, is to draw attention to the areas of need. Apart from some unilateral wrist disarticulation and long below elbow amputees who operate easily and efficiently without prostheses (whom we do not consider to be problem cases), arm amputees who have the opportunity to be fitted properly, but who fail to use their prostheses, most often fall into one of three classes:</p> <ol> <li>Women of limited strength who object to the weight of forearm and terminal device.</li><li>Persons with severe biomechanical limitations, such as forequarter amputees.</li><li>Individuals suffering from disabling pain.</li></ol> <p>Just to show that arm amputees are no exception to the general orneriness of mankind, the closing section covers cases presenting unsolved psychosocial problems.</p> <p>It will be clear that several of the case histories might have been classified under some of the other headings. For example, in view of the drastic effects that the patient's postampu tation decrease in earnings had on his family life, Case 9, discussed from the viewpoint of special equipment, could as reasonably have been classified under psychosocial problems. Case 13, discussed under biomechanical treatment, represents also an achievement in equipment modification. And so forth.</p> <p>The expression "man machine combination" is a well worn phrase in contemporary bio technical research. In limb prosthetics, one might say, there is a "man equipment training combination" in which the man may be modified by medicine, by surgery, by physical or occupational therapy, by developments in the psychosocial realm, or by training in control and use of the prosthesis. The equipment must be compatible with all these and may have to be modified by redesign or special fitting to overcome the man's biomechanical limitations. Training may be either of negligible importance, as in Case 12, or crucial, as in Cases 7 and 11. Its usual importance tends to be somewhere between the two extremes.</p> <p>Finally, it may be noted that the standards, procedures, and techniques employed in fitting, fabrication, and training are all described in detail in the <i>Manual of Upper Extremity Prosthetics, </i>2nd Edition.<a></a> Similarly, all materials and most of the components mentioned are listed in the <i>Manual, </i>together with sources and characteristics. Of the components not otherwise referenced directly, all have already been described in previous issues of Artificial Limbs, in the collaboration by Klopsteg, Wilson, <i>et al. </i><a></a>, in manufacturers' catalogs, or in the general literature of the field. A number of the special components are described in recent reports of the Engineering Artificial Limbs Project at UCLA.</p> <h3>Cases Responding Well to Standard Methods</h3> <h4>Case 1, Forequarter</h4> <h5><i>History</i></h5> <p>Case 1, male, a 30 year old medical photographer, was first seen in the Case Study in February 1951, eight years postoperative. His left forequarter amputation, in which the left scapula and two thirds of the clavicle had been removed, followed injury in wartime Naval service. The Navy had provided him with a Navy Fitch<a></a> arm (double coupled flexion type with wooden forearm, leather socket, catgut cords, and double chest strap harness) but had not trained him to use it. Because of socket discomfort, he had worn no prosthesis for the preceding five years and was unable to operate his Navy Fitch arm at all for testing purposes. He was able to fulfill all his functional needs satisfactorily with one hand, did not believe that any functional prosthesis for his level of amputation was available, and sought only a cosmetic replacement.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was 6 ft. 4 in. tall, weighed 195 lb., was well muscled, and had good posture considering the extent of his loss (<b>Fig. 1</b>). The operative scar on the left shoulder girdle was well healed and not tender, but the area of the axilla was hypersensitive to touch. The subject was able to move the end of the remaining third of the clavicle only very slightly in flexion extension but was judged to have a good range of motion in elevation depression.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Case 1. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The patient's unusually good conformation enabled him to be fitted with a modified shoul der disarticulation prosthesis rather than with the usual forequarter type. Accordingly, a sectional type of shoulder prosthesis was prescribed, with emphasis on the cosmetic shaping of the shoulder cap. It included (<b>Fig. 2</b>) a chest strap harness with four attachment points on the shoulder cap, an opposite shoulder loop for dual control of terminal device operation and forearm flexion, and nudge control of the elbow lock since the patient had no desire for an actively operated elbow. The nudge control failed mechanically several times, a circumstance which led to a satisfactory redesign. Originally provided with a Dorrance hook, the patient later requested and received an APRL hand and hook. The pressure control feature of the APRL hook proved "invaluable" in his darkroom work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Case 1. Prosthesis provided at UCLA. The unusually good physical conformation and range of motion of this forequarter amputee enabled him to be fitted successfully with a modified shoulder disarticulation type of prosthesis rather than with the full forequarter socket. There was more functional regain than usual considering the patient's level of amputation. Compare with Cases 15 and 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training in use of the prosthesis was aided by the patient's wife, who was an occupational therapist. After training, the amputee passed nine out of ten activity tests and was judged to perform with extreme smoothness and remarkable ease and dexterity considering his level of amputation. When followed up a year later, the subject reported that he wore his prosthesis during most of his waking hours, sometimes as much as 120 hours a week, using the hand for most of his picture taking and public contact work and the hook in developing negatives and making prints.</p> <h5><i>Summary</i></h5> <p>In this case, better results were obtained than might reasonably have been expected. A unilateral forequarter amputee, the patient was interested only in a cosmetic replacement, did not seek functional regain, and did not believe that it was possible. Yet by proper fitting, followed by good training, he became an excellent prosthesis user.</p> <h4>Case 2, Wrist Disarticulation</h4> <h5><i>History</i></h5> <p>Case 2, male, a 38 year old machine operator and assembler of tools and outdoor furniture, was first seen by the Case Study in June 1952, seven years after amputation. His left hand had been lost by a shrapnel injury to the wrist while he was serving in a Polish French tank combat crew in Berlin. He had been fitted with a plastic socket with interchangeable Dorrance No. 8 hook and Becker wooden hand but had not worn the prosthesis for the preceding five months because the socket was broken. Prior to the breakdown, the patient had used the wooden hand 10 hours a day.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a screwdriver shaped stump with the styloids intact (<b>Fig. 3</b>). Physical condition was good, although forearm rotation was somewhat limited. The amputee had never received any physical therapy or prosthetic training.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 2. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>There is available no wrist cap that matches the elliptical cross section of the human wrist, and the wrist disarticulation socket must therefore be faired out to meet the round wrist caps used. In this case, an attempt was made to develop a manually operated wrist unit of elliptical cross section using rubber O rings to supply the friction necessary for resistance to rotation. But the resulting appearance was not satisfactory, the added length (1.3 in.) was too great, and frictional characteristics were not as desired. Rather than devote the time and effort necessary to redesigning the unit, the practical solution was adopted of using a Sierra Model C wrist cap instead and fairing out the socket accordingly (<b>Fig. 4</b>). Use of the Model C wrist cap decreased the length by half an inch and improved the functional characteristics.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case 2. Prosthesis provided at UCLA. Because of required weekly cleaning and relative breakability in heavy work, the APRL hook shown here was later given up in favor of a Dorrance No. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In accordance with the patient's desire, he was supplied with an APRL hook. He preferred it because of the selective prehension and "better mechanism" and because he felt that exposed rubber bands, as in the Dorrance models, would accumulate grease in his work. But the hook required weekly servicing because of dirt accumulation, and when the patient ripped the stud off he requested a Dorrance No. 5 hook instead. After experience with the Dorrance hook, however, he reported that it tended to scratch the furniture he polished on the job. At the patient's insistence, an auxiliary prosthesis was constructed for use with the old Becker hand, which he considered ideal for the polishing operation. The patient's one remaining objection to his prosthetic equipment was that, with his limited pronation supination, the hook could not be positioned fast enough, but the length of his stump contraindicated use of a step up rotation prosthesis. At last report, the patient was wearing a prosthesis 10 hours a day, 70 hours a week.</p> <h5><i>Summary</i></h5> <p>Case 2 was a relatively uncomplicated case that responded well to standard methods of fitting and prescription. This particular case points up the unavailability of certain desirable equipment for the wrist disarticulation amputee and the importance of considering all the occupational requirements in prescribing a terminal device.</p> <h4>Case 3, Medium Below Elbow</h4> <h5><i>History</i></h5> <p>Case 3, male, a 48 year old butcher specializing in breaking and boning fore quarters of beef, was first seen in the Case Study in July 1951, nine months after amputation of his left arm below the elbow and one month after prosthetic fitting. He wore his new prosthesis at work but not otherwise, and he complained of stump soreness and pressure, a shoulder saddle that tended to slip under load, and awkward placement of the thumb of the Dorrance No. 1 hook. He had received no training in the use of his prosthesis.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a screwdriver shaped stump, 7.8 in. from epicondyle to tip, exceptionally finn and well muscled, with the radius approximately half an inch longer than the ulna (<b>Fig. 5</b>). The forearm flexors were markedly hypertrophied, and forearm flexion was limited to 120 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case 3. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Because of the patient's heavy work, a heavy duty short below elbow type of prosthesis was prescribed (<b>Fig. 6</b>). The amputee specified modification in harness which called for replacing the leather shoulder saddle by one of washable webbing. In view of the patient's desire for selective prehension force, an <b>APRL </b>hook was prescribed experimentally, but it was badly damaged in the course of the patient's work and was therefore replaced by a Dorrance No. 1 hook. An F-M disconnect was tried. But after the patient's hard use broke the gear teeth of the disconnect three times, a threaded type of disconnect was prescribed instead. The first three sockets fabricated proved unsatisfactory the first because it interfered with circulation, the next two because of rubbing against the distal end of the radius and the ulna when the patient rotated his forearm. The fourth socket proved satisfactory, but the cables continued to fray with use and had to be replaced every few weeks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case 3. Heavy duty prosthesis as prescribed for reason of occupation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>This case emphasizes the importance of rugged equipment for heavy work in the manual trades and the shortcomings in this respect of many available components. The amputee made a contribution to limb prosthetics in initiating the washable webbing shoulder saddle. His experience with cable wear and frequent replacement indicates the problem which has since been very largely solved by swaged fittings and by the nylon cable housing liner.</p> <h4>Case 4, Below Elbow Biceps Cineplasty</h4> <h5><i>History</i></h5> <p>Case 4, male, a husky 18 year old student, first entered the Case Study in December 1951, six years after a right below elbow amputation that followed an explosion in a chemistry experiment in his home. About six months after the accident, he had been fitted with a laced leather socket and wooden hand, but he abandoned the device because he continued to break the fingers in the course of surf casting and other outdoor activities. About a year later, the patient obtained his second prosthesis, with a David work hook, and wore it daily until it became inoperable. He had received no prosthetic training.</p> <h5><i>Examination and Evaluation</i></h5> <p>The stump was 83 percent of forearm length, screwdriver shaped, and well muscled. The patient had a complete range of motion except for forearm rotation, which was limited to 30 deg. of pronation, no supination.</p> <h5><i>Treatment</i></h5> <p>Classified as a long below elbow type, the amputee was fitted with the standard prosthesis for his level of amputation, with an APRL hand and APRL hook. Operation of the voluntary closing device was learned readily, and the patient was judged an excellent user. In the trainer's judgment, the wearer's performance of test activities was as good as that of a normal person.</p> <p>Having heard of the increased range of motion and the freedom from shoulder harness made possible by the cineplastic procedure, the amputee returned to the clinic three months later as a candidate for biceps cineplasty under the experimental program. The operation was prescribed, and the biceps muscle tunnel was constructed in July 1952 without postoperative complications (<b>Fig. 7</b>). Six weeks after surgery, the patient returned to the clinic, where his below elbow biceps cineplasty prosthesis was completed (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Case 4. Patient after construction of biceps muscle tunnel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Case 4. Patient wearing cineplastic prosthesis. Tunnel could develop 120 lb. of pull under 10 lb. of initial tension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After fitting and training, the patient was tested, and his performance was found to be nearly as good as it had been with the harness controlled prosthesis. At that time, he experienced pain when the load on the tunnel reached 15 lb., but when this problem was overcome he proved to have a tunnel that could develop 105 lb. of pull when under 1 lb. of initial tension and 120 lb. under 10 lb. of initial tension. Two or three years later, the amputee modified his epicondyle clip by cutting it down in size and padding it deeply with foam rubber. Vinyl plastic was tried as a covering material, but the patient proved sensitive to it and went back to leather.</p> <p>After almost five years, this patient was wearing his prosthesis with APRL hook all of his waking hours. He had no interest in a hand and would not consider a voluntary opening hook, although he complained of the relative susceptibility of the APRL device to breakage. After several years' experience, he no longer broke his hooks, but the rubber linings wore off the hook fingers and required replacement every few months.</p> <h5><i>Summary</i></h5> <p>This case is an example of successful application of the below elbow biceps cineplasty. Although the amputee was an excellent user of a satisfactory harness operated prosthesis, he thought the increased range of motion and freedom from shoulder harness worth the surgery. This case also shows the amputee's insistence on using his preferred terminal device, even for activities for which he knew it was unsuitable.</p> <h4>Case 5, Above Elbow/Humeral Neck Combination With Bilateral Pectoral Cineplasty</h4> <h5><i>History</i></h5> <p>Case 5, male, a 31 year old Air Force fighter pilot and former ail American football player, entered the project in November 1950 on special leave from a military hospital. He had been under medical treatment since 1947, when the fire that followed a jet crash landing severely burned his head, the left side of his body, and both arms, resulting in bilateral arm amputation. Both pectoral muscles had been tunneled. The patient had been fitted with Navy Fitch double coupled flexion arms, the cineplastic tunnels being used for prehension control.<a></a> He complained of poor socket fit, restrictive harnessing, rotation of the sockets on the stumps, and the absence of an elbow lock and expressed a desire to learn to perform essential services for himself independently. Except for a six month program of exercise to strengthen the muscle tunnels, he had never received any training in connection with his amputations.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a right above elbow stump and a left humeral neck amputation, the two sides having the same pattern of scarring over the deltoid and the anterior and posteromedial aspects. There was limitation of humeral motion on the right side and no motion at all on the left. Exercises were prescribed. The patient appeared to be in excellent general condition, physically and psychologically. The right tunnel had a maximum excursion of 3 in. and a maximum force of 51 lb., the left 2.75 in. and 56 lb.</p> <h5><i>Treatment</i></h5> <p>To overcome the rotation of the sockets when the pectoral tunnels were contracted, to enable the amputee to don his prostheses independently, and to avoid the restriction of motion involved in force transmission through bilateral pectoral cineplasty, the right side (above elbow) was fitted and harnessed without use of the pectoral tunnel. The tunnel pin on the left side (humeral neck) was modified in an effort to improve efficiency of the power transmission system and to make it possible for the amputee to insert the pin either by means of the opposite prosthesis or by means of the mouth.</p> <p>Forearm flexion and prehension control were of the standard, harness operated dual type powered on the right side by humeral flexion and on the left by scapular abduction (<b>Fig. 9</b>), elbow lock on the left being operated by the left pectoral tunnel. After about three hours of training in the control and use of his new prostheses, the amputee was judged proficient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Case 5. Prostheses provided at UCLA. Use of the pectoral tunnel for elbow lock on the left side was later given up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The unused right pectoral tunnel was removed surgically, and about three years later the patient gave up use of the other tunnel but continued to use the prescribed arms without modification. He had had new prostheses made in 1953 but used them only for gardening and similar activities because he considered the upper portion of the right arm too long. In February 1957, more than six years after fitting, he was still wearing the prescribed arms and the same harness, although he had worn out four Northrop Sierra two load hooks and had been interchanging the two Northrop Model C elbows throughout the six years whenever service was required. He used the right prosthesis for most functions, with occasional help from the left. The patient did not bother with his own buttons or cutting his meat for himself, but he was active in the insurance business, took up hunting, and reported: "I write, drive, just like anyone else only thing, I ain't as pretty."</p> <h5><i>Summary</i></h5> <p>One of many cases in which pectoral tunnels did not work out as planned, this bilateral arm amputee was made independent through standard prosthetic fitting and training. He modified his bilateral prosthetic control system to emphasize unilateral function.</p> <h3>Cases Aided by Special Equipment and Training</h3> <h4>Case 6, Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 6, male, a 23 year old office worker and preamputation bakery truck driver salesman, entered the clinic in September 1952, five months postoperative. His right arm had been disarticulated at the shoulder (<b>Fig. 10</b>) because of a malignant tumor.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Case 6. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed no medical contraindications to prosthetic fitting. Exercises to increase the range of motion of the shoulder girdle were prescribed.</p> <h5><i>Treatment</i></h5> <p>At first, a standard, sectional type of shoulder disarticulation prosthesis was prescribed and fitted, with dual control for forearm flexion and prehension and with nudge control of the elbow lock, a Dorrance No. 555 hook being used to keep weight to a minimum (<b>Fig. 11</b>). Later the patient was given a Northrop Sierra two load hook to evaluate; he adopted it enthusiastically.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Case 6. Pioneer fitting of a shoulder disarticulation, including prototype of the UCLA manually controlled, friction type shoulder joint The amputee refused to give up the prosthesis even when bodily changes due to illness made it irritating. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the amputee experienced difficulty in putting on a shirt or coat, he asked for a movable shoulder joint which would allow him to flex his prosthesis in the parasagittal plane. Designed to his satisfaction, this device proved to be the prototype of the UCLA manually controlled, friction type shoulder joint. At the patient's suggestion also, the nudge control was redesigned to cut down its protrusion and prevent clothing from catching in it. A month later, the subject reported that he wore his prosthesis 12 to 15 hours a day, that it was adequate for the needs of daily living, but that he would prefer a cosmetic hand of some kind for social occasions.</p> <p>In May 1955, the patient underwent surgery for removal of a large metastatic tumor mass in the right lung, and beginning in September 1956 he received x ray therapy for an inoperable lesion of the left lung. Loss of weight and atrophy of the shoulder girdle impaired the fit of the prosthesis, but the subject rejected medical advice that he wear only a shoulder cap to decrease the weight. He continued to wear the prosthesis until irritation of the bony prominences of clavicle and scapula necessitated prescription of a new soft socket liner in February 1957. At that time he was in good general health and working regularly.</p> <h5><i>Summary</i></h5> <p>This pioneer fitting of a shoulder disarticulation case resulted in devices now standard in the armamentarium. The satisfaction gained by the patient from his prosthesis is indicated by the fact that he insisted on wearing it even when bodily changes made it irritating physically.</p> <h4>Case 7, Bilateral Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 7, male, a 63 year old bridge and building construction foreman with bilateral shoulder disarticulations (<b>Fig. 12</b>), entered the clinic in November 1953, three months after the amputation of his right arm because of osteomyelitis. The left arm had been amputated 15 years earlier as an ultimate aftereffect of trauma in 1923. The patient had never worn a prosthesis. In addition to independence in self care, he particularly needed to be able to sign his name the one manual function required in his job.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Case 7. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a well healed scar in the left shoulder region but on the right some postoperative edema, encrustation, and weeping. Shoulder motion was limited, and strength was poor.</p> <h5><i>Treatment</i></h5> <p>After an interruption due to an unrelated operation (splenectomy), the amputee was fitted at the Prosthetics Training Center bilaterally and also unilaterally with a right shoulder disarticulation prosthesis. A year later, in 1955, he reported that he wore either the bilateral set or the unilateral prosthesis all his waking hours, usually the unilateral prosthesis, which had greater force and excursion and did not present the problem of interaction of controls. But he used this prosthesis only for picking up and carrying light objects and for nonprehension activities, such as pushing, pulling, striking, and hooking.</p> <p>In May and June of 1955, the patient spent seven days at the Prosthetics Laboratory for alterations, experimentation, and training. His shoulder turntable was modified by addition of a Belleville washer in order to maintain constant friction, and nylon cable housing liners were installed. Several experimental modifications of the elbow unit were tried in an attempt to secure smooth, reliable operation, but the final solution consisted of generous lubrication of the cable with paraffin, plus replacement of the housing by another long enough to allow an in line entry of the cable into the locking unit.</p> <p>The amputee's difficulties with the other components of his prosthesis resulted from lack of understanding of the mode of function, and he was therefore given intensive training. Patterns of activity feasible for this particular patient were worked out, and practice was supervised. Under this guidance, he learned to eat "all shapes and consistencies of food" with a fork, to write legibly, to unzip and zip his trousers (with a 3 in. elkhide thong attached to the zipper pull) for independent urination, to put on and take off a shirt or coat, to turn book and magazine pages, and to perform other activities. The therapist devised special equipment for his use, including a stand for his electric shaver and a simple trouser belt with a D ring buckle that he could tighten or loosen with one prosthesis.</p> <p>In January 1956, it was found that the patient had not been employing these techniques at home because it upset his wife to see him struggle and she preferred to do things for him. In March 1956, he was fitted with a unilateral prosthesis employing the UCLA manually controlled, friction type shoulder joint, modified arm rotation turntable, nylon cable housing liners, and a cable excursion multiplier (<b>Fig. 13</b>). He was the first of the amputees fitted with this system. Two months later, he wrote that he had leveled a building lot by hand and prepared it for planting, performed household chores, and worked in an office answering the phone, writing down messages, and checking workmen in and out with equipment. In December 1956, the amputee wrote, in his own shaky but legible penmanship, to report the prolonged illness of his wife, during which he had taken care of himself after years of dependence.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case 7. Successful unilateral fitting of the bilateral shoulder disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>This complex case has been given in some detail because it highlights several different aspects of the problem of the severely handicapped amputee. The interrelationship of equipment and training is pointed up. When the patient was unable to operate his components, the solution resided in modification of some, realignment in one case, and better training in use of the others. The effect of oversolicitous family members in keeping the handicapped person dependent is shown. Given usable prosthetic equipment and training, this elderly bilateral shoulder disarticula tion amputee was able to operate independently when his wife was no longer able to help him. The case meets one of the prevailing standards of rehabilitation gainful employment at an appropriate task.</p> <h4>Case 8, Very Short Below Elbow</h4> <h5><i>History</i></h5> <p>Case 8, male, a 32 year old clerk, was first seen in the Case Study in November 1950. His very short below elbow amputation had resulted from machine gun fire during service as an Army rifleman in France in September 1944. Except for the insertion of the biceps, the forearm musculature had been lost. Several unsuccessful efforts at prosthetic fitting unsuccessful because of the limited stump motion had convinced him that he would have to undergo reamputation above the elbow in order to be fitted with a useful prosthesis. He came to the Case Study as a last resort before reamputation.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination revealed a 3.8 in. below elbow stump. A bony block in the elbow limited forearm motion to between 150 and 165 deg. of extension.</p> <h5><i>Treatment</i></h5> <p>A very short below elbow split socket prosthesis was prescribed, with an above elbow type of dual control for forearm flexion and prehension and with a special device which enabled the 15 deg. of stump motion to operate the elbow lock (<b>Fig. 14</b>). This was the prototype of the stump actuated elbow lock now standard in the armamentarium.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Case 8. Amputee with very short (3.8 in.) below elbow amputation fitted with the stump actuated elbow lock. Reamputation previously considered, was avoided. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the patient rated the prosthesis as excellent, he felt that more practice was needed in learning to operate the elbow lock with his stump and was found not to be wearing the prosthesis as many hours a week as he had reported. Three years later, however, he was wearing the limb constantly.</p> <h5><i>Summary</i></h5> <p>In this clear cut case, the design of a special device to meet a special situation solved the amputee's problem. The patient was saved from reamputation by the development of a device that is now standard. The history suggests, however, that the solution would have been still more successful, in terms of prosthesis use, had the amputee received more training and perhaps psychological counseling.</p> <h4>Case 9,Very Short Below Elbow With Biceps Cineplasty</h4> <h5><i>History</i></h5> <p>Case 9, male, age 40, was seen as an industry counseling case in October 1951, two and a half years after an amputation which resulted from an industrial accident while he was working as an elevator and control system installer. On the patient's return to work, after nearly two years' disability, the elevator company had transferred him to office work at slightly more than half his former salary. On the reduced income, he had been forced to give up his home. his wife suffered a nervous breakdown, and the two children had to live with relatives during a long period of readjustment. He had been provided in 1949 with a cosmetic arm and "Realastic" hand but had never had a functional prosthesis.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a left very short below elbow stump, badly scarred, with flexion limited to 90 deg. by a bony block in the elbow. Shoulder motion also was limited.</p> <h5><i>Treatment</i></h5> <p>The amputee was given a short below elbow prosthesis with an APRL hand and with the forearm set in 20 deg. of initial flexion. Five months later he reported himself satisfied with this limb and, although he said he was wearing it 12 hours every day, he desired a step up hinge to increase forearm flexion. In September 1953, a split socket prosthesis with variable ratio step up hinge was fitted, with both hook and hand as terminal devices. The new prosthesis increased the patient's maximum forearm flexion to 120 deg., and he was judged as being "very adept" with both hand and hook. After acquiring a functional prosthesis, the amputee was able to return to his skilled trade with another employer, although he had to start as an elevator mechanic's helper.</p> <p>Learning that still greater functional regain (ability to operate the prosthesis above shoulder level) was possible with biceps cineplasty control, the patient had his left biceps muscle tunneled in August 1954 as an experimental subject in the below elbow biceps cineplasly program (<b>Fig. 15</b>). Shortly after the surgerv, he was fitted with a below elbow biceps cineplasty prosthesis with split socket, variable ratio step up hinge, and UCLA control system. In March 1956, an experimental prosthesis was fabricated for him using the new UCLA 1.5 ratio step up elbow hinge (<b>Fig. 16</b>). With this limb he was able to lift 11 lb., nearly twice his previous maximum. It should be remembered that in this case slump flexion was not aided by the biceps because the biceps tendon had, of course, been severed The 1.5 ratio hinge gave 5 deg. more forearm flexion than did the variable ratio hinge. Although this increase in forearm flexion was of no importance to the patient, who had fell that the variable ratio hinge gave all the forearm flexion he needed in his left arm, he greatly appreciated the ease and smoothness of action of the 1.5 ratio hinge. By 1957 he had advanced to the position of elevator inspector.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Case 9. Patient after construction of biceps muscle tunnel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Case <i>9 </i>Patient fitted with UCLA below elbow biceps cineplasty system using split socket and the 1.5 ratio step up elbow hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>This case highlights the contribution of new devices to the welfare of the amputee with a very short below elbow stump.. It also points up the socioeconomic value of a functional prosthesis in the manual trades. When this amputee was prevented from working at his highest level of skill, severe dislocation was experienced by an entire family. Fitting of a suitable prosthesis enabled him to return to gainful employment.</p> <h4>Case 10, Congentinal Below Elbow.</h4> <h5><i>History</i></h5> <p>Case 10, female, a 37 year old teaching nun, entered the clinic in January 1955. A congenital left below elbow amputee, she had worn cosmetic arms since the age of four She was wearing a cosmetic appliance 6 hours a day, 5 days a week, but desired more prosthetic function. Her particular desire was to be able to hold an open book while writing at the blackboard.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was of slight build (<b>Fig. 17</b>). Stump length was on the borderline of the very short below elbow type (3 in. below the epi condyles). Forearm flexion was limited to 90 deg., and strength was also limited. There was pain on pressure at the tip of the stump and along the anterior surface; x rays showed two bony spurs on the anterior surface of the ulna.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case 10 Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The patient was first fitted with a short below elbow prosthesis with Hosmer PC 100 hinges, flexion range being sacrificed for simplicity. Three months later, another prosthesis was made, with outside locking elbow hinges as commonly used with the elbow disarticula tion type of prosthesis. For greater gripping surface, the Dorrance No. 555 hook was replaced by a Dorrance No. 5X. To help relieve pressure on the stump during forearm flexion, the therapist suggested use of humeral abduction, and the patient found this technique made many activities more comfortable and less awkward.</p> <p>For further relief from pressure, a polyure thane foam socket liner was made the following July. The seam coincided with a bony prominence, however, so that a new liner was necessary. At the same time, the socket was cut out to free the medial epicondyle.</p> <p>When nylon cable housing liner was installed in February 1956, the patient reported that:, although it afforded great mechanical advantage, it deprived her of the "vibration feedback" on which she had previously relied for information as to her cable tension and amount of hook opening. The final modification (<b>Fig. 18</b>) was made in July 1956, when a chest strap was added to the harness to prevent it from slipping off the shoulder when the arm was raised in upward and backward motions. Over the period covered, the patient tried several hooks, alternating between her needs for greater gripping surface and for lighter weight. Her final choice was the Dorrance No. 5XA. In February 1957 she was provided with three interchangeable socket liners for purposes of cleanliness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18, Case 10 Present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This patient's desire to pass out papers to her classes was met by the technique of holding the stack of papers upright with the right hand and picking off copies with the hook.</p> <h5><i>Summary</i></h5> <p>This case indicates the experimental approach that must be adopted to meet the needs of an amputee with special physical limitations. It also suggests the use of the custom fitted soft socket liner when the amputee's stump configuration is too complex and painful to be made comfortable in the conventional plastic socket. The outside locking elbow hinge provided the needed stability for this short below elbow amputee with limited strength.</p> <h4>Case 11, Short Above Eelbow/Humeral Neck Combination</h4> <h5><i>History</i></h5> <p>Case 11, female, a 35 year old health educator and graduate dentist, entered the program in March 1953, 11 years after amputation. With right short above elbow and left humeral neck stumps, she had lost her arms as a result of electrical burns in a sailing accident. Before her marriage, she was self supporting as a teacher and lecturer. After marriage, she was an active housewife and mother of two small sons. She had been fitted with bilateral prostheses of modern type in 1947. Her second and third prostheses were for the above elbow side only, and the third, fitted in November 1952, was the first to incorporate an elbow lock. The family moved from Michigan to Los Angeles so that the patient could enter the UCLA program. They remained for two and a half years, during which various combinations of prosthetic equipment were tried.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a right stump extending 5.3 in. below the acromion, a left stump 3 in. below the acromion (<b>Fig. 19</b>). The patient was tall and broad shouldered, with excellent mobility of the shoulder girdles. The right stump required shrinkage, however, and in September 1954 the subject underwent surgery for excision of a neuroma, a spur, and a bursa. Simultaneously, excess fat and skin were trimmed off. About six months later, a fibular bone graft into the left humeral head was performed, but the stump thus produced was not functional, it projected at an awkward angle, and it proved sensitive to socket pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 19. Case 11, Patient as seen on referal. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Before the bone graft, the amputee was fitted bilaterally (<b>Fig. 20</b>). She was trained to use each arm effectively, but because of interaction of controls she had great difficulty in coordinated activities and she found that the left arm was in the way in many functions. She was taught to drive an automobile (for the first time) using the driving ring, obtained her driver's license, and from that time continued to drive for herself and to take her turn at the wheel on long trips. She prepared the family meals and washed the dishes but did not feed herself because of limited forearm ilexion. Later, with the addition of a wrist flexion unit and with intensive training, she learned to use a fork effectively but found it an activity too fatiguing for everyday use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Case 11. Patient as fitted bilaterally. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In June 1955, before the grafted slump was ready for fitting, the patient was fitted with a right prosthesis, with only a shoulder reaction cap on the left side (<b>Fig. 21</b>). Function was much better without cross controlling, <b>but </b>she stated that bilateral fitting was worth some sacrifices for the sake of body balance and prevention of spasm of the neck and back muscles.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Case 11. Patient as fitted unilaterally with opposite shoulder reaction cap. Properly aligned unilateral prosthesis gave body balance without counterweigh ting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The disadvantages mentioned were found to be due to subtle misalignment of the single arm and were corrected by fabrication of a unilateral prosthesis correctly aligned.</p> <p>In a final attempt to achieve successful bilateral fitting, the patient suggested a perineal strap. This change in harnessing, tried in January 1956, succeeded in separating the control motions but at the cost of limiting motion and preventing the wearer from putting on her prostheses independently. After this, the subject concluded that unilateral fitting without perineal harnessing gave her the maximum of function, especially with the aluminum Dorrance 5XA hook and a slightly shortened forearm. Several months after the family moved away, the amputee sent word that her final prosthesis was the lightest and most comfortable of all and reported that she fed herself quite nicely with the swivel "spork" (combination of spoon and fork).</p> <h5><i>Summary</i></h5> <p>The maximum comfort and function attained by this bilateral high level amputee was obtained with unilateral equipment. Even body balance was restored by careful alignment without further counterweighting of the opposite side. Intensive training, plus high motivation on the amputee's part, resulted in regain of many functions and the learning of some new ones <i>(e.g., </i>driving a car). The attempt to lengthen the humeral neck stump by a bone graft, while successful from a surgical viewpoint, was of no prosthetic value because of the angle of the resulting stump.</p> <h3>Cases Aided by Medical and biomechanical treatment</h3> <h4>Case 12, Shoulder Disarticulation With Weak Pectoral Tunnel</h4> <h5><i>History</i></h5> <p>Case 12, male, a 22 year old beekeeper, entered the program as an industry counseling case in February 1952, 18 months after the loss of his right arm in a mortar barrage during the Korean War. The small cineplastic pectoral tunnel that had been constructed was intended to operate the elbow lock of the shoulder disarticulation prosthesis with which he had been fitted. But when the patient was seen at UCLA, he was operating the elbow lock manually with the opposite hand because the tunnel pin excoriated his muscle tunnel and also because operation of the elbow required more excursion than he could produce (because of stretching of the nylon control cord).</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed the pectoral tunnel to be unusually narrow and superficially placed (<b>Fig. 22</b>). The maximum force developed during testing was 8 lb., less than one sixth the force normally available from a pectoral tunnel. Although the two shoulders were at the same height, the patient had developed a thoracic curve with compensating lumbar curve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case 12. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Prescribed physical therapy included posture instruction and practice, exercises to develop the left arm and right shoulder girdle, and DeLorme progressive pulley exercises for the muscle tunnel. After 20 half hours of supervised practice and eight hours of massage and irradiation, the maximum force available from the pectoral tunnel had more than doubled to 19 lb., still about a third of the normal amount but more than enough to operate the prescribed elbow lock. The tremor which had been evident on contraction had disappeared.</p> <p>A question mark muscle pin was prescribed to overcome the rubbing and pressure pain experienced with the straight muscle pin, and an adjustment turnbuckle was included. A larger shoulder cap (with circular cut out for the muscle tunnel) provided stability, and the modern cable transmission system lessened friction and increased efficiency (<b>Fig. 23</b>). Instead of the hinge joint which had allowed the patient to abduct his prosthesis by bending his body to the right, the prescribed prosthesis included the new UCLA manually controlled friction type shoulder joint, which allowed him to flex the humeral section.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case 12. Present prosthesis. By physical therapy and suitable adaptation of equipment, a weak, superficial pectoral tunnel was reclaimed for elbow lock operation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training results cannot be reported because the subject left for his home state as soon as his new prosthesis was checked out. The physical therapist, however, reported that the patient was "quite adept without instruction."</p> <h5><i>Summary</i></h5> <p>This amputee represents a case of a surgically inadequate pectoral tunnel which, by physical therapy and proper adaptation of equipment, was reclaimed for elbow lock operation.</p> <h4>Case 13, Female Congenital Below Elbow With Weak Biceps Tunnel</h4> <h5><i>History</i></h5> <p>Case 13, a 25 year old office worker first seen in March 1951, is the only female cineplasty case in the UCLA experience. A congenital left below elbow amputee, she had been fitted with her first prosthesis in October 1949 after biceps cineplasty and had never received any training. The patient reported that since graduation from high school she had been employed in secretarial work, bookkeeping, filing, sorting, operating "Mimeograph," running an "Addressograph," manning a PBX switchboard, and typing and that her amputation had not affected her earning power. She stated that her cineplastic Huffner prosthesis with magnesium forearm and metal hand was too heavy, fitted poorly, rubbed at the elbow joint, and caused damage to clothing. The tunnel pin was observed to slip to one side during operation, and the prosthesis rotated accordingly so as to require readjustment every 15 minutes.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a firm stump with a full range of forearm flexion. Curvature of the bones limited extension of the forearm to about 150 deg. The muscle tunnel showed a usable excursion of approximately 2.5 in. and a rest length force of 13 lb.</p> <h5><i>Treatment</i></h5> <p>Resistive exercises were prescribed to be performed at home, and tunnel exercise pins of increasing diameter up to 1/3 in. were given successively. Work on the prescribed prosthesis was started during the fifth week of exercise. Although there was a temporary gain of 1 in., tunnel excursion did not increase permanently as a result of exercise, but the force more than doubled to approximately 30 lb. While this value is markedly less than normal biceps cineplasty tunnel force in a male amputee, lack of comparative data on female cases prevents a judgment as to whether this relative weakness of the biceps is normal for the patient's sex.</p> <p>In any event, the tunnel was not adequate to operate the desired terminal device, the APRL hand. Accordingly the mechanical advantage of the lexer system of an APRL hand was doubled, thereby reducing the force requirements by one half but doubling the excursion requirements. The problem of slipping of the tunnel pin was eliminated by the development of the UCLA equalizing yoke, which also increased the available force by maintaining the tunnel ina slightly prestretched position (now the standard procedure). The new prosthesis (<b>Fig. 24</b>) enabled the patient to obtain 5 lb. of prehension force at 1 in. of opening, as contrasted to the 1 lb she was able to obtain with her old equipment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Case 1.3, Patient with new prosthesis Physical therapy, modification of equipment, and special training made useful an otherwise surgically inadequate biceps tunnel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unfortunately, family reasons required the patient's return to Chicago immediately after checkout, without any training. During the next two years she wore the prosthesis little. After two years, referral to Dr. Clinton L. Compere in Chicago resulted in the fitting of a new prosthesis, with proper training in its use, after which the amputee became a satisfied and consistent user When followed up three vears later, she continued to express satisfaction with her prosthesis and recommended cineplasty to other female amputees.</p> <h5><i>Summary</i></h5> <p>This case points up the interrelationship between considerations of surgery, physical therapy, engineering, and training. An essentially inadequate muscle tunnel (a surgical problem) was rendered useful by exercise, special individual modifications of equipment, and development of components which benefit all below elbow biceps cineplasty amputees. The results of physical therapy and engineering design were negated by lack of prosthetic training. When training became available, the amputee was changed from a virtual non wearer to an enthusiastic user.</p> <h4>Case 14, Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 14, male, a 27 year old purchasing liaison representative with a paralyzed right arm, first appeared at the project in June 1952. A brachial plexus traction injury six years earlier had resulted in loss of arm control and virtual loss of forearm control.</p> <h5><i>Examination and Evaluation</i></h5> <p>A few intrinsic muscles remained in the hand, the forearm could be flexed very slightly, and a low level of sensation remained, but all the major arm and scapular musculature had atrophied. The patient was exceedingly anxious to have the flail arm removed so that he could wear a functional prosthesis. He said that the flail arm was useless and in the way. He was experiencing marital difficulties during this period, and the clinic psychologist suspected that the desire for amputation might be an emotional reaction to the home situation. The clinic strongly recommended against amputation until functional bracing had been tried. It prescribed such bracing. But this advice was not followed, and the arm was amputated.</p> <h5><i>Treatment</i></h5> <p>In August 1952, the patient reappeared at the clinic, a month postoperative, for fitting as a shoulder disarticulation amputee (<b>Fig. 25</b>). He was instructed in how to correct posture and was given shoulder exercises to do. Fitting and training in the use of a standard shoulder disarticulation prosthesis resulted in excellent use (<b>Fig. 26</b>). The amputee continued to serve the schools of the Prosthetics Training Center and the UCLA research program as an amputee subject, was considered an excellent user of his prosthesis, and stated three years after amputation that he had never regretted his decision. As far as the staff can judge, his emotional difficulties appear to have been resolved by the amputation and successful prosthetic fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Case 14. Patient as seen one month after voluntary disarticulation of a flail arm against clinic advice. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Case 14. Successful shoulder disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>It is difficult to prescribe the removal of an extremity that retains some sensation and some function, with a view toward replacing it with a mechanism. This patient knew what he wanted, obtained it against the advice of the clinic, and is apparently well satisfied with the results.</p> <h3>Cases Presenting Unsolved Problems of Biomechanical Limitation</h3> <p>The chief unsolved problem of biomechanical limitation in upper extremity prosthetics is the case of the forequarter (interscapulo thoracic) amputee, whose entire scapula and clavicle have been removed. In the UCLA experience to date, there has been no congenital forequarter amputee and only one caused by injury.<a style="text-decoration:none;">*</a> All the rest had undergone amputation because of malignancies. With the possible exception of one traumatic child case, which is still in question, within the knowledge of the staff no true forequarter amputee has become a successful user of a prosthesis.</p> <p>In forequarter cases, any functional regain is achieved at the cost of great effort because so little excursion is available by way of body control motions and because so much area must be covered by the socket for stability virtually the entire thorax and back to the mid line on the side of amputation plus a curved lobe that hooks around the neck onto the opposite shoulder. So far, none of our forequarter cases have considered the effort and discomfort worthwhile. Their attitudes may be influenced by a conscious or unconscious fear of stirring up malignancies, for the mortality rate among these cases has been high.</p> <h4>Case 15, Forequarter</h4> <p>Case 15, a 30 year old housewife, entered the project in June 1955, seven months after amputation for a recurrence of rhabdomyosarcoma. She was intelligent and anxious to cooperate. After a three month period of training and practice in use of the prescribed prosthesis, she doubted whether the functional regain was worth the effort and discomfort. Later, word of her death reached the clinic.</p> <h4>Case 16, Forequarter</h4> <p>Case 16, a 31 year old housewife, was seen in July 1955, about four months after amputation for a malignant synovial tumor. After prescription, fitting. and instruction, she was unable to operate the prosthesis enough to check it out for mechanical functioning. Because she was able to manage adequately with one hand all of her activities except sewing and knitting, and because she found the prosthesis hot, heavy, uncomfortable, and difficult to operate, she withdrew from the program and was referred to a maker of cosmetic restorations.</p> <h4>Case 17, Congenital Quadrilateral</h4> <h5><i>History</i></h5> <p>Case 17, male, a 27 year old congenital quadrilateral amputee 29 in. tall, entered the clinic early in 1951. Born without legs (bilateral hip disarticulations), he managed locomotion at home by hopping on his pelvic musculature. Away from home he was dependent on others for transportation; he could maneuver his wheelchair into the street but not across curbs. On the right was a below elbow stump, while the left stump was above elbow.(<b>Fig. 27</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Case 17. Upper extremities<b> </b>of patient<b> </b>as<b> </b>seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient operated a 24 hour telephone answering service at home with the help of his wife and one part time employee. He often worked the switchboard for eight hours without relief, writing down messages by means of a pencil inserted in a leather band worn on the below elbow stump. He also ran a baby sitting agency and from time to time recruited and managed telephone sales crews for special sales campaigns. His regular working day was 10 hours. His businesses were growing, but he felt handicapped by his inability to visit prospective clients. He had been fitted with artificial arms at the age of 21, but he found them in the way for the quick motions necessary in his work. Except for a wooden ladder used to reach chairs, toilets, and so on, he took care of all his vocational, avocational, and personal hygiene activities without the use of prostheses or special facilities.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed the above elbow stump to be limited lo 70 deg. of abduction, 95 deg. of flexion, and 5 deg. of extension, with no rotation at all. The arm on the below elbow side was limited to 80 deg. of abduction, 120 deg. of llexion, 15 deg. of extension, and 10 deg. of rotation, the elbow being fused at approximately 90 deg. The patient had never had physical therapy, and none was prescribed because his strength was satisfactory and it was felt that, in view of the fact that he was a congenital amputee, the muscles could not be stretched without severe pain.</p> <h5><i>Treatment</i></h5> <p>The new prostheses fitted to the patient (<b>Fig. 28</b>) were evaluated by him and shown by test to be excellent in relation to his old pair. But 20 hours of training led to the conclusion that interference with old habit patterns was insurmountable, especially because the subject wore the prostheses only six hours a week and was too busy to practice. At no time did his performance of test activities with the prostheses approach his performance with bare stumps. But he found the limbs useful for social occasions. His evaluation remained the same after a year of wearing the prostheses six hours a week.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Case 17 Prostheses provided Right prosthesis is cut out to accommodate characteristics of the below elbow stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One benefit the patient received from his participation in the UCLA program was the design of a special pigeonhole device which served his filing needs far better than did the notebook system he had been employing. A specially designed prosthesis holder enabled him to put his arms on without help.</p> <h5><i>Summary</i></h5> <p>In the case of an amputee who combines severe limitations (by ordinary standards) with well established habit patterns that enable him to function quickly and efficiently without prostheses, training in the use of prostheses may be futile. This amputee, who in his vocation operated far better without prostheses than with, nevertheless appreciated prostheses for wear on social occasions.</p> <h3>Cases Presenting Unsolved Medical Problems</h3> <h4>Case 18, forequarter</h4> <p>Case 18, a 68 year old housewife, was seen in November 1953, seven months after her right forequarter amputation. The medical report obtained from her physician indicated that she had undergone a simple mastectomy of the right breast in October 1944, x ray therapy of the axillary areas in 1945 and 1947, and a left radical mastectomy for metastasis to the contralateral breast and axilla in 1950. Paralysis of the right arm had developed in 1952, and forequarter amputation was performed in March 1953.</p> <p>In view of the advanced age and history of malignancy, the clinic agreed that a functional prosthesis was contraindicated. A soft cosmetic shoulder cap was prescribed to meet the amputee's need for body balance and symmetrical appearance.</p> <h4>Case 19, Shoulder Disarticulation/Short Above Elbow Combinations</h4> <h5><i>History</i></h5> <p>Case 19, male, a 60 year old railroad pensioner, entered the clinic in November 1951. Ten years earlier, he had been run over by a boxcar. Shoulder disarticulation of the right arm, amputation of the left arm about 3 in. below the acromion, and application of a tibial graft to the above elbow stump had followed (<b>Fig. 29</b>). The stumps proved too sensitive to be fitted with prostheses, and the patient had been unemployed ever since, living on his railroad pension and dependent on others for his daily needs. Throughout that time, he had had intense sensation of phantom hands, with the "fingers" painfully pinched together and somewhat overlapped.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Case 19 Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>In May 1952, the patient underwent with good results a partial resection of the pectoralis major tendon for the purpose of lengthening the above elbow stump. At the same time, three supposed neuromata, which turned out to be tender masses of scar tissue, were removed from the most sensitive areas. The operation was of some help, but the pain remained in the scar areas and in the distal 3 in. of the anterior aspect of the bone graft and prevented the amputee from sleeping and from wearing the prosthesis prescribed and fitted to him.</p> <p>Later in 1952, the patient was hospitalized for two weeks at the Pain Clinic at the University of California Medical Center in San Francisco. Under relatively mild sedation of phenobarbital and Seconal, he slept well and required only a few grains of codeine. Indefinite continuation of the mild sedation was recommended. The phantom pain disappeared after injections of sodium amytal, but the tender areas of the stump were not eliminated. Efocaine was ineffective, and treatment with a strong vibrator was not well tolerated. The intraspinous injection of sodium chloride solution as a counterirritant caused the trigger points to disappear only temporarily. Finally, in view of the patient's improved frame of mind, it was decided that minor pressure, such as would be exerted by the prosthesis, might be tolerated.</p> <h5><i>Treatment</i></h5> <p>Although pairs of prostheses of modern design were prescribed and fitted to the patient during the schools at the Prosthetics Training Center, his stump pain remained an unsolved problem. In April 1956, when the subject was 65 years of age, intensive research began on the case. The decision was made to fit the shoulder disarticulation side only and to make a reaction cap socket for the above elbow side rather than to make further attempts at bilateral fitting. Sectional plates were modified to form the UCLA manually controlled, friction type shoulder joint and skewed 20 deg. to the sagittal plane so as to enable passive flexion and abduction of the humeral segment. The arm rotation turntable was modified by addition of a Belleville washer for finer adjustment of tension, and a cable excursion multiplier was added. The use of nylon cable housing liners, which had been adopted as standard procedure at UCLA, greatly decreased cable friction and increased smoothness.</p> <p>Mechanically, the prosthesis enabled the patient to perform simple grooming and eating manipulations for himself. But pain under the left reaction cap intensified with the use of the prosthesis. Investigation showed that this problem was due partly to inadequate training. In addition to left shoulder flexion to stabilize the reaction cap, the amputee was employing flexion of the above elbow stump. Although training in the correct motion was given, it was not expected that the patient would overcome his faulty habit patterns, and a mechanical solution was sought.</p> <p>After several unsuccessful trials, a reaction cap was made from a wrap taken with the humeral segment snug against the body but with the distal end of the stump projecting slightly (<b>Fig. 30</b>). This expedient transferred the undesirable pressure to the anterior portion of the stump. To alleviate the pressure there, a cutout was made and margined with foam rubber padding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case 19. Patient as fitted unilaterally with specially designed opposite shoulder reaction cap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Staff evaluation was that, while the mechanical results were very good, the potential functional regain would be somewhat limited by the patient's outlook and by his habits of dependence. It should be mentioned, perhaps, that this amputee supplemented his meager pension by earnings in part time employment at a men's club. With his prosthesis he carried a specially built tray for holding several drinks.</p> <h5><i>Summary</i></h5> <p>Here was a very complicated case in which intense phantom pain of 11 years' standing was eliminated but in which stump pain persisted. Mechanical problems were solved by the UCLA unilateral equipment for bilateral shoulder cases, but the amputee's habits and motivations limited full prosthetic effectiveness. At least this patient was enabled to earn some money for the first time in 15 years.</p> <h4>Case 20, Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 20, male, a 26 year old Polish born Israeli plumber, well driller, and, after amputation, clerk, entered the project in August 1951. During the Arab Israeli War of 1948, when a jeep in which he was riding struck a land mine, he had suffered a crush injury to the left arm, which resulted in shoulder disarticulation. Afterward, the patient experienced intense and continuing phantom pain in the missing hand, in the distal third of the phantom forearm, and occasionally in the entire phantom arm. Usually the phantom hand was localized in the normal position, but sometimes it was perceived as telescoped to the phantom elbow.</p> <p>Paravertebral punctures had been employed, but the relief lasted only until the anesthetic wore off. Sympathectomy of the thoracic chain had no effect, nor did eight electric shock treatments administered by a psychiatrist. The patient was then sent by the Israeli Government to California for treatment.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed marked scoliosis (the left shoulder carried 1.5 in. higher than the right), an extreme anterior protrusion of the thorax, and lateral curvature of the spine (<b>Fig. 31</b>). The patient had never received physical therapy, and the left shoulder girdle was atrophied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Case 20. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Exercises to correct scoliosis and to increase range of motion were prescribed, the Sayre head sling was used to stretch tight neck musculature, and self corrective mirror instruction in posture was given. When last seen in May 1952, the subject was still performing his exercises, and his posture and shoulder mobility had improved markedly.</p> <p>Case 20 was fitted with a standard shoulder disarticulation prosthesis (<b>Fig. 32</b>), which he valued highly and which he wore all of his waking hours despite the discomfort of a perineal strap, which, because of unhealed operative wounds, he preferred to an opposite shoulder loop. But his phantom pain continued to be disabling. Two stellate ganglion blocks were attempted but failed. In October 1951, a neuroma of the left brachial plexus was removed, and a marked fibrotic scalenus anticus muscle was cut and allowed to retract. The patient was pain free for 10 days during the next month, but thereafter the pain returned with even greater intensity. In December 1951, therefore, he was referred to the Pain Clinic at the University of California Medical School in San Francisco.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Case 20 Standard shoulder disarticulation prosthesis supplied to patient, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>On examination, the staff of the Pain Clinic found a strip of complete anesthesia below the left clavicle (thought to be related to the scalenectomy) and generally poor sensation on the left side of the entire body, with reduction of urinary and sexual function. These deficiencies were gradually eliminated during the weeks of the patient's treatment at the Pain Clinic. But no relief whatever of the phantom pain was obtained by counterirritant injection of sodium chloride into the intraspinous ligaments, by injection of sodium amytal into the trigger point in the neck, by vibration treatment, or by intravenous injection of ponto caine. The amputee was enabled to sleep, however, by the use of phenobarbital, plus almost daily intravenous injections of 10 percent sodium amytal to the point of slight drowsiness. The latter did not eliminate the pain but seemed to relax the phantom hand and lower the pain to tolerable levels. On the clinic's recommendation, these injections were continued, but within a few weeks the patient proved refractory to the sodium amytal. When he left Los Angeles in May 1952, he was resigned to living with his phantom pain and hoped only to keep busy enough to keep his mind from it.</p> <h5><i>Summary</i></h5> <p>This case was a success prosthetically but a complete failure from the standpoint of relieving the amputee's phantom pain. Neurosurgery, drug therapy, and psychiatry were equally fruitless; the first resulted only in the additional pain of multiple operative wounds.</p> <h3>Cases Presenting Unsolved Psychosocial Problems<a style="text-decoration:none;">*</a></h3> <h4>Case 21, Very Short Below Elbow</h4> <p><i>History</i></p> <p>Case 21, male, age 52, entered the clinic in October 1951, five years after the explosion of an enemy mine resulted in the very short below elbow amputation of his right arm. A revision had been performed five months after the amputation. Before his wartime service as a captain and major, the patient had worked for a railroad for 20 years, his civilian occupation being given as trainmaster. Since his amputation, he had been unemployed much of the time, living on rental income and Federal pension benefits.</p> <p>While in an Army hospital in 1946, the patient had been fitted with a modern prosthesis with polycentric hinges. He was wearing it five years later and at that time stated that he wore it 12 hours a day. But he was not satisfied with the limb. During the four years between 1947 and the lime of the patient's appearance at the clinic, the VA paid for three additional prostheses and also for an extensive series of modifications. Finally, in January 1951, convinced that the amputee was not wearing any prosthesis regularly, and under pressure from him for a satisfactory prosthesis, the VA representative referred him to the UCLA Case Study.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a stump 3 5/8 in. long measured from the medial epicondyle to the end (<b>Fig. 33</b>), the distal area of the stump being sensitive to pressure. The amputee had received physical and occupational therapy and prosthesis use training, all of which he evaluated as excellent. Strength and range of motion were good, and no exercises were prescribed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Case 21. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>After the patient's first UCLA prosthesis (<b>Fig. 34</b>) had been fitted, revised several times, and worn for a short period, and after the amputee had complained of the same pressure pain as before, a special study of his forearm flexion was made. Thereafter the clinic prescribed a prosthesis with flexible insert hinges, thus sacrificing flexion step up in order to provide a comfortable fit. To obtain a useful range of flexion, the socket was so formed and the hinges so aligned as to place the forearm in 20 deg. of initial flexion. After wearing the second arm a short time, the amputee rejected it with the complaint that the outer wall of the socket was bent laterally about 15 deg. from the normal plane of flexion, thus preventing him from using it in driving a car. He complained also that the prosthesis lacked a stop to prevent him from hurting his stump on full extension. The staff was unable to relate these complaints to any objective measurements, and no stump soreness or discoloration was found.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Case 21 First prosthesis provided at UCLA, using split socket and variable ratio step up hinges to increase forearm flexion Because the patient complained of pressure pain upon flexion, the step up hinges were later abandoned in favor of flexible insert hinges. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Investigation of the patient's Army and VA records revealed no personality disturbance that might explain a hypercritical attitude toward prostheses. The UCLA staff psychologist examined all of the amputee's previous prostheses (which, except for the first, were in nearly new condition) and obtained the patient's relative ranking of each. It was found that the amputee's rankings were consistently related to the degree of misalignment between the epicondylar axis and the elbow axis of the prosthesis.</p> <p>When, in 1952, the prosthesis last prescribed was fitted, the relationship of the prosthetic elbow center to the epicondylar axis was measured as a function of forearm flexion, and the greatest discrepancy was found to be 1 in. with the forearm fully flexed. It was explained that this degree of misalignment was within the unavoidable error of the best techniques then available. As before, the prosthesis passed all checkout tests, was taken home, and returned with little evidence of wear. The amputee complained of the same pressure pain as before. Since the staff's resources had been exhausted, the case was closed. The staff psychologist was of the opinion that the patient was unconsciously rejecting a satisfactory prosthesis to retain a disabled state that absolved him from the necessity of working at a lower level of prestige and authority than characterized his preamputation history as safety engineer, trainmaster, and field officer.</p> <h5><i>Summary</i></h5> <p>Case 21 was a frustrating case for everybody concerned. It raised many questions and provided no answers.</p> <h4>Case 22, Below Elbow With Biceps Cineplasty</h4> <h5><i>History</i></h5> <p>Case 22, male, a 30 year old unemployed right below elbow amputee, appeared before the cooperating VA hospital clinic in October 1954 requesting a cineplasty operation, although he had never had personal contact with any cineplasty case. His amputation three years earlier had resulted from an automobile accident, and there had been a reamputation six weeks later. The patient had never had a prosthesis and stated that he could not get a job without one. His previous employment record was poor.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a man 6 ft. 2 1/2<i> </i>in. tall, weighing 155 lb., with a normal range of motion and no conditions requiring medical or physical therapy (<b>Fig. 35</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Case 22. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The patient was referred to the Prosthetics Training Center to observe cineplasty wearers. There he served as an amputee subject, was fitted satisfactorily with a conventional below elbow prosthesis (<b>Fig. 36</b>), and impressed the staff favorably by his cooperative attitude. He returned to the VA hospital with even greater enthusiasm for cineplasty, and with some misgivings a biceps tunnel was prescribed and constructed in November 1954. Postoperative convalescence was uneventful but was marked by a multitude of vague complaints with no assignable physical foundation, a demand for attention, and unwillingness to leave the hospital until forced to do so. The amputee returned to the next prosthetics course, where a cineplasty prosthesis was fabricated about seven weeks postoperative. During training, it became evident that his attention span was poor; disassociation of elbow flexion from biceps contraction was slow, and he was an inept student.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Case 22. Conventional below elbow prosthesis first fitted to patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>About three months after his operation, while in the laboratory, the subject induced an episode of hyperventilation during which he seemed to be choking. He was removed by ambulance to the Los Angeles County General Hospital, where a tracheotomy was performed, but he signed out on discovering that he was scheduled for a laryngoscopy. On his return, he informed all the laboratory staff that his tracheotomy was necessitated by cancer of the larynx. Thereafter he delighted in wheezing through his tracheotomy tube on every possible occasion until the tube was removed.</p> <p>It had previously been noted that the patient delighted in wearing short sleeved shirts and exposing his muscle tunnel to everyone with whom he came in contact. He also revealed himself as an inveterate fabricator, and psychiatric consultation disclosed him to be a dependent and insecure individual. About two months after the hyperventilation episode, he was admitted to the hospital with chest pain and unexplained fever. The hyperventilation was noted again in the hospital. His "fever" was explained when he was observed putting the thermometer on the radiator. Upon discharge, the patient disappeared.</p> <h5><i>Summary</i></h5> <p>The results of prosthetic fitting, which were in the main successful, were largely negated in this case by the extreme maladjustment of the amputee. Again the principle of careful selection in a cineplasty program was emphatically illustrated.</p> <h4>Case 23, Bilateral Below Elbow</h4> <h5><i>History</i></h5> <p>Case 23, male, an unemployed 31 year old bilateral below elbow amputee, was referred by the California State Department of Rehabilitation in October 1951. He had lost his hands in August 1949 in a punch press accident while learning to be a tool and die maker. He gave his previous work as coilspring winder and crane operator. He had been fitted with below elbow rotation prostheses (APRL Sierra) on both sides but with no wrist flexion device. He reported that he wore his prostheses 15 hours a day but that he found them inadequate for all but the simplest personal tasks and could not return to the trade he had been learning. He was anxious to dress himself, eat independently, drive a car, and so on.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed no postural abnormalities. The patient was well muscled and had a good range of motion. His right stump was 84 percent of estimated forearm length, his left 73 percent (<b>Fig. 37</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Case 23 Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Although the length of the left forearm placed the patient in the medium below elbow class, long below elbow prostheses were prescribed for both arms because both retained forearm rotation (160 deg. in the right, 110 deg. in the left). Wrist flexion units and Dorrance No. 5 hooks with rubber lined fingers were prescribed for both prostheses (<b>Fig. 38</b>). In mechanical tests, the new prostheses and the original pair made approximately the same scores.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Case 23. Bilateral prostheses as fitted at UCLA. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the amputee had had no prosthetic use training and was inadequate in the use of his original prostheses, after about four hours of training in the use of the prescribed prostheses he was judged proficient. His level of performance with either side was regarded by the trainer as excellent.</p> <p>Because the patient desired independence, much practice was given in opening doors and similar activities. When training was completed in October 1951, the subject stated that he felt independent and that he was going to move out of his parents' home and seek employment. After two weeks, he reported that he was totally independent and required no help in his everyday activities. He gave much of the credit to the wrist flexion units, with which he accomplished many activities formerly impossible for him.</p> <p>The day after the patient's discharge from the project in November, his picture was in the local newspapers under such headlines as <b>NAB HANDLESS BANDIT IN MARKET ROBBERY. </b>The stories revealed that he had had a brief notoriety as the "Paper Bag Bandit" in 1945, when a series of seven bank robberies in four months netted him approximately S10,000 and a 5 year to life term at Folsom Prison. There he had lost his hands in a license plate pressing machine. He had been on parole when referred to the clinic. To the humiliation of the UCLA amputee trainer, the subject was captured in the market parking lot as he struggled to open the door of the stolen stale vehicle he was using as his getaway car. The clinic staff which had discharged the patient with new prostheses one day earlier was surprised also to read his statement that he had turned to robbery because he ''needed money fast to replace a broken pull wire and a couple of rubber tips."</p> <h5><i>Summary</i></h5> <p>Does rehabilitation mean returning the patient to his former occupational status?</p> <h4>Conclusion</h4> <p>From the case histories given here, certain facts emerge. A primary feature is the individual nature of the problem, in which rules are only general guides. The amount of functional regain cannot always be predicted. Compare, for example, the results obtained with hree of the forequarler amputees (Cases 1, 15, and 16). Even in the abbreviated histories here, and far more in the actual case records, it is clear that the fitting of an arm amputee is a custom job usually involving a certain amount of experimentation and successive approximation before satisfaction is achieved.</p> <p>It is now obvious that by far the majority of arm amputees can be satisfactorily and usefully lilted with prostheses. The exceptions, as of this writing, are those amputees with long arm stumps who have so much residual function that they may not feel the need for mechanical assistance and, at the other extreme, amputees who are so handicapped that it is difficult to provide enough stability and body control motions. During the course of the UCLA study thus far, the titling of the shoulder amputee was raised from a marginal to a truly worthwhile procedure, as was the fitting of the bilateral high level amputee. The forequarler amputee remains, in most cases, an unsolved problem.</p> <p>At this lime, it appears that unilateral fitting of the bilateral high level amputee (shoulder and very shorl above elbow types) provides greater function than does bilateral fitting. A bilateral shoulder amputee can achieve considerable independence if equipped with the UCLA manually controlled, friction type shoulder joint, cable excursion multiplier, arm rotation turntable modified for constant tension by addition of a Belleville washer, and swaged cable fittings with nylon cable housing liner. The latter two apply to all arm amputees. Some cases of phantom pain are refractory to every therapeutic measure Yet painful pressure sensitive areas on the stump may often be dealt with by careful fitting techniques. In general, below elbow. biceps cine plasty cases were successful while other types involving cineplasty were not. The stories behind the development of now standard armamentarium components are drawn from the UCLA experience, and such background is therefore necessarily given only for UCLA developed items and not for the valuable developments of other agencies such as Northrop Aircraft, the Army Prosthetics Research Laboratory, and the commercial limb industry.</p> <h3>Acknowledgments</h3> <p>The authors wish to express their thanks both to the amputees whose records are presented here and also to the past and present members of the Engineering Artificial Limbs Project whose notations are found in the case files, particularly Tonnes Dennison, Jerry Leavy, Hyman Jampol, Gilbert M. Motis, Lester Carlyle, William R. Santschi, Harry E. Campbell, Jeannine F. Dennis, and William H. Henderson.</p> <p><b>References:</b></p> <ol> <li><p>Artificial Limbs, passim.</p> </li> <li><p>Canty, Thomas J., <i>Amputations and recent developments in artificial limbs</i>, Armed Forces Med. J., 3: 1147 (19S2).</p> </li> <li><p>Gottlieb, M. S., <i>Final report of the UCLA upper extremity amputee case study</i>, Department of Engineering, University of California (Los Angeles), in preparation 1957.</p> </li> <li><p>Henderson, William H., <i>Artificial arms for child amputees fabrication and fitting developments to July 1</i>, 1956, Department of Engineering and School of Medicine, University of California (Los Angeles), October 1, 1956.</p> </li> <li><p>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human Limbs and their substitutes</i>, McGraw Hill, New York, 1954.</p> </li> <li><p>Navy Prosthetic Research Laboratory, U. S. Naval Hospital, Oakland, Calif., <i>Interim Progress Report</i>, Research Project NM 007 084.26, <i>Cine plastic above elbow prosthesis</i>, 1 November 1954.</p> </li> <li><p>Taylor, Craig L., <i>The objectives of the upper extremity prosthetics program</i>, Artificial Limbs, January 1954. p. 4.</p> </li> <li><p>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics</i>, 2nd ed., W. R. Santschi and Marian P. Winston, eds., in press 1957.</p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Two of the three problem cases included in this section are clear cut. That Case 21 is placed in the category of psychosocial problems represents a judgment on the part of the staff and of officials of the Veterans Administration; from Case 21s viewpoint, his problem related to inadequate fitting and alignment.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Case 1, although classified as a forequarter, is excluded from this discussion because he retained most of the clavicle, which had a good range of motion.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Navy Prosthetic Research Laboratory, U. S. Naval Hospital, Oakland, Calif., Interim Progress Report, Research Project NM 007 084.26, Cine plastic above elbow prosthesis, 1 November 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Canty, Thomas J., Amputations and recent developments in artificial limbs, Armed Forces Med. J., 3: 1147 (19S2).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., W. R. Santschi and Marian P. Winston, eds., in press 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Since these case histories are drawn from the UCLA experience, the devices presented as solving problems are those designed by this particular project. We were in no position to present the stories behind valuable components which emerged from other laboratories and limbshops.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Henderson, William H., Artificial arms for child amputees fabrication and fitting developments to July 1, 1956, Department of Engineering and School of Medicine, University of California (Los Angeles), October 1, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs, passim.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Gottlieb, M. S., Final report of the UCLA upper extremity amputee case study, Department of Engineering, University of California (Los Angeles), in preparation 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Taylor, Craig L., The objectives of the upper extremity prosthetics program, Artificial Limbs, January 1954. p. 4.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Marian P. Winston, B.A. </b></td></tr><tr><td class="clsTextSmall">Editor, Engineering Artificial Limbs Project, Department of Engineering, University of California (Los Angeles); formerly., Prosthetics Education Project, UCLA Medical Center,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering and Physiology, University of California (Los Angeles); Project Leader, Engineering Artificial Limbs Project, Department of Engineering, University of California (Los Angeles); member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert L. Mazet, JR., M.D. </b></td></tr><tr><td class="clsTextSmall">Clinical Professor of Orthopedic Surgery, University of California Medical School (Los Angeles); Chief of the Orthopedic Service, Wadsworth Veterans Hospital; member, Committee on Prosthetics Research and Development, PRB, NRC; Past President, American Board for Certification of the Prosthetic and Orthopedic Appliance Industry, Inc.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Marvin S. Gottlieb, M.A. </b></td></tr><tr><td class="clsTextSmall">Formerly Junior Research Engineer, Engineering Artificial Limbs Project, Department of Engineering, University of California (Los Angeles).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-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 Some Experience with Prosthetic Problems of Upper Extremity Amputees Creator An entity primarily responsible for making the resource Marvin S. Gottlieb, M.A. * Robert L. Mazet, JR., M.D. * Craig L. Taylor, Ph.D. * Marian P. Winston, B.A. * https://staging.drfop.org/files/original/673830cf47fc4145408e60fb59c2e58e.pdf daa60cba2d873060d065a59d7d151976 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_001.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Collaboration for Rehabilitation</h2> <h5>Mary E. Switzer <a style="text-decoration:none;">*</a><br /></h5> <p>I welcome the opportunity to express my appreciation for the wonderful cooperation and assistance that the Vocational Rehabilitation Administration has enjoyed in our many close relationships with the National Academy of Sciences-National Research Council. Our associations with the Committee on Prosthetics Research and Development and the Committee on Prosthetic-Orthotic Education have been long and fruitful, and the contributions of these committees have been substantial in the development and coordination of the research and informational programs for the fields of prosthetics and orthotics. VRA is glad to be associated with the National Institutes of Health-which is another agency of the Department of Health, Education, and Welfare-and with the Veterans Administration in supporting the CPRD program; and, naturally, we look with special pride on the CPOE program since we are its primary support.</p> <p>In our search for the judgment of the most knowledgeable people in each field which we support, the members of our National Advisory Council on Vocational Rehabilitation and the consultants on our Medical Advisory Committee have come to respect the professional competencies of the engineers, physicians, therapists, prosthetists, and orthotists who serve on CPRD. The professional advice and recommendations available to the Academy-Research Council on this basis assure impartial excellence in judgment and accessibility to professional skills that are not readily available from any other source in this country.</p> <p>I have been particularly impressed with the extensive informational program that CPOE has developed, especially the brochures, films, and slides for use in schools of medicine, physical therapy, and occupational therapy and for the work that has been initiated in the development of new amputee clinics in several of our State programs.</p> <p>There are special reasons why the functions of the Committees continue to hold special significance to our total rehabilitation program: State-Federal, research and demonstrations, and training activities.</p> <p>A recent study was made of the 120,000 persons who were rehabilitated in the State-Federal program during 1964, and it was found that the classifications of amputations, absence of extremities or other orthopedic deformities, accounted for a total of 42,352 persons rehabilitated. Approximately 35% of the total group, therefore, were orthopedic rehabilitants. Thus, it is obvious that, even with the changing emphases in disability groups needing service, the thread of orthopedic disabilities runs through the entire program of rehabilitation, and orthopedic cases are almost four times as large as the next largest category of disability.</p> <p>The VRA program of research and demonstrations, which began with a trickle ten years ago, has broadened into a flow of new ideas, methods, and patterns of service to facilitate and improve the restoration of the disabled to worthwhile lives. There have been approximately 850 VRA research projects approved during the period 1955-1964, and about seven per cent of these projects have been for studies primarily concerned with problems caused by or related to orthopedic disability. Thirty-one universities, hospitals, or rehabilitation centers have sponsored 55 research projects relevant to this field of work. During fiscal year 1964, VRA awarded research grants to 13 new projects relating to the orthotic-prosthetic field and an additional 14 ongoing projects received continuation grants.</p> <p>Some of the most imaginative and creative work in our total program is going on in this field of research, and we are constantly aware of the dramatic advancements that are taking place. The collaboration of medical rehabilitation and engineering with some of the discoveries in the space program should bring a whole new dimension to the war on disability. So naturally we are pleased that CPRD has followed our recommendation to hold a conference on the Control of External Power in Upper-Extremity Rehabilitation so that leading engineers, physicians, and scientists can come together to formulate and coordinate their programs and assist us in developing future plans for support of their efforts.</p> <p>Our training program, which continues to pour a steady stream of new professional rehabilitation workers into the ranks, has expanded so that professional training in all of the fields that contribute to rehabilitation has been influenced by VRA training grants: medicine, nursing, physical therapy, occupational therapy, rehabilitation counseling, social work, speech pathology and audiology, rehabilitation of the blind and deaf, the mentally ill and the mentally retarded, and recreation for the ill and disabled.</p> <p>Since 1953, over 600 short-term courses in prosthetics and orthotics with a total enrollment of about 9,500 trainees have been attended by physicians, surgeons, therapists, counselors, prosthetists, orthotists, and related rehabilitation personnel. Last year alone, over 1,500 persons were enrolled in 90 courses which were a part of the extensive offerings in upper- and lower-extremity prosthetics and orthotics, management of the juvenile amputee, and general orientation courses for these fields. The work of the University Council on Orthotic-Prosthetic Education has done much to achieve a more uniform approach in curriculum offerings, teaching materials and methods, and evaluation procedures for the courses.</p> <p>The semester courses at UCLA and Northwestern, the Associate in Arts courses proposed at Cerritos College and Chicago City Junior College, and the undergraduate curriculum at New York University-all these attest to the professionalism that is developing in prosthetics and orthotics.</p> <p>CPRD's and CPOE's paramount asset to us is a technical proficiency while ours is a resource of public funds and a wealth of experience which we try to combine through the State-Federal partnership and our research and training projects into a comprehensive program for helping the disabled to reach their physical, economic, social, and personal goals. Our task, as public servants, is to administer these Federal funds as wisely as we can, always bearing in mind the true function of the law and purpose of our program: to convert dependency into competence and independence. As we work together along the paths of rehabilitation, exchanging our knowledge and our resources, perhaps we can all share in the conviction expressed on the seal of the Department of Health, Education, and Welfare which reminds us constantly that Hope is the Anchor of Life.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Mary E. Switzer </b></td></tr><tr><td class="clsTextSmall">Commissioner, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, Washington, D. C. 20201.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Collaboration for Rehabilitation Creator An entity primarily responsible for making the resource Mary E. Switzer * 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 Text Any textual data included in the document <h2>Building A Positive Self Image In Patients</h2> <h5>Mary Point Novotny, RN., MS.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>"Poems are made by fools like me, but only God can make a tree. "</i></p> <p>Momentary reflection on this literary work brings into perspective the complex task of rebuilding the image of one who has lost a limb. It is a task which requires not merely the professional and technical abilities of the prosthetist, but also a personal concern for the self image of the patient.</p> <p>Body image is the constantly changing mental picture one has of his individual, body appearance. It develops through reflected perceptions about one's body and sensations originating from internal and external stimuli as the individual adapts to a kaleidoscopic variety of living activities. All too frequently body image is overlooked in the rehabilitation plans for a patient with chronic disease, disability, or surgical intervention, because physical diagnosis and mechanical advances have become paramount in our fast-paced acute care settings. The concept is so basic, it is not hard to see why it is overlooked; yet, if one begins to examine the personal effect of alterations, such as mastectomy, amputation, colostomy or stroke, we can begin to identify with the grief, anxiety and fear accompanying the loss of a body part and the ensuing alteration in functional ability.</p> <p>Research of Schilder and others has shown that since body image is primarily a psychological entity, alterations in it are extremely subjective experiences which vary in intensity, dependent on the unique characteristics of each individual, in three distinct categories. These sources of self image include:</p> <ol> <li> <p>Past experiences which are gradually built up through the years from physiologic, psychologic, and social components, organized and integrated by the central nervous system.</p> </li> <li> <p>Social interactions which include the reaction of significant others and of society to the person's body, as well as his own interpretation of that reaction.</p> </li> <li> <p>Current sensations, such as perceptions of physical appearance, alterations incurred, and images, attitudes and emotions regarding the body.</p> </li> </ol> <p>Because these components are subject to constant revision, the body image of any individual is constantly changing. Survival of a healthy self image is determined by the amount of flexibility available to adapt to new situations and one's ability to realize that the image he projects to others is the one others see.</p> <p>The loss or absence of a limb, therefore, has varying consequences dependent on the individual and his stage in the life cycle. Studies have shown that an individual is capable of incorporating a firmly-attached object, such as a prosthesis, cane, etc., into his self image. This seems to be particularly evident with congenitals fitted very early in life, before developing unilateral coordination and functional abilities. Of the acquired amputees, early fitting and functional use of the prosthesis also increases the chances of reconstructing a complete image of one's self. A juvenile amputee, up to 3 years old, is not able to consciously deal with "loss," and congenitals, up to 6 years old, generally do not perceive themselves as "different." Yet amputation in later years results in the patient undergoing the process of grief, which includes feelings ranging from denial, anger and hopelessness, to reorganization and adaptation.</p> <p>Schilder places a positive emphasis on the necessity for communication of these feelings. He believes we constantly construct, dissolve, and reconstruct our own body image as well as the body images of others. He points out that the tendency to destroy a previous body image is essential to acceptance of a new, altered image.</p> <p>This appears to be a critical area in successful care of any patient. Because most amputees and their families have limited, if any, exposure to others with similar problems, their greatest fears are of the unknown. Will amputation ruin my personal life? End my career? Leave my child handicapped and dependent? With little factual information in the areas of prosthetics and a body image distortion that has not been reconciled, the patient frequently arrives at the professional door seeking an opportunity to communicate his fears and frustrations to an individual who will, hopefully, aid in the design of a prosthesis and promise for the future. While personal style and approach vary with the needs of individual patients, certain factors should be considered in dealing with an amputee: personality type, expectations, stage of adjustment, support system, and medical conditions.</p> <p>Recent amputees, for example, would benefit from an opportunity to see and touch a prosthesis, with a complete explanation of the stages of fitting and fabrication to limb completion. Be open and honest with patients, keeping in mind that cosmesis may be a priority for some while function and durability are essential for others. While no prosthesis will ever replicate human functioning, once you determine what a patient expects to achieve through prosthetic usage, you can then fulfill his needs and likewise increase his acceptance of an artificial limb.</p> <p>Parents of a congenital amputee frequently need much more support than the child who can learn to lead a "normal" life if allowed to develop and achieve, unhampered by "concerned" adults who would treat him "special/different."</p> <p>Meeting with another amputee who has mastered life with a prosthesis can have a very positive effect on the older child or adult who is attempting to re-adjust his self image. Family members or significant others should be encouraged to be present at such meetings, as the fear of new amputees is generally in direct proportion to the acceptance reaction of those whose opinion he values most. Seeing is believing!, and once normal functioning in everyday living is explained, there will be less chance of the amputee being treated as a "handicapped" individual, which he is not.</p> <p>Lastly, bear in mind that you are a very important person in the eyes of your patient. This is because you are now the professional most heavily relied on for advice, support and adjustment in the initial period of building a new self image. So grin and bear those minor repairs, etc., keeping in mind that a well-worn prosthesis is your best measure of success. Function and form go hand-in-hand in establishing a sense of completeness in self image.</p> <p>While you may not have the power of our creator, you can surely have a part in the final design of his creations.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, "Behavioral and Psychological Reactions of Juvenile Amputees." Reprinted from <i>Limb Development and Deformity: Problems of Evaluation and Rehabilitation</i>, Charles C. Thomas, Publisher, 400-407.</li> <li>La Fleur, Jean and Novotny, Mary, "A Study of Human Figure Drawings by Amputee Children and Verbalization of their General Adjustment," Masters' thesis, De Paul University, 1978.</li> <li>Schilder, Paul, <i>The Image and Appearance of the Human Body</i>, International Universities Press, Inc., New York, 1950.</li> <li>Schilder, Paul "Symposium on the Concept of Body-Image," Nursing Clinics of North America, VII (December, 1972).</li> </ol> <em><b>*Mary Point Novotny, RN., MS. <br /></b>Nurse-educator for health professionals; Consultant, University of Illinois at the Medical Center, Amputee Clinic, Chicago, Illinois; has lectured across the country on body image alterations and the role of professionals in assisting patients with adjustment.</em> Page Number(s) 1 - 2 Year 1979 Volume 3 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Building A Positive Self Image In Patients Creator An entity primarily responsible for making the resource Mary Point Novotny, RN., MS. * https://staging.drfop.org/files/original/05797d097e7ea7bad20de2770f06ed76.pdf d699846094a3209fce59adbb13245529 https://staging.drfop.org/files/original/f98ef36fe95f94695881ac19925c87a9.jpg 30eb9bb0dc166fc3e4b3e982d869a061 https://staging.drfop.org/files/original/3f4b5b9d7c4f70854173c781c4481798.jpg 5ca81b27f54f0f31107e402d7d5b9cb2 https://staging.drfop.org/files/original/e349ce4b1ee6b4c02285e4909c234840.jpg 8de21023d178bf28467ea698c6b1c205 https://staging.drfop.org/files/original/4d87c9d67d81a8f92e52306ee2883f12.jpg b931c8ba3d44b6753e00a7f4493ef3af https://staging.drfop.org/files/original/d8ae7a1cea1830e2967b85b3afa776ab.jpg 1c823de12ebbf9e31f89866f0b07d59f https://staging.drfop.org/files/original/dbea119e932addf689fac9106cd0855e.jpg dc1f371a8c41a1e8da75e9ff08e496b6 https://staging.drfop.org/files/original/a6b7887debc002729c288b71ad391f6d.jpg de80f95e85cf71e745f38c6290765c9c https://staging.drfop.org/files/original/cefb99637af02427a4920d527a6cde80.jpg 4d5b9c08311b42d45b26abb4f1dfbeb9 https://staging.drfop.org/files/original/8570f07fd1f37cb83a54e7a55184cb89.jpg 107e71ad31ce064c650020317eb40e6e https://staging.drfop.org/files/original/ddde5450ec9bcccfc098853075b0d207.jpg 0e79c7eda7e3e3a0e5fa51bde27aa4f5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_022.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 22 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Elastic-Liner Type of Syme Prosthesis: Basic Procedure and Variations</h2> <h5>Maurice A. LeBlanc <a style="text-decoration:none;">*</a><br /></h5> <p>In the past few years, a number of pros-thetists have been fabricating elastic-liner types of Syme prostheses, and their procedures have been described in the literature. <a></a> This article presents the most commonly used procedure and some of the variations to it.</p> <p>The elastic-liner type of Syme prosthesis has the advantage of eliminating the door on the conventional prosthesis (<b>Fig. 1</b>), thereby allowing greater strength (with no openings) and a smoother cosmetic finish (with no straps) while maintaining total contact and suspension (<b>Fig. 2</b>). However, it cannot be used if the bulbous end of the stump is too large for satisfactory cosmesis of the cylindrical portion or for making the liner (not possible when the distal end is larger than the proximal brim).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Conventional Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Elastic-liner Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Basic Procedure</h3> <ol> <li>Felt patches are placed on the stump for relief of bony prominences and/or sensitive areas.</li><li>A plaster cast is taken of the stump with partial weight-bearing and with blocks making up the length discrepancy.</li><li>The largest diameter of the bulbous end of the stump is measured, and the proximal level of the stump model is marked where its largest diameter equals that of the bulbous end.</li><li>Using nylon stockinette, the inner socket is vacuum-laminated with Silastic (TM) elastomer #384 from the level marked in step 3 to the end of the stump (<b>Fig. 3</b>).</li><li>The remainder of the inner socket (the proximal brim down to the level of the elastomer) is laminated with Laminac (TM) #4110 polyester resin.</li><li>A wax build-up is made over the center portion of the inner socket between the bulbous end and the level marked in step 3 (<b>Fig. 4</b>). The build-up is cylindrical in shape to allow entry of the stump into the socket.</li><li>The outer shell of the socket is laminated with Laminac #4110. <b>Fig. 5</b> shows a cutaway view of the inner socket and outer shell of the prosthesis. Note that the end of the liner must be attached to the outer shell so it will not pull out with the stump.</li><li>Using reference lines established on the plaster cast, the socket is statically aligned following the attachment of a SACH foot which has been cut and shaped to receive the bulbous end of the socket. (There is normally about a three-inch height discrepancy with the Syme's amputation.)</li><li>The socket is then dynamically aligned to the amputee's gait. Depending on the method of attachment of the SACH foot to the socket, adjustment is usually provided by means of an alignment disc or by repositioning the socket with quick-setting epoxy resin.</li><li>The prosthesis is completed by laminating the socket and keel of the SACH foot and reattaching the sole (<b>Fig. 6</b>). Fiberglass reinforcement is usually used in the lamination.</li></ol> <h3>Variations</h3> <ol> <li>Alginate can also be used to make the negative impression of the stump. It gives better detail, and its elasticity allows easy stump removal. However, it is expensive, and one cannot see to position the heel pad while it is setting.</li><li>Modification can be accomplished on the plaster model instead of using the felt patches. Either way is satisfactory, but using the patches saves time and is equally effective if they are properly placed.</li><li> A combination of 80% of Silastic elastomer #384 and 20% of #386 (foam) for the liner can be used to increase its expandability. More than 20% of #386 foams too much and reduces durability. <a></a></li><li> One variation on the size of the liner is to laminate the liner down to the largest diameter of the bulbous end rather than including the entire end. It is then not necessary to attach the end of the liner to the outer shell (<b>Fig. 7</b>).</li><li> Another method of sizing the liner is to make an elastic window in the inner socket instead of making a whole inner bladder (<b>Fig. 8</b>). This allows entry by rotating the stump as it goes into the socket, and makes possible a very cosmetic prosthesis.</li><li> Instead of making a wax build-up, it is possible to use Silastic elastomer #386 foam for the space between the liner and outer shell and to leave it in the prosthesis. It is lightweight and can be compressed to allow entry of the stump. (This procedure is being used by William Sinclair, C.P.O., at Jackson Memorial Hospital in Miami, Florida.)</li><li>Another way to modify the SACH foot and attach it to the socket is shown in <b>Fig. 9</b> and <b>Fig. 10</b>.</li></ol> <p>A wooden block is fitted and fastened to the distal end of the socket, and the bottom is sanded so it establishes the flexion and adduction angles of the socket. The wooden block forms a socket base for attachment of the SACH foot with the hardwood base and plug which reinforce the keel.</p> <h3>Acknowledgments</h3> <p>The author wishes to thank Herbert W. Marx, C.P.O., and Robert Mazet, Jr., M.D., for lending several of the illustrations used in this article.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Eckhardt, Arthur L., and Harold Enneberg, The use of a Silastic liner in the Syme's prosthesis, Inter-Clinic Inform. Bull., 9:6:1-4, March 1970.</li> <li>Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</li> <li>Mazet, Robert, Jr., Syme's amputation, a follow-up study of fifty-one adults and thirty-two children, J. Bone Joint Surg., 50-A:8:1549-1563, December 1968.</li> <li>Meyer, Leslie C, Harry L. Bailey, and Dewey Friddle, Jr., An improved prosthesis for fitting the ankle-disarticulation amputee, Inter-Clinic Inform. Bull., 9:6:11-15, March 1970.</li> <li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, Spring 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Eckhardt, Arthur L., and Harold Enneberg, The use of a Silastic liner in the Syme's prosthesis, Inter-Clinic Inform. Bull., 9:6:1-4, March 1970.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Mazet, Robert, Jr., Syme's amputation, a follow-up study of fifty-one adults and thirty-two children, J. Bone Joint Surg., 50-A:8:1549-1563, December 1968.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Meyer, Leslie C, Harry L. Bailey, and Dewey Friddle, Jr., An improved prosthesis for fitting the ankle-disarticulation amputee, Inter-Clinic Inform. Bull., 9:6:11-15, March 1970.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Maurice A. LeBlanc </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Research Council-National Academy of Sciences.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-10.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 Elastic-Liner Type of Syme Prosthesis: Basic Procedure and Variations Creator An entity primarily responsible for making the resource Maurice A. LeBlanc * https://staging.drfop.org/files/original/694c8659897265452c14e9ca3192624d.pdf 58cc45863e2c275da7497de4ff593ec2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_013.pdf Text Any textual data included in the document <h2>Innovation and Improivement of Body-Powered Arm Prostheses: A First Step</h2> <h5>Maurice A. LeBlanc, M.S.M.E., CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Standard body-powered upper-limb prostheses have not changed significantly since developments in the 1950's which were spurred by World War II. They still employ aircraft technology using shoulder harnesses and steel cables for operation. If one looks at the <i>Manual of Upper Extremity Prosthetics</i> first edition (1952)<a></a> and the <i>Orthopaedic Appliance Atlas—Artificial Limbs</i> first edition (1960)<a></a> compared with 1985 state of the art, one will not find a great deal of change.</p> <p>It is the consensus of several leading prosthetists in the U.S. that many arm amputees are being led into purchasing externally powered arm prostheses because they look more modern and "hi-tech." Present body-powered arm prostheses simply do not offer a good alternative. They look more archaic, and the shoulder harnesses are uncomfortable and restrictive.</p> <p>Body-powered systems have more sensory feedback and generally are more functional (for unilaterals) than externally powered systems.<a></a> However, little or no research is being conducted to improve body-powered arms. More and more amputees are opting for externally powered prostheses,<a></a> and the gap is getting larger between the two types.</p> <p>Estimates of population in the U.S. place the number of upper-limb amputees at about 100,000.<a></a> Of the 50,000 arm amputees estimated to be wearing prostheses, surveys of prosthetic facilities suggest the following levels of amputation: 58% below-elbow, 27% above-elbow, and 15% at the hand/wrist and shoulder.<a></a> Of prostheses being worn, educated guesses suggest that the percentage of externally powered prostheses has increased from five to 10% in the past five years.<a></a></p> <p>It is the desire of the author to undertake work to effect innovation in body-powered arm prostheses toward the ultimate goal of increasing the acceptance and use of "conventional" upper-limb prostheses for arm amputees in the U.S. Other people have stated this need.<a></a></p> <p>The author has received support to conduct a one-year study of feasibility for accomplishing the above goal. As a first step, the author has conducted a survey to verify needs and priorities of arm amputees in order to give guidelines for future work.</p> <h3>Conduct Of Survey</h3> <p>Arm amputees and professionals were contacted to assess what wearers like most and like least about their prostheses. Also, ideas for change were solicited.</p> <p>A questionnaire was prepared to provide a standard format, and 30 people were contacted in person or by phone to complete the questionnaire. The people were:</p> <blockquote> <p>17 amputees<br />8 prosthetists<br />3 occupational therapists<br />2 VA prosthetic reps (also arm amputees)</p> 30 total <p></p> </blockquote> <p>Of the 17 arm amputees, there were:</p> <p></p> <blockquote>10 adults and 7 children<br />13 males and 4 females<br />14 unilaterals and 3 bilaterals</blockquote> <p></p> <h3>Results Of Survey</h3> <p>The survey included 11 questions. Results are reported below with the numbers of responses shown. (Some totals exceed 30 because respondents gave two or three answers per question.)</p> <ol> <li> <p><i>What do you like most about your prosthesis?</i><br />Most frequent answers:</p> <ul> <li> <p>Function: 17</p> </li> <li> <p>Reliability: 9</p> </li> <li> <p>Symmetry/body image: 6</p> </li> </ul> </li> <li> <p><i>What do you like least about your prosthesis?</i><br />Most frequent answers:</p> <ul> <li> <p>Axilla/harness uncomfortable: 10</p> </li> <li> <p>Appearance poor: 9</p> </li> <li> <p>Socket hot: 5</p> </li> </ul> </li> <li> <ol> <li> <p><i>Is the harness/cable control system satisfactory?</i> 13—Yes, 16—No</p> </li> <li> <p><i>Does this type of control system need improvement?</i> 25—Yes, 4—No</p> </li> </ol> </li> <li> <ol> <li> <p><i>Are the harness and socket comfortable?</i> 12—Yes, 17—No</p> </li> <li> <p><i>Does the general comfort need improvement?</i> 25—Yes, 4—No</p> </li> </ol> </li> <li> <ol> <li> <p><i>Do the motions and terminal device give you enough function?</i> 11—Yes, 18—No</p> </li> <li> <p><i>Does the function of the prosthesis need improvement?</i> 29—Yes, 0—No</p> </li> </ol> </li> <li> <ol> <li> <p><i>Are you pleased with the appearance?</i> 11—Yes, 19—No</p> </li> <li> <p><i>Does the general appearance need improvement?</i> 25—Yes, 5—No</p> </li> </ol> </li> <li> <p><i>Rate the following four aspects of your prosthesis in importance to you (1 = most important and 4 = least important)</i></p> <blockquote> <p>Average Scores:<br />Function: 1.53<br />Comfort: 1.85<br />Appearance: 2.79<br />Control system: 3.53</p> </blockquote> </li> <li> <p><i>Any other general complaints of this type of prosthesis?</i>—Text answers to these questions were combined with text answers to questions 3-6 and will be discussed later.</p> </li> <li> <p><i>Any other ideas for improvement you would like to see worked on?</i>—Text answers to these questions were combined with text answers to questions 3-6 and will be discussed later.</p> </li> <li> <p><i>If you could dream and create your own perfect prosthesis, what would it look like?</i></p> <p>Most frequent answers:</p> <blockquote> <p>Natural/normal: 12<br />Soft/smooth endoskeletal: 11<br />More function in fingers and wrist: 9</p> </blockquote> </li> <li> <p><i>Do you want your prosthesis to look as normal as possible or would you prefer to have some fun with the appearance in colors and designs?</i></p> <p>Most frequent answers:</p> <blockquote> <p>Want it to look normal: 21<br />Want to have some fun with it: 4</p> </blockquote> </li> </ol> <h3>Miscellaneous Considerations</h3> <p>In talking with each of the 30 people surveyed, a number of interesting comments were made which deserve consideration.</p> <ul> <li> <p>The prosthesis is not a second best arm but something different to itself and should have form and beauty for its own sake.</p> </li> <li> <p>While most people stated the goal of having a prosthesis which looks natural, they asked for one which is smooth, inconspicuous, natural in motion, fast, quiet, and streamline rather than asking for a prosthesis which looks human.</p> </li> <li> <p>Several people visualized having an arm transplant or regeneration.</p> </li> <li> <p>A couple of people talked about "functional appearance" or having a prosthesis which is dynamically alive and not dead looking.</p> </li> <li> <p>Many people expressed a desire for a prosthesis which is soft inside, adjusts to the body, feels like part of the body, and feels flexible.</p> </li> <li> <p>Cleanliness is a big issue with a harness, sockets, and prosthesis exterior. Some expressed the desire for throw-away parts and coverings. Also, it is difficult for bilaterals to clean their prostheses when doffed.</p> </li> <li> <p>Bilateral amputees stressed the importance of using their feet as well as the prostheses. There is more dexterity and sensory feedback for function and a preference for using feet except where social situations dictate using the prostheses.</p> </li> <li> <p>Several amputees stressed the importance of the sensory feedback/proprioception inherent in body-powered arm prosthesis. A few voiced the opinion that increased sensory feedback would provide increased function even with present components.</p> </li> <li> <p>A few parents confirmed the desire for very early fitting of infants for various reasons: body image, balance, symmetry, acceptance and function. One parent felt strongly that an infant should have an arm prosthesis because "the brain is looking for a hand" and it affects the growth/development of the child.</p> </li> <li> <p>While the author was conducting interviews with amputees, many of them asked the author for current information about arm prostheses and components. It was clear that some prosthetists are not fully informing amputees of their options and including them in the decision-making process.</p> </li> <li> <p>A few prominent professionals stated very strongly the importance of the prosthetist conducting a very thorough evaluation with the amputee prior to any prosthetic prescription and fitting. It provides the opportunity for the prosthetist to use his/her ingenuity to truly meet the needs of the amputee.</p> </li> <li> <p>Clinic teams sometimes make decisions on prosthetic fitting in five minutes, which is insufficient time to conduct a thorough evaluation.</p> </li> <li> <p>Central fabrication also can be a detriment to successful prosthetic fitting because standard components are applied by a third party without direct amputee contact, thereby reducing the incentive and likelihood for creative and individual solutions to amputees' needs.</p> </li> <li> <p>Education of prosthetists focuses mainly on the mechanics of fabricating prostheses with available components rather than looking comprehensively at the amputee as an individual with special needs. They "follow the book" too much and are "too rigid in prescribing."</p> </li> <li> <p>The success of upper-limb prostheses depends heavily on the skills of the prosthetist. It is too dependent on individuals. It would be beneficial if systems were more modular whereby they would be easier to fit, and performance could be predicted better.</p> </li> <li> <p>Two trends which seem to be gathering professional concurrence are (1) to fit an arm amputee within the "Golden Period" of 30 days after amputation and (2) to fit all arm amputees with a conventional, body-powered prosthesis first.<a></a></p> </li> </ul> <h3>Conclusions</h3> <p>Function is clearly the most important feature which amputees want and expect from upper-limb prostheses. While the results may be biased because the survey was of body-powered wearers versus myoelectric wearers with hands, the numbers and opinions overwhelmingly emphasize function first.</p> <p>Uncomfortable harness and poor appearance were a close first and second for the most negative feature of arm prostheses. Body-powered arm prostheses need improvement across the board. When making changes, the upper-limb prosthesis should be viewed as a whole system rather than just looking at components. Amputees want a natural moving, pleasant appearing, inconspicuous prosthesis which does not necessarily have to look human.</p> <p>The questionnaire demonstrated a good cross check in validating what amputees and professionals said with how they rated the various aspects of upper-limb prostheses. There has been a great deal of encouragement from amputees and professionals to work on the improvement of body-powered systems. All are anxious to see some innovation and positive change.</p> <h3>Acknowledgment</h3> <p>This work is being supported by Research Fellowship #133FH40021 from the National Institute of Handicapped Research, US Department of Education.</p> <p><b>References:</b></p> <ol> <li><a href="poi/1981_02_092.asp">Agnew, P.J., "Functional Effectiveness of a Myoelectric Prosthesis Compared with a Functional Split-Hook Prosthesis: A Single Subject Experiment," <i>Prosthetics Orthotics International</i>, Vol. 5, No. 2, August 1981.</a></li> <li>Aylesworth, R. Deane, Editor, <i>Manual of Upper Extremity Prosthetics</i>, Artificial Limbs Project, University of California at Los Angeles, 1952.</li> <li>Childress, Dudley S., Ph.D., Director, Rehabilitation Engineering Center, Northwestern University, Chicago, Illinois, personal communication, April 1984.</li> <li>Cottenden, A.M.; B. Stocking; N.B. Jones; S.L. Morrison and R. Rothwell, "Biomedical Engineering-Priorities for Research in External Aids," <i>Journal of Biomedical Engineering</i>, Vol. 3, October 1981.</li> <li>Epps, Charles H., Jr., M.D., "Prosthetic-Orthotic Research-A New Thrust Is Needed: A Clinician's Perspective," <i>Clinical Prosthetics and Orthotics</i>, Vol. 8, No. 1, Winter, 1984.</li> <li>LeBlanc, Maurice A., M.S., CP, Patient Population and Other Estimates of Prosthetics and Orthotics in the USA," <i>Orthotics and Prosthetics</i>, Vol. 27, No. 3, September, 1973.</li> <li>Malone, J.M., M.D.; L.L. Fleming, M.D.; J. Rober-son, M.D.; T.E. Whitesides, Jr., M.D.; J.M. Leal, CP; J.V. Poole, O.T.R. and R. Sternstein Grodin, O.T.R., "Immediate, Early, and Late Postsurgical Management of Upper-Limb Amputation," <i>Journal of Rehabilitation Research and Development</i>, Veterans Administration, May, 1984.</li> <li>National Center for Health Statistics, US Department of Health and Human Services, "Prevalence of Selected Impairments-United States-1977," Series 10, No. 134, February, 1981.</li> <li><i>Orthopaedic Appliance Atlas-Volume 2-Artificial Limbs</i>, American Academy of Orthopaedic Surgeons, J.W. Edwards-Publisher, 1960.</li> <li>Stein, R.B. and M. Walley, "Functional Comparison of Upper Extremity Amputees Using Myoelectric and Conventional Prostheses," <i>Archives of Physical Medicine</i>, Vol. 64, No. 6, June, 1983.</li> <li><a href="http://www.acpoc.org/library/1983_04_009.asp">Trost, Francis J., M.D., "A Comparison of Conventional and Myoelectric Below-Elbow Prosthetic Use," <i>Inter-Clinic Information Bulletin</i>, Vol. 18, No. 4, Fall, 1983.</a></li> <li>Veterans Administration, Rehabilitation Research and Development Service, National Workshop on Prosthetics and Orthotics, Washington, D.C, April 27-28, 1983.</li> </ol> <div style="width: 400px;"><em><b>*Maurice A. LeBlanc, M.S.M.E., CP. </b> Maurice A. LeBlanc, M.S.M.E., CP. is with the Rehabilitation Engineering Center at Children's Hospital at Stanford, Palo Alto, California 94304.</em><br /><br /><br /></div> Page Number(s) 13 - 16 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Innovation and Improvement of Body-Powered Arm Prostheses: A First Step Creator An entity primarily responsible for making the resource Maurice A. LeBlanc, M.S.M.E., CP. * https://staging.drfop.org/files/original/d1e6d37381974afea447207e5e2dcbe4.pdf 098f55530355bceeb283da47fcc350e7 https://staging.drfop.org/files/original/0666e268b5cec1356b0b7c65cbfadb51.jpg 34526111ef1e2eb773fafce8d671b491 https://staging.drfop.org/files/original/cc9fd87e23971d5b30a0750aca41f5a3.jpg 63bf988ca05ee052c35c60bac08961ea https://staging.drfop.org/files/original/85d3b8a378a156a011e468adb5269da1.jpg 5bf92dc7bf504dcff53808541d517251 https://staging.drfop.org/files/original/227e6156213f99f0da1e50d223dee8a0.jpg 3db61f11e3ba6a4f7e34e896d5442696 https://staging.drfop.org/files/original/9a578284ee6908603aea1c033d17b00a.jpg e8da77889765cbddc376316eae272fe9 https://staging.drfop.org/files/original/2cdd2bdc87a91cc20b1bd2e2c8de8fdb.jpg bc32bfecba3ba120e95537d67188be8d https://staging.drfop.org/files/original/08887b5a399d3835a423a7465e92c363.jpg b49025384d7feb416227e5c087356179 https://staging.drfop.org/files/original/3bdc683c4fd3a3b01dd291dcc05442a7.jpg dc3f77f6a7dc6e8f10d15f57a79b4bd5 https://staging.drfop.org/files/original/baa8c678a811a389abfecf5c63ec394a.jpg fadb2fb86dfab8eae20656c2668c41bf https://staging.drfop.org/files/original/8af81fcc4e2a1200c4b3ebacefd7dcdc.jpg 71e21b708994bac32da23d1191b72f33 https://staging.drfop.org/files/original/df8f5de5f6e51604721fe6c8eac18d00.jpg daf7122151ce6dea1bd294319637ca83 https://staging.drfop.org/files/original/fc36c0b09aa6f3af1a634440b2895b0c.jpg 737f8f6f58dd6ce0aa0bafb5bc333f08 https://staging.drfop.org/files/original/f23de5b7227d292fd049b5c53370ad5e.jpg 322c5646d98f492326ba9b2ad1189f10 https://staging.drfop.org/files/original/12807becbc364793ce64139f3ed19ca0.jpg 76b2ffd63899936900e983217326addb https://staging.drfop.org/files/original/c7c004b4cacc9f9a708a3486dc137efa.jpg d1ecb9180a51ca39aec2e6a1a746c16d https://staging.drfop.org/files/original/0b96ee4588a2a50ba8ae866ee38bd212.jpg 9ce093f92ed02602e5a59abd344d72a8 https://staging.drfop.org/files/original/6dca045beee9acf9d8ca40d95e842f26.jpg 261149ab340dc088401ee1852c05995d https://staging.drfop.org/files/original/1dfabfd667493e59ce35c164c328039a.jpg d22c081e2b4704fdbf8a951a6c62136a https://staging.drfop.org/files/original/70bc99ba51deb9adc1649fc859b83790.jpg 1315b524e4b6252efd9c727af36bddc5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_015.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 15 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Upper-Extremity Prosthetics Armamentarium</h2> <h5>Maurice J. Fletcher, Lt. Col., USA (MSC) <a style="text-decoration:none;">*</a><br /></h5> <p>The word "armamentarium" is defined as "the equipment, instruments, apparatus, or paraphernalia used by the practitioner of medicine." As applied to artificial limbs, it refers to the array of components necessary for the prescription fitting of prostheses in relationship to the site of amputation.</p> <p>In the prosthetics armamentarium, it is desirable that a complete range of components be available in order to provide satisfactory prostheses for all sites of upper-extremity amputations. A few gaps still remain in the present armamentarium of devices, but such temporary inadequacies are in the area of special cases, such as in transcarpal and fore-quarter amputations and in children's prostheses. The few remaining gaps are being rapidly filled, and supplementary components for fortifying the present armamentarium, such as additional hand sizes, are under consideration at the present time. The fact that devices now exist in each category of necessary arm components does not necessarily mean that they are the ultimate. They might even be interim devices, but they do permit prescription fitting of arm prostheses to a degree of efficiency heretofore unattainable. As a device is made available for each category of the armamentarium, improve-ments are attempted in these individual devices to increase their efficiency and useful-ness to the amputee. New models and methods of operation are being exploited in the hope of providing, eventually, even more efficient restorative prostheses. It is the purpose here to provide brief descriptions of the functions provided by the basic units of the present upper-extremity armamentarium. For a more detailed treatment of the devices and the philosophy underlying their design, reference may be had to <i>Human Limbs and Their Substitutes</i> (McGraw-Hill, in press) and to the <i>Manual of Upper-Extremity Prosthetics</i> (University of California at Los Angeles, 1952).</p> <h3>Terminal Devices</h3> <h4>APRL Model 4c Voluntary-Closing Hand and Cosmetic Glove</h4> <p>As the name implies, in the APRL voluntary-closing hand (<b>Fig. 1</b>) prehension force is obtained voluntarily by the amputee. Tension applied to a control cable closes the index and middle fingers against the thumb in a three-jaw-chuck pattern. These one-piece, hollow, metal fingers move through a 1 1/2-in. range, but since the thumb tip can be set in either of two positions 1 1/2-in. apart, objects up to 3 in. wide can be grasped. Finger angles are such that a grasped object is forced inward toward the palm. Security of grasp is further increased by the use of felt pads on the inner surfaces of the fingers and thumb. Any degree of prehensile force up to about 35 lb. can be obtained. The ring and little fingers are of cast latex and are attached so that they roughly conform to the shape of the object being handled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. APRL model 4C voluntary-closing hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The actuating mechanism, shown in <b>Fig. 1</b>, consists of a cam-quadrant type of clutch which automatically locks the index finger and middle finger in place when tension in the control cable is released. Reapplication of tension automatically unlocks the mechanism, and a spring forces the fingers to the fully open position, at which point the mechanism is recocked and ready for another cycle. Backlash is eliminated in the lever system by incorporation of an auxiliary spring-and-lever system. In fact a certain amount of frontlash may be introduced into the system. The voluntary-closing type of mechanism permits fuller utilization of the potentialities of a cineplasty tunnel than any device heretofore available.</p> <p>The APRL hand is covered by a cast polyvinyl chloride glove of extremely natural appearance (<b>Fig. 2</b>). Developed especially for the APRL hand, it has been designed with particular regard to eliminating as much as possible the resistance to operation of the fingers. In order to reduce the necessarily high cost of coloring each glove on a custom basis, after careful experimentation six Caucasian and six Negroid shades have been provided. They satisfy the majority of amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. APRL model 4C voluntary-closing hanc covered with APRL cosmetic glove. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>APRL Voluntary-Closing Hook</h4> <p>The APRL voluntary-closing hook (<b>Fig. 3</b>) contains essentially the same mechanism employed in the APRL hand. One hook finger is closed against a stationary hook finger, the two designed to accommodate objects up to 3 in. in size. A control button permits the engagement of a stop to limit hook opening to 1 1/2-in. so that the hook finger does not have to move through its full range before recocking of the locking mechanism takes place. Moreover, locking action in the l 1/2-in. open position can be eliminated at the will of the amputee when this is desired for repetitive tasks. The rubber-lined, lyre-shaped, aluminum hook fingers are specially designed to provide maximum function. The smooth exterior surfaces present the least amount of friction to aid in entering pockets, while the rubber linings provide friction to aid in handling objects. Duckbill finger tips lend facility in handling small objects. By removing the fingers and reinstalling them 180 deg. from the original position, a right hook can quickly be converted to a left, or vice versa.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. APRL voluntary-closing hook in open and closed positions. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Northrop-Sierra Voluntary-Opening Two-Load Hook</h4> <p>In the Northrop-Sierra voluntary-opening two-load hook (<b>Fig. 4</b>), designed primarily for bilateral amputees, tension on the control cable causes one hook finger to open against a spring force, which in turn provides prehensile force between the hook fingers when there is no tension on the control cable. The spring force is provided by two identical coil-type springs. When both are engaged, a prehensile force of approximately 7 lb. is available at the ringer tips. When only one spring is engaged, 3 1/2 lb. of force are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Northrop-Sierra voluntary-opening two-load hook. Schematic diagram (above) shows arrangement of hook thumb and enclosed coil springs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The lyre-shaped fingers are the same as nose used in the APRL hook.</p> <h4>Dorrance Voluntary-Opening Hook</h4> <p>Prehension in the Dorrance hooks is provided by rubber bands which force the hook fingers together. Adjustment of the prehension force is accomplished by adding or removing bands. Hook fingers are available in many different sizes and shapes of both steel and aluminum. Dorrance hooks offer the extreme in ruggedness and simplicity. The model known as Utility #5, shown in <b>Fig. 5</b>, is very popular.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Dorrance #5 utility hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Length Adapters and Fairings</h4> <p>To provide a constant effective prosthetic length when terminal devices of different lengths are interchanged, as in the case of the APRL hook and hand, length adapters and fairings (<b>Fig. 6</b>) have been made available. The length adapter is simply a stud with male threads at one end and female threads at the other so that it may be inserted between terminal device and wrist unit. Also available is a plastic fairing which covers the length adapter and provides a smooth transition between the oval end section of the APRL hand and the circular section of the wrist unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Wrist fairing and length adapter for APRL model 4C hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Wrist Units</h3> <h4>Manual Friction-Type Wrist Units</h4> <p>Female threads receive the stud of the terminal device, the wrist-flexion unit, or the length adapter to permit attachment of these units to the arm. Compression of a rubber washer between the terminal device and the wrist unit provides sufficient friction to permit a certain amount of adjustment in the rotation of the terminal device without slippage under average operating conditions. SierraEngineering Company supplies the friction-type wrist unit in one size, 2 in. in diameter, suitable for the average adult male, while Hosmer supplies essentially the same unit in three sizes-2 in. in diameter for the average male, 1 3/4-in. in diameter for women and large children, and 1 3/8-in. in diameter for small children. All these units are designed to facilitate incorporation into plastic-laminate arms.</p> <h4>Manual Lock-Type Wrist Units</h4> <p><b>Hosmer F-M Wrist Unit</b></p> <p>Rapid interchange of terminal devices and positive locking of the terminal device in the pronation-supination plane are afforded by the Hosmer F-M (Fletcher-Motis) unit (<b>Fig. 7</b>). A serrated steel adapter with an annular groove is attached to the stud of the terminal device by threads. To connect the terminal device to the arm, the stud is forced into the wrist unit until a locking yoke and gear segment are engaged. To adjust the amount of rotation of the terminal device, the control button is depressed to the first detent, which releases the gear lock and permits rotation since the terminal device is retained by engagement of the locking yoke in the annular groove on the adapter. Further depression of the control button disengages the locking yoke and permits removal of the terminal device. A coiled compression spring attached to the end of the adapter facilitates operation of the F-M unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Hosmer F-M wrist unit, with exploded view showing arrangement of parts. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Quick-Change Wrist Unit</b></p> <p>The Hosmer quick-change wrist unit provides essentially the same function as the F-M unit but is not quite as rugged and is more difficult to operate in some instances. The adapter and terminal device are released by rotating the forward portion of the wrist section, which disengages a detent-type lock. The quick-change unit is lighter in weight than the F-M unit and is used when weight is an important factor.</p> <h4>Northrop-Sierra Wrist-Flexion Device</h4> <p>The Northrop-Sierra Model B wrist-flexion device (<b>Fig. 8</b>), when used, is installed between the terminal device and the wrist unit. Consisting of a simple detent-type lock with three positions, it permits manual positioning and locking of the terminal device at 0, 25, and 50 deg. of flexion. Depression of a control button at the base of the unit disengages the lock to permit a change in the amount of wrist flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Northrop-Sierra model B wrist-flexion device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Bilateral amputees find this device especially useful for working in areas close to the face and body, and some unilateral amputees have found it helpful in certain tasks necessary to their particular occupation.</p> <p>The APRL-Sierra below-elbow wrist-rotation unit (<b>Fig. 9</b>) has been developed to step up or multiply the residual pronation-supination of below-elbow amputees. A given rotation of the inner socket by the stump produces, through a planetary gear system, 2.3 times that amount of rotation in the terminal device. A locking mechanism, actuated by relative motion between the forearm and upper arm, and by which the unit is unlocked upon full extension of the forearm and locked upon flexion, is provided when desired.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. APRL-sierra wrist-rotation step-up unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Below-elbow amputees with little or no pronation-supination and nearly conical stumps have been fitted successfully with this unit, since rotation of the inner socket can be produced by rotating the humerus. In this case the lock must be provided so the stump may rotate relative to the socket upon flexion.</p> <h3>Below-Elbow Hinges</h3> <h4>Robin-Aids Flexible Hinges</h4> <p>Where no wrist-rotation step-up unit is used, the Robin-Aids flexible hinge (<b>Fig. 10</b>, bottom) is employed between the socket and arm cuff or triceps pad to impart axial stability to the entire prosthesis and yet to permit maximum use of the residual pronation-supination. The Robin-Aids hinge consists of a metal cable covered with a wrapped-wire housing and having flat terminal plates designed for firm anchoring in the plastic-laminate forearm and for fastening to the upper-arm cuff.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Below-elbow hinges. Top, Sierra insert hinge; center, Hosmer variable-ratio step-up hinge; bottom, Robin-Aids flexible hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Leather-Strap Hinges</h4> <p>Nylon-coated leather straps may be fabricated in the shop and used in lieu of the Robin-Aids flexible hinge.</p> <h4>Single-Axis Hinges</h4> <p>Metal single-axis hinges specially designed for plastic fabrication are available from several manufacturers. This type of hinge is used where maximum stability is required, such as in short below-elbow cases and in heavy-duty arms.</p> <h4>Polycentric Hinges</h4> <p>Polycentric hinges may be substituted for the single-axis hinges. They are preferred by many prosthetists because less care is required in location to give the same amount of comfort to the patient. Instead of a single axis, two hinge points are provided in this unit, thereby exerting less pressure on the stump through the socket when the forearm is flexed and when some slight misalignment exists.</p> <h4>Northrop-Sierra Insert Hinges</h4> <p>Insert-type hinges might be classified as semiflexible hinges, since they provide a degree of stability somewhere between that offered by the flexible Robin-Aids hinge or the leather strap and the solid steel hinges. They are generally used on medium below-elbow prostheses where sufficient stability cannot be obtained with the flexible hinge but where the stump is long enough to provide sufficient stability so that the metal-strap hinges are unnecessary. Insert hinges are installed in "ears" on the distal end of a leather arm cuff so that the cuff may be hinged about the proximal end of the forearm socket. The method of assembly is illustrated in <b>Fig. 10</b>, top.</p> <h4>Step-Up Hinges</h4> <p><b>Hosmer MA-100 Hinges</b></p> <p>The Hosmer MA-100 step-up hinge (<b>Fig. 11</b>) was developed to permit full flexion of the prosthetic forearm when flexion of the stump is limited to 90 deg. or more. Step-up action is provided through two gears so that flexion of the stump 90 deg. results in 135 deg. of forearm flexion. The multiplication in motion results in a corresponding decrease in torque about the prosthetic forearm, and often an assistive lift is required for forearm flexion. This is accomplished by employing one of the above-elbow harnessing systems.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Hosmer MA-100 step-up hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Variable-Ratio Step-Up Hinge</b></p> <p>The Hosmer variable-ratio hinge (<b>Fig. 10</b>, center) provides approximately the same function as the MA-100 hinge but is usually preferred because the changing ratio of stump action to forearm action provided by the sliding lever system results in easier operation. This ratio in the fully extended position is 1:1.8, increases to 1:1.3 when the forearm is flexed 90 deg., and decreases to 1:1.8 at the 135-deg. position. Furthermore, because of the sliding action of the hinge, the stump does not extend as far below the forearm in flexion as in the case of the MA-100 hinge, a fact which in many instances eliminates the necessity for enlarging the sleeve of the garment covering the artificial limb.</p> <h4>Robin-Aids Stump-Actuated Elbow Lock</h4> <p>The Robin-Aids elbow (<b>Fig. 12</b>) was designed for short below-elbow cases where flexion of the forearm is limited to less than 90 deg. or for those cases where the torque about the elbow is too weak to offer sufficient stability. Full extension of the stump forces a lever into a detent on a segment about the elbow axis, locking the forearm in flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Robin-Aids stump-actuated elbow lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Elbow Units for Above-Elbow Cases</h3> <h4>Northrop Model C Elbow</h4> <p>An alternating-type control for the locking mechanism is the prominent feature of the Northrop Model C elbow (<b>Fig. 13</b>). The first pull on the control cable drops a lever into a detent on a sector, resulting in a positive locking action about the elbow axis. The next pull on the control cable removes the locking level from the detent, thereby making the forearm free to rotate about the elbow axis. Eleven locking positions are available. In the average above-elbow case, the control cable is generally actuated by humeral extension, leaving the other hand or prosthesis, as the case may be, free. The excursion required, about 3/8-in., is so slight that after some practice most amputees are able to operate the locking unit with a motion that goes unnoticed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Northrop model C elbow unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attachment to the upper arm is afforded by a single bolt in a turntable arrangement which permits the amputee to select at will the plane of forearm flexion and extension. A specially designed saddle for lamination into plastic is used for attaching the unit to the forearm.</p> <p>The Northrop elbow is presently available in one size only, 3 in. in diameter.</p> <h4>Hosmer Elbow Unit</h4> <p>Locking action of the Hosmer elbow unit (<b>Fig. 14</b>) is accomplished by permitting two tightly wound coil springs to wrap themselves around a shaft. Such an arrangement permits an infinite number of locking positions. Attachment to the arm and forearm and operation by the amputee follows the same pattern as in the case of the Northrop Model C.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Hosmer elbow unit, without turntable or forearm saddle attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Hosmer unit is available in two sizes, approximately 2 and 3 in. in diameter. Recently Hosmer has added to its line a smaller elbow designed for children.</p> <h4>Elbow-Disarticulation Prostheses</h4> <p>The APRL-Sierra side-locking elbow hinge (<b>Fig. 15</b>) was developed expressly for elbow disarticulation and for very long above-elbow cases where insufficient room exists for the fully enclosed type of elbow unit. An alternating-type locking unit on the outside of the inner hinges permits locking and unlocking of the elbow by humeral extension, as in the case of the standard above-elbow amputee. This unit may also be used on short below-elbow cases where use of the Robin-Aids forearm-actuated lock is not feasible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. APRL-Sierra outside-locking elbow hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Control Systems</h3> <p>For terminal-device operation and forearm control, Bowden-type controls, along with such parts as retainer and terminal fittings specially designed for use on artificial arms, are available from a number of sources for both the harness and cineplasty applications. This type of control system (<b>Fig. 16</b>), consisting of high-strength woven wire cable enclosed in a wrapped-wire housing, has proven infinitely more satisfactory than anything else used to date, mainly because of its resistance to stretching and its relatively high power-transmission efficiency.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Bowden-type control cable and attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Below-Elbow Biceps Cineplasty Control Systems</h4> <p>Special control-system kits are available for below-elbow amputees with biceps cineplasty tunnels. The twin-cable system (<b>Fig. 17</b>), often referred to as the UCLA system, is available with either straight or ox-bow acrylic tunnel pins reinforced with a copper core. Provisions have been made for quickly attaching or removing the control cables with respect to the pin. Rapid selection of the initial tension on the muscle tunnel is made possible by the incorporation of a turnbuckle type of unit which controls the effective cable length. A single-cable system using a sheave-type equalizer and known as the APRL system is also available (<b>Fig. 18</b>). Cable-tension adjust-ment is provided by a single cable-length ad-juster installed between the sheave and the terminal device. Each of these systems is considered merely as a replacement for the shoulder-operated control system, since all other portions of the prosthesis are the same whether operated from the shoulder or from the muscle tunnel.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Twin-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. APRL single-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Nudge Control</h4> <p>For the shoulder-disarticulation case, in which it is impossible to provide from shoulder movement force and excursion necessary to operate the Northrop Model C or Hosmer elbow, there is available the Nudge Control, which permits the elbow lock to be controlled by chin movement. The nudge control (<b>Fig. 19</b>) is especially useful for bilateral shoulder-disarticulation cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Nudge control for operation of elbow lock in shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Conclusion</h3> <p>This, briefly, completes the basic items of the armamentarium of devices available for prescription fitting relative to sites of amputation. There are, however, many supplementary devices, available in the field and well known to the industry, which are used with the devices described.</p> <p>With the existence of the many devices now on the market, it is possible to custom-build prostheses to rare or irregular cases, and to increase the number of items in the armamentarium makes such custom-building more feasible. A number of improvements are constantly being made in the research establishments on existing devices, and these, of course, will be fed into the industry as they are developed to the point where they are considered commercially marketable and necessary items of the armamentarium.</p> <p>Needless to say, each existing armamentarium item is being accorded careful study by the various research groups in an effort to increase efficiency and utility. Many new devices are now in the research stage; some are approaching the transitional period; others are known to be necessary and steps have been taken to prove such devices and to production-engineer them to the point where they will be marketable from the standpoint of increased efficiency, decreased maintenance, and economics. To mention a few items, the goals sought include improved terminal devices, both hand and hook; the cosmetic glove; improved elbow-lock mechanisms and elbow mechanisms themselves; the cosmetic approach to the entire prosthesis, up to and including the shoulder; and improvement of the over-all control systems to make them more efficient and more durable than are those now available. Already existent items of the armamentarium, such as harnesses, harness materials, and fittings, have been passed by purposely in this discussion, since they are well known to the industry. The use of some of the new synthetic materials, such as nylon, orlon, and dacron webbing, is standard practice in most limbshops. These new webbings are perspiration-resistant and possess adequate strength to meet the requirements of modern prosthetic devices. New webbings of various types and structures are constantly under study and test. Steady improvement has been made in the process of weaving these materials to prevent stretching.</p> <p>It is hoped that, through the gradual improvement of all items of the armamentarium, the comfort and utility of upperextremity prostheses will be increased to the point where an amputee will continuously wear and use a prosthetic device and will no longer be considered by society as a handicapped person. It may then be realized that the amputee can perform his job as well as can the normal person. The prescription fitting of each individual case may become so precise and so efficient that there will no longer be a question as to the value of the prosthesis to the amputee in returning to his place in society. The continuous development of new items for the armamentarium, and improvement in items existing in the present armamentarium, will make available to the prosthetist a variety of components permitting the satisfactory fitting of each amputee in conformance to his own individual pattern of life and will permit the new amputee to resume many jobs without loss in efficiency.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Maurice J. Fletcher, Lt. Col., USA (MSC) </b></td></tr><tr><td class="clsTextSmall">Director, Army Prosthetics Research Laboratory, Walter Reed Army Hospital; member, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-012.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-013.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-014.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-015.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-016.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-017.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-018.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-019.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 Upper-Extremity Prosthetics Armamentarium Creator An entity primarily responsible for making the resource Maurice J. Fletcher, Lt. Col., USA (MSC) * https://staging.drfop.org/files/original/475312ad901e4ae50427aca982b96391.pdf 16c5a7f900bf5cd9f0075d663907a89c https://staging.drfop.org/files/original/f946e814ca104b1ab87b53b87b6b3c43.jpg 4eebe01c35bb30eaec673139c764c259 https://staging.drfop.org/files/original/49517f0922e98539ac3edf1a8ffdee4d.jpg d7ecf857cfc2c67c1e8a164c675ffae8 https://staging.drfop.org/files/original/e1a3036e9d2bcea88e93e31c9321ee05.jpg 8f41bfd2fd79a1fcf5b6b869231034da https://staging.drfop.org/files/original/da9fc3922ff615899e8cd528ace5c3d8.jpg c10cfb063259e8b5b8c497db3b3825ca https://staging.drfop.org/files/original/5c28655b2bac581bd2b3251173ef77d4.jpg 13d4fbf3a65ed2ac03d8aae664728070 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_014.pdf Text Any textual data included in the document <h2>Partial Foot Prostheses/Orthoses</h2> <h5>Melvin L. Stills, CO.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Prostheses and orthoses prescribed for partial foot amputations vary in design and principle. Authors have described the need or the lack of need of toe lever arms, extensions above or below the ankle, and hard and soft sockets. Almost every design violates a principle thought to be a requirement of the other designers of partial foot prostheses/orthoses. The purpose of this paper is to describe some of the designs now being advocated and to give the rationale for their use.</p> <h3>Above the Ankle</h3> <p>Many authors and designers believe that the proper management of a mid-transverse metatarsal amputation, or more proximal, must include an extension above the ankle. Many of these designs take the form of an ankle-foot orthosis (<a href="/files/original/f946e814ca104b1ab87b53b87b6b3c43.jpg"><b>Fig. 1</b></a>). This orthosis may be fabricated from thermoplastic materials (polypropylene), thermoset plastics (polyester or acrylic) which may be incorporated with graphite or other space age materials to reduce weight and increase strength (<a href="/files/original/49517f0922e98539ac3edf1a8ffdee4d.jpg"><b>Fig. 2</b></a>), or may be incorporated into conventional metal and leather types of orthoses. Those devices fabricated from thermoplastics and thermoset materials are generally formed over a positive model of the amputated extremity. The portion of the device contacting the foot is designed to achieve total contact and is generally lined with a soft interface material to increase comfort and/or provide better distribution of forces. The normal profile of the foot may be restored during the initial fabrication process or added later as a buildup of foam. This foot buildup acts as an extension of the foot lever arm, or in some instances may only act as a shoe filler. If an attempt is made to extend the foot lever arm, it may be necessary to complete shoe modifications which would include a full length spring steel shank cushion heel and walker sole. It is considered that this combination of prosthesis, orthosis, and shoe will provide a smooth transition from foot flat to heel off and permit an effective push off.</p> <strong><a href="/files/original/f946e814ca104b1ab87b53b87b6b3c43.jpg">Figure 1</a>. Polypropylene ankle-foot orthosis with foam toe filler.</strong><br /><br /><strong><a href="/files/original/49517f0922e98539ac3edf1a8ffdee4d.jpg">Figure 2.</a> Graphite reinforced laminated posterior prosthetic shell for transtarsal amputation.</strong><br /> <p>Tarso-metatarsal amputations may require a solid ankle device. This device employs similar methods of construction with the addition of an anterior section extending from the level equal to the height of the posterior section and distally to the dorsum of the remaining foot. This addition acts to lock the foot and lower leg into the posterior section and eliminates ankle motion. The shortened foot is difficult to retain in the posterior section, and the addition of the anterior shell provides better purchase and retention. The proximal region of the anterior section may take the form of a patellar tendon bearing socket, or extend to midcalf, or in some designs extend only to the area just above the ankle. Variations of all three commonly exist, and the amount of ankle control will be determined by the design selected. If a design is selected which limits ankle motion, most authors agree that shoe modifications are required to achieve normal gait. A cushion heel applied to the shoe will permit smooth transition from heel strike to foot flat. Prosthetists who routinely employ these designs have reported good results with successful ambulation.</p> <h3>Below the Ankle (Slipper Type)</h3> <p>A number of designs exist that do not extend above the ankle joint. They appear to be divided into the following categories: (1) rigid, (2) semi-rigid, (3) semi-flexible, and (4) flexible. All of these systems are fabricated on a positive model of the residual limb. The positive model is modified to increase loading of good tissue and to relieve or decrease pressures on sensitive areas prior to the forming of the definitive socket.</p> <p>The rigid and semi-rigid systems are based on a laminated or thermoform socket. Limited flexibility is built into these systems, using flexible resins in fabricating the semi-rigid shells. A foam lining is generally employed to act as an interface between the rigid walls of the socket and the skin of the residual limb. The profile of the foot is restored with a buildup added to the socket. Complications may be encountered in using the rigid/semi-rigid designs when motion occurs inside the socket. Breakdown on the distal plantar surface of the residual limb is not uncommon, and this complication has led to the development of the semi-flexible and flexible designs.</p> <p>Semi-flexible designs utilize a combination of material, generally having a base of urethane elastomer. One such system which is semi-flexible in nature and utilizes a laminated rigid University of California-Berkley shoe insert as its base. The insert is bonded to a modified monoelastic cushion heel foot and the entire system is laminated together with a urethane elastomer.<a></a> The resultant system does not interfere with normal ankle motion, and authors report good acceptance (<a href="/files/original/e1a3036e9d2bcea88e93e31c9321ee05.jpg"><b>Fig. 3</b></a>).</p> <strong><a href="/files/original/e1a3036e9d2bcea88e93e31c9321ee05.jpg">Figure 3.</a> UCBL thermaformed shoe insert with Lynadure forefoot.</strong><br /> <p>Another semi-flexible design uses solely a urethane elastomer for fabrication of the socket and foot. This design is referred to as a slipper-type elastomer prosthesis (STEP). The STEP design is somewhat complex in its design and fabrication. Permanent tooling is developed for each individual patient and may be retained by the patient for possible fabrication of replacement devices at a later date. This tooling consists of a permanent polyester resin positive model of the residual limb and a negative mold of the finished prosthetic foot. This device is fabricated using semi-flexible urethane elastomer.<a></a> If a pressure point is noted on the residual limb, modifications are made to the prosthesis by removing material from the exterior surface of the prosthesis in order to reduce rigidity in that area and to insure a smooth socket interface. Good results have been reported from the use of this prosthesis.</p> <h3>Flexible Foot Prostheses</h3> <p>A flexible cosmetic prosthetic foot (<a href="/files/original/da9fc3922ff615899e8cd528ace5c3d8.jpg"><b>Fig. 4</b></a>) has been developed which utilizes only reinforced silicone materials. A negative weight bearing alginate impression is made of the residual limb and contralateral foot. An exact detailed dental stone positive model of the residual limb is made from this impression. A wax check socket is fabricated on this model and checked for comfort and fit on the patient. Modifications are made to relieve sensitive areas and to load appropriate surfaces. Appropriate loading is based on the prosthetist's impression of soft tissue density and how much pressure the patient can tolerate. A mirror image model of the sound foot is sculpted from wax and checked for sizing against the patient. A negative model of the sculpted foot is then made using a lost wax method. The resulting negative model of the foot may then be used in conjunction with the rectified model of the residual limb to produce the prosthesis. The material employed is a pure reinforced silicone that is precolored to match the patient's skin tones. At the fitting, the detailed colored matching is achieved using the sound side as a model for cosmetic restoration. To date, approximately 100 patients have been fit with this flexible silicone cosmetic prosthetic foot, and patient acceptance has been almost 100 percent. The developer<a></a> initially intended the prosthesis solely as a cosmetic device (<a href="/files/original/5c28655b2bac581bd2b3251173ef77d4.jpg"><b>Fig. 5</b></a>). However, patients reported they had increased comfort and functional levels with the reinforced silicone prosthesis.</p> <strong><a href="/files/original/da9fc3922ff615899e8cd528ace5c3d8.jpg">Figure 4</a>. Reinforced silicone slipper type prosthetic foot. See Figure 2 for earlier fitting.</strong><br /><br /><strong><a href="/files/original/5c28655b2bac581bd2b3251173ef77d4.jpg">Figure 5.</a> Cosmetic functional silicone foot prosthesis.</strong><br /> <p>Requests for cosmetic restoration by males are almost equal in number to those requested by females. The psychological effect of cosmetic restoration has not yet been evaluated; however, it is probable that this has some influence on the functional acceptability of the prosthesis by the patient. Many of the patients fitted with a flexible silicone cosmetic prosthetic foot have previously been fit with partial foot prostheses of the types previously described. Mechanical comparisons of function of these designs would be valuable, but to my knowledge, have not yet been done.</p> <h3>Summary</h3> <p>A balanced foot is almost a necessity for successful fitting of any of the prosthetic systems. Trauma related amputations apparently do well with the slipper-type prosthesis, and the developer of the silicone system reports successful fitting in diabetic patients as well. The need for the prostheses to extend above the ankle appears to be limited to those patients with very short amputations, but successful fittings have been demonstrated with the slipper-type, sometimes using an ankle strap for suspension.</p> <p>There is no definitive statement that I can make recommending any one system over another. It appears that many partial foot amputees are being successfully managed with prostheses that do not extend above the ankle. It also appears that a higher rate of success is occurring when semi-flexible and flexible prostheses are being fit. It is believed by many that partial foot amputation can offer significant functional improvement over Symes level amputations and the use of this surgical technique needs to be reevaluated in light of the new technologies and materials available today for providing the partial foot amputee with a functional prosthesis.</p> <h3>Acknowledgements</h3> <p>A number of talented individuals have contributed to the information and materials presented in this paper, and in order to avoid inadvertently omitting someone's name, I wish to thank them all as a group for their assistance.</p> <h3>Bibliography</h3> <p>Childs, Charles and Timothy Staats, "The Slipper Type Partial Foot Prosthesis," Advanced Below Knee Prosthetic Seminar, UCLA Prosthetic and Orthotic Education Program, Fabrication Manual, 1983 Edition.</p> <p>Condie, David and Melvin Stills, "Biomechanics and Prosthetic/Orthotic Solutions—Partial Foot Amputations," Presented and to be Published as Proceeding "Dundee 85".</p> <p>Fillauer, Karl, "A Prosthesis for Foot Amputation Near the Tarsal-Metatarsal Junction," <i>Orthotics and Prosthetics</i>, Vol. 30, No. 3, September, 1976, pp. 9-11.</p> <p><a href="http://www.acpoc.org/library/1978_01_011.asp">Hayhurst, Donald J., "Prosthetic Management of Partial Foot Amputee," <i>Inter-Clinic Information Bulletin</i>, Vol. XVII, No. 1, January-February, 1978, pp. 11-15.</a></p> <p>Lunsford, Thomas, "Partial Foot Amputations—Prosthetic and Orthotic Management," <i>Atlas of Limb Prosthetics</i>, American Academy of Orthopedic Surgery, The C.V. Mosby Company, 1981, pp. 322-325.</p> <p>Wilson, Michael T., "Clinical Application of RTV Elastomers," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 4, December 1979, pp. 23-29.</p> <p><b>References:</b></p> <ol> <li>Lynadure, Medical Center Prosthetics, Inc., Houston, Texas.</li> <li>Calthane 1900, Cascade Orthopedic Supply, Inc., Chester, California.</li> <li>Mr. H. Buckner, C.O.T., Life-Like Laboratory, Dallas, Texas.</li> </ol> <em><b>*Melvin L. Stills, CO. </b> Melvin L. Stills, CO., is with the University of Texas Health Science Center, Division of Orthopedics, 5323 Harry Hines Blvd., Dallas, Texas 75235.<br /><br /><br /></em> Page Number(s) 14 - 18 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-5.jpg 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 Partial Foot Prostheses/Orthoses Creator An entity primarily responsible for making the resource Melvin L. Stills, CO. * https://staging.drfop.org/files/original/809ea89a32d4d8e36fa8e6385772fa3a.pdf 3ee99a2bf09bacedf1558f9b28f4ed07 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/1978_02_001.pdf Text Any textual data included in the document <h2>A Proposal for Delivery of Externally Powered Upper-Limb Prostheses</h2> <h5>Michael J. Quigley, C.P.O.&nbsp;</h5> <p>Prepared by the American Academy of Othotists and Prothetists, 1444 N St., N.W., Washington, D.C. 20005. Editor: A. Bennett Wilson, Jr., B.S. M.E.; Managing Editor: Brian A. Mastro, B.A.; Editorial Board: Joseph M. Cestaro, C.P.O., Charles H. Epps, Jr., M.D., Robert B. Peterson, R.P.T.</p> <p>There are about 322,000 amputees in the United States today. Of this number, approximately 9,000 people have upper-arm amputations and 16,000 have forearm amputations. Many arm amputees choose not to wear a prosthesis for three major reasons; 1) lack of sensory feedback, 2) poor function and 3) poor cosmesis.</p> <p>Unfortunately, the vast majority of physicians, therapists, and prosthetists seem to believe that new amputees should always be provided a hook first, and a hand later, if the hook is accepted. Nearly all patients, however, want a hand first and dread the thought of using a hook for obvious cosmetic and psychological reasons. In a great number of cases, the hook and prosthesis are rejected due to the undue amount of attention attracted to the wearer.</p> <p>Body powered mechanical hands are heavy, cumbersome, and far less functional than hooks. The same amount of harnessing and body power is required to control these hands as with the hooks. The cosmetic gloves that cover these hands are easily stained, torn, and discolored. The major indication for prosthetic hands has been for unilateral amputees who are engaged in light-duty work and are very conscious of cosmesis.</p> <p>The introduction of the VA- Northwestern University, Otto Bock, Variety Village, and other powered hands and elbows for prostheses should change the dismal attitude concerning prosthetic hands. These prostheses are extremely cosmetic, and require very little body motion and little or no harnessing to control the hand. The hand can be controlled easily whether the wearer is reaching for something over his head or behind him, which was previously very difficult. Powered prostheses are of greatest value for patients with high amputations, whether they are unilateral or bilateral. These patients are normally present complicated problems because they lack the muscle power and leverage to control mechanical prostheses, but they can easily control powered prostheses by myoelectric or switch controls.</p> <p>Powered prostheses have received a very cool reception in the United States due to a number of factors; the cost of the prostheses is high- four to five times that of conventional prostheses-and therefore many third-party payers refuse to pay for them. The prosthetist fitting an externally powered prosthesis must be well trained in order to evaluate myoelectric potentials and to properly fit and maintain the prosthesis. As most prosthetists have no background in electronics, more than a short orientation course is required. Even after thorough training is obtained, the prosthetist may only see two or three patients per year requiring these types of prostheses, and therefore much of the information will be forgotten. In many cases, components that were intended to be modular in concept and simply plugged in need to be reworked or redistribued around on the socket in order to accommodate a long or non-standard type of amputation. In a study conducted by the Veterans Administration 18 prosthetists were involved in an evaluation of powered prostheses. All prosthetists were given a one-to-two-week course by the VA on myoelectric prostheses and patients were referred to them through VA clinics for fittings. Despite all this education, prosthetist errors were responsible for more malfunctions than any other cause. Faced with all of the above facts plus the fact that the cosmetic glove is still a problem, most prosthetists chose not to handle externally powered prostheses. Further, since such a small percentage of the amputee population can be fitted with this type of prosthesis, most prosthetists find it impractical to invest the great amount of time and money for education and equipment before they can provide satisfactory service.</p> <p>It has been shown that in areas where prosthetists learned enough about powered prostheses to be able to properly fit and maintain them, the prostheses received wide acceptance. John Billock, C.P.O., in Warren, Ohio uses a number of different powered prosthesis systems, including hybrid models using components of different systems on severely disabled upper-limb amputees that are referred from all over the Midwest. William Sauter at Ontario Crippled Childrens Center has also proven the practicality of powered systems on adults and children. In each area, however, institutional support has been the determining factor. Mr. Billock's success was achieved after years of participation in the research program at Northwestern University and Mr. Sauter's work is done in a large Rehabilitation Center. Similarly, the Bock system is used in Minneapolis due to a great amount of support from the Germany-based Otto Bock Company to its United States headquarters in Minneapolis. The Otto Bock Company is presently offering a free one-week course on the basic below-elbow system, and plans future courses on advanced powered components.</p> <p>We are faced with the situation that powered upper-limb prostheses are presently available but are not used for the many reasons stated previously. How do we solve the service delivery problem, particularly for the more severely disabled upper-limb amputee? I suggest that specialized fitting centers are the best solution to the problem. Such centers can be privately owned or located in an institution. The advantage of this system is that the prosthetist would see enough patients to become truly expert in the area of powered prostheses, and could well afford the expense of taking all relevent courses or preceptorships and obtaining the necessary staff and equipment.</p> <p>I have visited one such center in Warren, Ohio, which is owned by John Billock, C.P.O. Mr. Billock and his staff at Warren Orthotics and Prosthetics Restoration Laboratory fit three to four powered upper-limb prostheses per month, including all levels of amputation. His staff includes a full time electrical engineer and an electronics technician. There are enough equipment and spare parts available so that essentially all maintenance is carried out on the scene, which avoids long delays when repairs are done elsewhere. Patient referrals are mostly from the Midwest and East Coast, although patients from the West Coast are not uncommon. One patient being seen during my visit had a right shoulder disarticulation and a left above-elbow amputation and was being fitted with powered hands, elbows and wrist rotators controlled by switches. Components from at least three manufacturers had to be made compatible in the ten-month long project.</p> <p>I feel that a total of four centers in the United States could adequately handle the patient load. The average prosthetist with a good understanding of powered prostheses will be able to treat most unilateral below-elbow patients, so referrals to a powered prosthesis center will usually be for more difficult cases. It will be important for private centers to be closely allied with a rehabilitation center, as these patients will require therapy, counseling, and other services while the prosthetic services are being performed.</p> <p>It seems obvious to me that powered prostheses will be more common than body powered designs within the next twenty years, and it is time now to establish an efficient service delivery system.</p> Page Number(s) 1 - 2 Year 1978 Volume 2 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Proposal for Delivery of Externally Powered Upper-Limb Prostheses Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O.  https://staging.drfop.org/files/original/ff3340abee0b201874784eb994f1540f.pdf c2e3cc34fa9285809d54831e90850af8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_011.pdf Text Any textual data included in the document <h2>The Role of Test Socket Procedures in Today's Prosthetic Practices</h2> <h5>Michael J. Quigley, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The proper role of a test socket procedure is a controversial topic in today's practice of prosthetics. A test socket procedure can be defined as that stage in the design of a prosthesis when a socket is fabricated solely for the purpose of determining proper socket fit. Although test sockets were originally used for upper limb prostheses, the true advent of the test socket was in 1972 when Mooney and Snelson<a></a> described the polycarbonate clear test socket as developed at Rancho Los Amigos Hospital. During the 13 years since that article, the proper role of the test socket procedure has still not been defined.</p> <p>There are several reasons for the controversy over test sockets. First, when a test socket procedure is done, there is an implication that the mold, mold modifications, and socket design principles instilled in the prosthetist may not be correct. After all, if the prosthetist's techniques were perfect, the socket would fit perfectly and the need for a test socket would be obviated. However, any time a clear test socket is used, the prosthetist immediately notices a few things he would like to change in the definitive socket or, in some cases, the next test socket.</p> <p>It is safe to say that the majority of United States prosthetists believe in the value of test sockets and use them on a regular basis. Indeed, insurance companies and most other third party reimbursers, including Medicare, pay for test sockets, thereby recognizing twin values. A test socket procedure makes good sense, and there is no question that it improves prosthetic fitting. However, it is also true that many prosthetists do not use these sockets, or use them only rarely. The group that does not use test sockets feels that they can fit nearly all prostheses well without test sockets and do not want to spend the additional effort that test sockets require, or they simply do not want to change the methods they learned many years ago. The present Veterans Administration's (VA) procedure for obtaining approval for test sockets seems to favor this latter group, since it is an intentionally cumbersome system that, in effect, discourages test socket procedures on VA patients.</p> <p>Test socket users also include prosthetists who routinely use multiple test sockets on every patient, with the principle that each successive socket brings you one step closer to the perfect fit. If one test socket procedure is good, shouldn't two be better? Or three? Or more? This is a major area of controversy that could be discussed here but not resolved. Probably the best example of this use of test sockets is at the Institute for the Advancement of Prosthetics (IAP) in Lansing, Michigan (although a number of other prosthetic practices are also using multiple test sockets, or featuring them as a type of "first class" service).</p> <p>An average of six test socket procedures are done on each patient in Lansing: beginning with static fittings in clear sockets with the patient wearing no prosthetic socks, going on to clear socket dynamic (walking) fittings, and progressing to a definitive socket with a gel liner for below knee amputees. The patient is seen every day for two to three weeks until the socket fit is perfected, and only then is the prosthesis finished. This, of course, is an expensive undertaking, but it seems logical to assume that with so much time and energy spent, the patient would end up with a better fit. The multiple test socket users lead an Utopian existence, seeking the perfect fit, and see only one or two patients every week or continue fittings for many months if they are seen only on a weekly basis. For the average prosthetist who fits 100 or more patients alone each year, the sheer logistics of using multiple test sockets on every patient is staggering.</p> <p>Another area of controversy regarding test sockets is that they provide an incentive for prosthetists to delay being satisfied with the socket fit if they are paid separately for every test socket used. If they fit six test sockets, they are paid six times more than if they fit one test socket. The only response to this problem is that there are a few difficult cases where the only way a good fitting can be achieved is with multiple sockets, and the prosthetist should be reimbursed for his effort. On the other hand, there are always the few people who will abuse the system. In practice, less than five percent of all prosthetists have the time or inclination to routinely use multiple test sockets. After all, there are also very few patients or insurers who want to bear the expense, are able to make all the appointments necessary, and are willing to wait the many months for a finished prosthesis when multiple test sockets are used.</p> <p>Before summarizing, one final comment is necessary. Having test socket procedures available and using test sockets properly are two different things. There are no standardized, recommended, or documented procedures for the proper use of a test socket. Some people use clear sockets, some do not. Some use "wet fit" procedures with no prosthetics socks; others use prosthetic socks. Some test sockets are used statically, others dynamically. Alginate procedures are used in some areas. Even when a clear socket is used directly against the skin, how do we interpret what we are seeing? The result of the confusion over the proper use of a test socket is that the prosthetist converts one of the few objective tools he has available (a clear socket) into a subjective one by having to use educated guesses to determine the modifications needed to improve socket fit. The whole area concerning the optimum use of test socket procedures is in great need of study and documentation.</p> <p>In summary, test socket procedures are good procedures. When a prosthetist knows that the socket he is fitting is not the final product, he is more likely to make major socket modifications and, therefore, less likely to provide a poor fitting prostheses. Multiple or successive test sockets will always be required on a few difficult cases. In some areas, the patient and prosthetist will afford the luxury to use successive test sockets to try to achieve the perfect fit, but this will probably include less than one percent of the patient population.</p> <p>It is obvious that these socket procedures are here to stay and that the use of test sockets will increase as new materials and techniques are introduced. Hopefully, some meaningful documentation will be developed to enable prosthetists to obtain as much information as possible from a test socket procedure. Without a true understanding of how to properly use a test socket, each prosthetist is left to practice and develop his own technique, and the art of prosthetics again overwhelms the science.</p> <p><b>References:</b></p> <ol> <li>Mooney, V. and Snelson, R., "Fabrications and Applications of Transparent Polycarbonate Sockets," Orthotics and Prosthetics, 26 (1), p.p. 1-13, March 1972.</li> <li>Personal communication, Jan Stokosa, CP., May 6, 1985, Lansing, Michigan.</li> </ol> <p><b><em>*Michael J. Quigley, C.P.O. </em></b><em> Michael J. Quigley, C.P.O. is President of Oakbrook Orthopedic Services, Ltd. 1 South 132 Summit Ave, Ste 102, Oakbrook Terrace, IL 60181.</em></p> <p><em>&nbsp;</em></p> Page Number(s) 11 - 12 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Role of Test Socket Procedures in Today's Prosthetic Practices Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. *