12 20 371 https://staging.drfop.org/files/original/eaf0a7b425c90dc8b9205c09b4cfeddd.pdf 15e97b748c74abe2a1ca3e141ad14231 https://staging.drfop.org/files/original/b4340fe7dc6294b06bd93a46a9eefcfb.jpg 106945255e1ae54dde98455ab0a3f13e https://staging.drfop.org/files/original/eb21a4e75152f4ff61417686c70f9188.jpg 2bfb40cb9fe53bb031b025e027a5cc4b 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_01_001.pdf Text Any textual data included in the document <h2>Prosthetics Up-Date 1980: Foot and Knee Components</h2> <h5>H. Richard Lehneis, Ph.D., C.P.O.&nbsp;</h5> <p>This paper is, in part, based on a lecture given by the author at the International Congress on Technical Orthopedics, 1979, in Nurenburg, Germany.</p> <p>The data relating to prosthetic foot and knee components was obtained from a survey of the relative sales volume of the various components by three of the largest U.S. distributors of prosthetics components from practically all manufacturers. The distributors cooperating in this were Knit Rite, Inc., Kansas City, Missouri; Northeast Paramedical Industries, New York, New York; and PEL Supply Company, Cleveland, Ohio.</p> <p>These firms were requested to provide the relative percentage of sales of the various foot (<b>Table 1</b>) and knee components (<b>Table II</b>), rather than the absolute volume of sales. The table on knee components includes conventional versus modular constructions. The average (mean) percentages &nbsp;of the various prosthetic feet and knee components sold by the three firms are listed in the last columns of Tables I and II respectively. On the basis of these data, one may infer current prescription and fitting practices in the United States.</p> <p>An attempt to get similar data on below-knee and above-knee suspension systems, based on the percentage of sales of supracondylar cuff, BK side joints, hip joints, suction socket valves, and Silesian belts, appeared not valid after analysing the data collected because of the possibility of various combinations of suspension systems that may be prescribed and used. It is, therefore, hoped that readers of the Newsletter will return the questionnaire on Page 10 which addresses the subject of BK and AK sockets and suspension systems with due consideration of the various possibilities of combination of suspension systems.</p> <h3>Discussion</h3> <p>Referring to <b>Table 1</b>, there appears to be a vastly increased use of SACH feet versus other types of prosthetic feet. This may be interpreted in terms of the far greater frequency in recent years of BK versus AK amputations due to improved surgical techniques. Although, from the author's experience, it appears that SACH feet are used to an increasing extent and with great frequency in AK prostheses. <img src="/files/original/b4340fe7dc6294b06bd93a46a9eefcfb.jpg" br="" /><br /><br />In <b>Table II</b>, one notes a surprisingly low use of hydraulic mechanisms. This may be interpreted in terms of the increase in the geriatric population who, in general, do not benefit as much as younger amputees from the hydraulic systems. Support for this interpretation may be viewed in the larger percentage of safety knees, and single-axis knees with manual knee locks used which total 66 % of all knee units sold.<img src="/files/original/eb21a4e75152f4ff61417686c70f9188.jpg" br="" width="440" height="525" /></p> Page Number(s) 1 - 2 Year 1980 Volume 4 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1980_01_001/1980_01_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1980_01_001/1980_01_001-2.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 Prosthetics Up-Date 1980: Foot and Knee Components Creator An entity primarily responsible for making the resource H. Richard Lehneis, Ph.D., C.P.O.  https://staging.drfop.org/files/original/7df3c3d20edd1fa9693adfc0e42b932d.jpg 2822f04bd9699291f73b3aa0786a5d84 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL www.prosthetika.org Contact Name/Title Jonathan Batzdorff CPO - Director Address 1275 4th ST #142 City Santa Rosa State/Province California Countries Served Haiti, Bolivia, Ukraine, Mexico, India, Guyana Postal Code 95404 Email jon@prosthetika.org Organization Type Including ID and tax status Non-profit Tax ID 34-2002891 Not-for-profit Type 501 (c) 3 Services Provided Prosthetic Fitting, Orthotic Fitting, Education, Prosthetic Fabrication, Orthotic Fabrication, Rehabilitation / Training, Professional training Need I Financial Assistance Need II Volunteers OPPORTUNITIES: Prosthetist Logistics Orthotist Videography/Photography Physical Therapist Clerical Technical Assistance Other Need III Materials, Components, and Equipment: New or used Other: digital video camera, surplus prosthetic components Mission ProsthetiKa’s mission is to provide appropriate and sustainable assistance to disabled people in developing countries. Phone 707-235-0905 Facebook Page https://www.facebook.com/prosthetika 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 Prosthetika Description An account of the resource ProsthetiKa helps improve the lives of physically disabled people who require artificial limbs and orthopedic braces. https://staging.drfop.org/files/original/a933a60df9bfb8a9985e45b2f28415a4.png 581974ad855e0092b439b977e70fd602 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL https://protesisimbabura.com/ Contact Name/Title USA Contact Info: Robert and Kit Frank Independence Road Corporation 501(c) 3 266 Independence Blvd. Asheville, NC 28805 828 774 7222 Address Prótesis Imbabura and Fundación Jen lee Carlos Proaño 21-34 y Av. Eugenio Espejo City Ibarra State/Province Imbabura, Ecuador Countries Served Ecuador Phone (593) 06 2 858 777, (593) 96 851 9025 (593) 98 551 3931, (593) 98 575 2521 Email protesisimbabura@hotmail.com; bobkitfrank@gmail.com Organization Type Including ID and tax status For Profit Private Services Provided Prosthetic Fitting, Orthotic Fitting, Prosthetic Fabrication, Orthotic Fabrication Need I Financial Assistance Need II Volunteers: Protesis Imbabura offers opportunities for student affiliations, training, internships and independent study in the areas of prosthetics, orthotics, engineering, occupational therapy, physical therapy, and others. Our average stay is 4-6 weeks. Inexpensive housing is available. Need III Materials, Components, and Equipment: New, Disassembled, Used Mission Prótesis Imbabura’s mission is to provide Ecuadorian patients with quality affordable prosthetics (artifical limbs), orthotics (braces) and adaptive equipment. Prótesis Imbabura, with the collaboration of Fundación Jen Lee, and the help of foreign volunteers, fabricates affordable prosthetics, orthotics and adaptive equipment of high quality, thus helping those with needs for assistive technology to overcome adversity and meet challenges. Additional Info & Comments Protesis Imbabura partners with Independence Road Corporation. Independence Road Corporation is a non-profit organization registered in the United States as a 501c3. Facebook Page https://www.facebook.com/protesis.imbabura 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 Prótesis Imbabura Description An account of the resource Prótesis Imbabura provides prosthetics, orthotics, and adaptive equipment in Imbabura Province and throughout Ecuador. https://staging.drfop.org/files/original/d7bbda5fa4a94c9b44ad420c291a651d.pdf 1fbf7ce3189a6a47e65af6fd71c3f8d6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_225.pdf Text Any textual data included in the document <h2>Psychological Aspects of Spinal Cord Injury</h2> <h5>Katharine S. Westie, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Spinal cord injury (SCI) is a massive assault to the psyche as well as the body. Within moments, a person who had been active and independent becomes immobilized, loses control of bowel, bladder, sexual and other bodily functions, and is dependent on others to meet the most basic needs. The instantaneous effects of the injury result in total disruption of the victim's life, and the beginning of a life-long psychological adjustment process. Optimal emotional adjustment is imperative to the recovery and rehabilitation process, due to the tremendous psychological energy and motivation required for a SCI patient to learn self-care, independence, and psychosocial coping skills.</p> <h3>Theories of Psychological Adjustment</h3> <p>Psychological adjustment to SCI has been conceptualized in terms of three major models. The first is referred to as the "stages" theory, and is derived from the well known work on grieving done by Lindeman and Kubler-Ross.<a></a> This theory proposes that individuals adjusting to losses, such as SCI, experience certain psychological stages in the readjustment process. These include (1) shock and denial, (2) depression, (3) anxiety, (4) anger, (5) "bargaining," and (6) adaptation. In using this model, it is important to understand that not all patients go through all stages, that a patient may go through a stage more than once and that stages are not necessarily experienced in a given order. This model is helpful in recognizing these emotional responses as a normal, healthy, and appropriate part of adjustment to SCI.</p> <p>The second model is referred to as the "developmental" theory. It is derived from Er-ikson's work on psychosocial stages of development, from infancy to adulthood.<a></a> As applied to SCI, the developmental theory assumes that the trauma results in a natural regression, followed by a reworking of some developmental tasks previously mastered in childhood, starting with (1) basic trust, (2) autonomy, and (3) initiative. Physically and emotionally, SCI patients must progress through tasks of infancy and childhood again. Like infants, they initially may be unable to verbally communicate, need to be fed and moved, have no bowel and bladder control, and are totally dependent. As they progress through rehabilitation, they relearn childhood tasks such as rolling, feeding, developing a bowel and bladder routine, mobility, and other basic activities of daily living. They experience the adolescent task of separation from parental figures as they work toward the independence of adulthood. The rehabilitation program can be seen as facilitating attainment of these developmental landmarks.</p> <p>The third model, the "individual differences" theory, proposes that adjustment is primarily related to individual differences in patients' premorbid personalities.</p> <p>These models provide three different approaches to understanding psychological adjustment to SCI. However, they need not be seen as mutually exclusive. In fact, when used together, they provide a more complete picture of SCI patients' complex adjustment process.</p> <h3>Psychological Responses of Staff</h3> <p>Rehabilitation professionals working with SCI may find that certain patients elicit grieving responses in them, similar to those of their patients. When staff members identify with or become emotionally attached to patients, they may find themselves experiencing symptoms of depression, anger, or even denial. Highly motivated staff may also find it difficult to cope with noncompliance of depressed or angry SCI patients. Occasionally, when staff members' goals for resistant patients are not met, they may blame themselves for perceived failures or subconsciously direct anger and frustration toward patients. Although these are normal emotional responses, they may interfere with staff members' well-being and effectiveness. When situations such as these occur, consultation with the rehabilitation psychologist can provide the staff member with behavioral management techniques and enhance personal coping skills and insight. Professionally facilitated groups designed to provide peer support, teach stress management skills, and prevent "burnout" are also recommended.</p> <h3>Head Injury in SCI</h3> <p>Closed head injury (CHI) frequently accompanies traumatic SCI, though it often goes unrecognized. The reported incidence of head injury in SCI ranges from 10% to 58%.<a></a> Recent studies indicate that neuropsychological deficits are common among SCI patients.<a></a> Morris, et al. state that 50% of all SCI patients may be expected to exhibit evidence of CHI and some degree of cognitive impairment.<a></a></p> <p>Even mild head injuries can significantly affect cognitive and emotional functioning, especially during the first months post-injury. The most prominent areas of cognitive dysfunction following CHI are in learning, memory, and speed of information processing, all important to learning of new skills in rehabilitation settings.<a></a> Thus, patients' ability to acquire new knowledge may be greatly diminished at the precise time that intense demands to learn are placed on them.<a></a> CHI-related behaviors such as poor social judgment, poor frustration tolerance, impulsivity, emotional lability, perseveration, difficulty in initiating behavior, decreased mental stamina, fatigability, and irritability are often misperceived by staff as enduring premorbid personality traits. Neuropsychological testing can enhance patient and staff insight into the effects of CHI and facilitate treatment planning.</p> <h3>Psychological Treatment Approaches in the Rehabilitation Setting</h3> <p>Though the primary responsibility for psychological care of the SCI patient is assigned the psychologist and social worker, other rehabilitation professionals on the interdisciplinary team play an important role. Sensitivity to the patients' emotional status allows for treatment planning and interaction that maximizes physical and psychological rehabilitation.</p> <p>Ideally, psychological rehabilitation begins in the Intensive Care Unit (ICU) soon after injury. At this time, many SCI patients are intubated and unable to verbally communicate. They often experience disorientation, depression and anxiety, sensory and sleep deprivation, and perhaps the temporary delusional and hallucinatory state known as "ICU psychosis." This is a critical time for team members to offer emotional support, establish a communication system and determine what the patient wants to know. Some need extensive information about their injury and care in order to best cope with fears and anxiety. Others clearly want to delay knowing more about their condition. Most welcome reassurance that their emotional responses and concerns are normal and accepted.</p> <p>As the patient progresses through acute care into the rehabilitation setting, regularly scheduled psychotherapy sessions can facilitate the adjustment process. The psychologist can help the team understand the patient's stage of adjustment, and provide consultation on behavioral management approaches.</p> <p>Emotional responses dealt with by psychotherapy include a range of ego defenses, most commonly repression and denial. It is important to recognize that these defenses protect the psyche from material too traumatic to deal with consciously, thereby preventing decompensation. In this regard, denial and repression are adaptive, and indeed may be the reason SCI patients are able to function in the stressful rehabilitation situation so soon post-injury. Typically, as denial decreases over time, depression, anxiety, and anger increase. How these emotions are expressed depends largely on the patient's premorbid personality style.</p> <p>Normal emotional responses to SCI may be manifested in behaviors which impede progress in the rehabilitation setting. For instance, depression may cause psychomotor slowing, decreased motivation, and social withdrawal. Anxiety may create psychogenic somatic symptoms and poor concentration. Anger may result in noncompliant or destructive behavior. Psychotherapy can help via reinforcing adaptive coping skills and teaching new coping strategies. The psychologist may also work with the interdisciplinary team to develop behavioral modification programs, based on learning theory, to decrease these behaviors. Contingency management and behavioral "contracting" are most frequently used in rehabilitation settings. Approaches emphasizing positive reinforcement to "shape" desired behaviors are particularly effective.<a></a> Although such programs may be time-consuming initially, they can rapidly decrease maladaptive behavior and ultimately increase the patient's sense of control and self-esteem.</p> <p>Psychological treatment of SCI often includes group psychotherapy, which is an excellent method to both maximize patient learning and efficiently use therapist time. Patient groups can provide emotional support, peer role models, teach new coping skills, and decrease social discomfort. Likewise, multiple-family group psychotherapy is a powerful and effective tool for facilitating family adjustment to SCI.<a></a> Family members experience similar emotional responses to the patient and similarly benefit from psychological intervention. If not included in the team effort, a well-meaning family member could inadvertently sabotage the independence-oriented rehabilitation approach, or be too psychologically distressed to provide the emotional or physical care the patient needs.</p> <p>Other issues which need to be routinely addressed by the psychologist, in conjunction with the rehabilitation team, are sexual adjustment, vocational rehabilitation and pain management training. Prevention of medical complications, particularly those which have significant behavioral/emotional components, need to be emphasized. An example is pressure sores, which often occur when depression and/ or substance abuse lead to poor self-care.</p> <h3>Psychological Response to Orthotic Devices</h3> <p>SCI patients' ability to emotionally adjust to orthotic devices (sometimes referred to as "gadget tolerance"), is related to type of orthosis, premorbid personality factors, and stage of emotional adjustment.</p> <p>Orthoses used to stabilize the spine after surgery sometimes become the "target" of patients' emotional distress. For instance, it is easier for the patient who is denying the seriousness of his SCI to blame pain and decreased function on the TLSO. Anger expressed toward an inanimate object is "safe," whereas anger directed toward family or staff may have negative repercussions. Insight into these psychody-namics can help the orthotist deal with constant requests for adjustments to orthoses, or anger responses of post-surgical SCI patients.</p> <p>Upper and lower limb orthoses used to increase independence elicit a variety of emotional responses. The potential for increased function often provides a major psychological "lift," enhancing patients' sense of competence and self-esteem. However, inclusion of psychological factors in the selection of candidates for orthoses is critical. Fitting a patient who is not emotionally ready for an orthosis will result in loss of time and a failure experience for all concerned.</p> <p>There are numerous reasons why SCI patients may resist orthotic devices, or are unsuccessful with them, including the following:</p> <p><i>Body image</i></p> <p>Many SCI patients value the fact that they look "normal" except for the wheelchair. The magnitude of disability may be "invisible." When orthoses are introduced, patients sometimes report that people stare at them more. Their sense of "being different" and social discomfort increases. For this reason, sensitivity to aesthetics is important in designing orthoses for this population.</p> <p><i>Independence-Dependence Conflicts</i></p> <p>In some patients, there are secondary gains in their dependent state, though they may not be consciously aware of this. For example, when an upper limb orthosis significantly increases independence in activities of daily living, the patient may experience withdrawal of valued reinforcers (e.g. time and attention from caregivers). This can lead to rejection of the orthosis. If significant others (family and staff) are willing to provide extra attention and reinforcement for the new independence behaviors, these issues usually resolve well.</p> <p><i>Self-Concept</i></p> <p>SCI patients may not integrate disability into their self-concept for some time. In one study, 130 SCI patients were interviewed about their dreams in order to examine subconscious content regarding self-perception. The authors found that 75% of these patients, injured less than one year, had never seen themselves in a wheelchair in dreams.<a></a> This is one illustration of the initial need of SCI patients to maintain an underlying self-image as nondisabled. Orthoses may conflict with this self-image in more recently injured SCI patients.</p> <p><i>Denial</i></p> <p>Orthoses may threaten patients' denial systems. Patients not yet ready to acknowledge the extent or permanence of their disabilities frequently reject orthoses. Alternatively, they may accept temporary orthoses, but reject definitive ones. Patients with self-image and denial issues benefit from psychotherapy and being given more time to adjust emotionally to their disability. They should be provided with information on obtaining recommended orthoses for the future. At the other extreme, patients sometimes build denial systems based on unrealistically high hopes for orthoses. For example, a patient using lower limb orthoses for ambulation may find they are not practical for use in valued pre-injury activities. This could lead to breaking down of denial and increased depression or anger, which may temporarily create decreased motivaton or rejection of the orthoses. Clear communication, emphasizing realistic expectations before introducing orthoses, may prevent some of these responses.</p> <p><i>Premorbid Personality</i></p> <p>Longstanding personality attributes (such as poor frustration tolerance, risk-taking behavior, and substance abuse) and stage of adjustment (especially depression) can lead to poor self-care resulting in pressure sores or poor follow-through in any activities requiring sustained effort. Attention to psychological factors in selecting candidates for orthoses is the most important factor in preventing these problems.</p> <h3>Summary</h3> <p>Spinal cord injury results in an overwhelming physical and emotional adjustment process. By understanding emotional responses, and applying them in treatment planning and interaction with patients, rehabilitation professionals can greatly enhance the psychological adjustment of SCI patients.</p> <p><b>References:</b></p> <ol> <li>Bond, M.R., "Neurobehavioral Sequelae of Closed Head Injury," in I. Grant and K.M. Adams (Eds.), <i>Neuropsychological Assessment of Neuropsychiatric Disorders</i>, New York: Oxford University Press, 1986, pp. 347-371.</li> <li>Davidoff, G., J. Morris, E. Roth, and J. Bleiberg, "Cognitive Dysfunction and Mild Closed Head Injury in Traumatic Spinal Cord Injury," <i>Archives of Physical Medicine and Rehabilitation</i>, 66, 1985, pp. 489-491.</li> <li>Dunse, C, R. Eichberg, and D. Deboskey, "The Incidence of Neuropsychological Deficits in the Spinal Cord Population," paper presented at the Third Annual Houston Conference on Neurotrauma, Houston, Texas, February, 1987.</li> <li>Erikson, E.H., <i>Insight and Responsibility</i>, W.W. Norton, 1964.</li> <li>Hoffman, Loren L., "Auditory-Verbal Memory Abilities Following Traumatic Spinal Cord Injuries: A Comparative Study," doctoral dissertation, Georgia State University, 1987.</li> <li>Kubler-Ross, Elisabeth, <i>On Death and Dying</i>, New York: MacMillan Publishing Company, Inc., 1969.</li> <li>Lindenmann, Erick, "Symptomatology and Management of Acute Grief," <i>American Journal of Psychiatry</i>, 101:143, September, 1944.</li> <li>Morris, J., E. Roth, and G. Davidoff, "Mild Closed Head Injury and Cognitive Deficits in Spinal-Cord-Injured Patients: Incidence and Impact," <i>Journal of Head Trauma Rehabilitation</i>, 1(2), 1986, pp. 31-42.</li> <li>Rohren, K., B. Adelman, J. Puckert, B. Toomey, B. Talbert, and E. Johnson, "Rehabilitation in Spinal Cord Injury: Use of a Patient-Family Group," <i>Archives of Physical Medicine and Rehabilitation</i>, 61, 1980, pp. 225-229.</li> <li>Taylor, G.P., and R.W. Persons, "Behavior Modification Techniques in a Physical Medicine and Rehabilitation Center," <i>The Journal of Psychology</i>, 74, 1970, pp. 117-124.</li> <li>Westie, K.S., and J. Evans, "Self-Perception as Disabled in Dreams of Spinal Cord Injured Persons," paper presented at American Psychological Association Convention, New York, 1987.</li> <li>Westie, K., and W. McKeon, "Multiple-Family Group Psychotherapy in Treatment of Spinal Cord Injury Families," paper presented at American Association of SCI Psychologists and Social Workers Convention, Las Vegas, Nevada, November, 1987.</li> <li>Wilmot, C.B., D.N. Cope, K.M. Hall, and M. Acker, "Occult Head Injury: Its Incidence in Spinal Cord Injury," <i>Archives of Physical Medicine and Rehabilitation</i>, 66, 1985, pp. 227-231.</li> </ol> <em><b>*Katharine S. Westie, Ph.D. </b> Katharine S. Westie, Ph.D., is Director of Clinical Psychology for the Spinal Cord Injury Service at the University of Miami/Jackson Memorial Rehabilitation Center in Miami, Florida.<br /><br /><br /></em> Page Number(s) 225 - 229 Year 1987 Volume 11 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Psychological Aspects of Spinal Cord Injury Creator An entity primarily responsible for making the resource Katharine S. Westie, Ph.D. * https://staging.drfop.org/files/original/a4e24d04daaec423ee9b4e3a36bda7ea.pdf 1c53d4c491f0f059b170578f088b4157 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/1983_02_006.pdf Text Any textual data included in the document <h2>Questionnaire: Extra-Ambulatory Prostheses</h2> <p><i>The following analysis and comments were drawn from responses to a recent questionnaire on extra-ambulatory prostheses. The article, "Extra-Ambulatory Activities and Amputee/' by Drew A. Hittenberger, CP, appeared in the Autumn, 1982 issue of </i>C.P.O.<i> (Vol. 6, No. 4).</i></p> <p>As of January 25, 1983, five responses had been received to the questionnaire on extra-ambulatory prostheses. This is a very low response and of course no valid conclusions can be drawn from it.</p> <p>In response to question number one, "How many extra-ambulatory prostheses have you made?," four responses said six-15 and one said 16-25.</p> <p>On question number two, "What percent of your patients are involved in some form of physical exercise?," the average response was nine percent with a high of 20%, a low of five percent and one who said he had never thought to ask.</p> <p>When asked, "What percent of your patients ask you about extra-ambulatory prosthetics?," the average response was 11% with a low of two percent and a high of 25%.</p> <p>The respondees were asked to list, in order of occurrence, extra-ambulatory activities in which their patients participate. There were four mentions of swimming, although one was not the first activity listed; there was also one mention of scuba diving. Snow skiing was mentioned three times and water skiing once. Running and racquetball (a running sport) were both mentioned once, as were hunting, fishing, weight-lifting, and horseback riding.</p> <p>The respondees were asked what percentage of patients used their prosthesis for more than just daily activities and the average response was seven percent, with a high of ten percent, a low of five percent, and one who didn't know.</p> <p>As to how many of their patients had one prosthesis for daily activities and one for extra-ambulatory activities, the respondees on the average said four percent, with a low of one percent, to a high of ten percent.</p> <p>All the respondents said that they informed their patients of handicapped sports organizations. One said he had a directory posted, and another said that there were no such organizations in his area.</p> <p>Three of the respondents said that they were not satisfied with the level of prosthetics and its role in extra-ambulatory activities. One said yes, and the fifth said yes, but with reservations.</p> <p>Reasons given for amputees not being more involved were:</p> <ul> <li> <p>lack of interest</p> </li> <li> <p>not involved before amputation</p> </li> <li> <p>non-positive social conditioning</p> </li> <li> <p>fear of injury</p> </li> <li> <p>ignorance</p> </li> <li> <p>embarrassment</p> </li> <li> <p>rejection</p> </li> <li> <p>poor post-operative management</p> </li> </ul> <p>All five said that they would like to attend a seminar on the topic. Several additional comments were received and are listed below. In addition, Carl A. Caspers, CPO, of Minneapolis, Minnesota took the time to write a long, thoughtful letter in response. Parts of it are quoted below.</p> <p>Additional comments:</p> <ol> <li> <p>"Yes—we need better research on different designs of prostheses for different functional activities."</p> </li> <li> <p>"Technical reports detailing alignment and fabrication for these specialized devices [are needed]. I have had to research, design, and devise techniques to create extra-ambulatory prostheses. Also preprinted bulletins with photographs for the patients would offer greater understanding and perhaps desire for these devices."</p> </li> </ol> <p>Mr. Caspers writes, in part:</p> <p>"This letter is in response to Drew Hittenberger's article on extra-ambulatory activities and the amputee in the Autumn issue of <i>Clinical Prosthetics &amp; Orthotics</i>—<i>CPO</i>. I was very pleased to see this article covering this subject as this has been a sadly neglected area for a long time.</p> <p>"Mr. Hittenberger brings up some very good questions regarding the rehabilitation team's capability of maximizing the patient's activity level and more importantly the resultant poor postoperative care and management of the amputee. The vast [majority] are suffering from diabetes or other vascular complications. Obviously, the level of activity and the requirements for these people are going to be considerably less strenuous than those of a younger amputee. I think the problem goes back one step further and does not start with the post-operative care but in the operative management of the amputee. To date, the physician's main concern has been with the medical needs of the patient at that time and very little thought is given to the patient's functional needs after amputation. Such things as myodesis procedures, tibia-fibula stabilization, and lengths of lever arms are all crucial in the long-range function of an amputee. . . .</p> <p>"In the area of limitation, I think Mr. Hittenberger covered this very well. There is an economic limitation that needs to be covered here also. The rehabilitation team's knowledge of extra-ambulatory activities and its awareness of the many extra-ambulatory prosthetic devices is somewhat limited. This thereby creates an economic factor that many amputees are unable to deal with. As has been well documented in the field of prosthetics, there is a need for extra-ambulatory devices and these should be considered in the total rehabilitation, physically, psychologically, and economically.</p> <p>"In the areas of prosthetic design, I think there are a number of things to provide [the patient] the capability of participating competitively or recreationally in extra-ambulatory activities. A sound pain-free residual limb is essential for good function in these areas. A good understanding of bio-mechanics as applied to the amputee is essential for the prosthetist to provide a well designed prosthetic device . . .</p> <p>"In this day and age we have available to us a very sophisticated armamentarium of component parts and space-age type materials that lend themselves extremely well to prosthetic device fabrication, particularly in the specialized limbs geared toward specific physical activities.</p> <p>"In recent times there has been much use of things such as rotational absorbers, Greissinger feet, and multi-axis type ankle joint foot complexes. All of these types of items offer capability to the amputee but should not be applied in a general fashion. There are many activities where a rotator or multi-axis type foot complex is extremely detrimental to the function-ability of an amputee. Any sport which requires rapid directional changes would be a good example where these items should not be used. A person making quick and rapid adjustments in dynamic balance requires immediate response from the floor through floor reaction with his foot. This cannot be accomplished adequately with such items.</p> <p>"In conclusion, I feel that extra-ambulatory activities of the amputee and the resultant prosthetic devices that may be required for his successful participation in these activities is a relatively untouched area. A great deal of input is needed, both from the amputees in this country and the individual prosthetic practitioner, along with the physician and rehabilitation team members. I, myself, have been an amputee for 23 years and have been involved in numerous competitive and recreational activities and sports. I have found there are many areas in which I can participate in a non-handicapped world, and can be very competitive either on a one to one basis or as a team member. I have found this to be extremely fulfilling for myself and feel this is one of the ultimate goals that any amputee would strive to achieve."</p> <p>As regards the question of torque absorbers and use of the more sophisticated ankle foot complexes, Mr. Caspers raises a very interesting question. Certainly many prosthetists hold decided views on the topic and it would be interesting to receive Letters to the Editor on the matter.</p> <p style="margin-left: 10%;">The Editor</p> Page Number(s) 6 - 7 Year 1983 Volume 7 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 Questionnaire: Extra-Ambulatory Prostheses https://staging.drfop.org/files/original/5724c58acfdabe747b7c60927a4a24b5.pdf 4a65f44f3c20bce5b481525068819737 https://staging.drfop.org/files/original/8d0af8c9cdc4c818379f8f4094eeec16.jpg 52aaa3f3899a02ce896dc9f5fd82ba1c https://staging.drfop.org/files/original/ace50222cdc84974cc159ef1646c56ad.jpg 784acabf15b2c43c1dadb7ce14e7d49e https://staging.drfop.org/files/original/f101d6c6bc81000f4f4882cccedb60ba.jpg e449ffc3b155c41c90a50c19331e96b7 https://staging.drfop.org/files/original/5c4e1ab1e0cd9ee721de1e4279d2d9e0.jpg db093c4fcf07979d3cd3a7508481c2de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_036.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 36 - 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/1969_02_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_036.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>Radiographic Evaluation of Stump-Socket Fit</h2> <h5>C. B. Taft <a style="text-decoration:none;">*</a><br /></h5> <p>The critical relationship between accurate fit of a prosthesis and amputee comfort and function constitutes the foundation of all prosthetic fitting. Consequently, one of the most important features of a lower-extremity prosthesis is the distribution of the pressures applied to the stump by the socket. Since World War II, considerable progress has been made in the design of sockets, leading to the widespread use of "total-contact" sockets for amputations at all levels. However, reliable objective information regarding the relationship of the stump to the socket below its proximal brim is masked by the opaqueness of the socket material. The use of conventional materials <i>(e.g., </i>chalk, talcum, clay, and lipstick) to determine the adequacy of fit and the achievement of total contact has proved of limited value in the accurate diagnosis of fitting problems.</p> <p>The use of X-rays as a means of checking stump-socket fit has been discussed by several investigators. <a></a> Conventional X-ray films of the stump in the socket from the front and side under weight-bearing conditions have been of considerable value in determining total contact, fit, and alignment, but the films obtained by conventional techniques do not always reveal a clear demarcation between the soft tissues of the stump and the inner surface of the socket. <a></a> A radiographic method or procedure that would consistently give an adequate visualization of the stump-socket interface would provide valuable information for the physician and for the prosthetist in fitting patients. Such a procedure would also contribute to overall knowledge in this area of prosthetics, and this knowledge would aid in teaching the proper fabrication of sockets.</p> <p>Some preliminary experimental work relevant to the above-stated deficiency, reported by Dr. N. C. McCollough, involved the topical application of an X-ray contrast material to the skin of the stump. <a></a> Two or three coats of a saturated solution of sodium iodide in absolute alcohol were applied to the stump with a sponge and allowed to dry. The usual number of stump socks were then applied, the stump was inserted into the prosthesis, and films were made under weight-bearing conditions in the anteroposterior and lateral projections. The films obtained by this method provided a clear outline of the periphery of the stump, and any lack of total contact was easily recognized.</p> <p>The purposes of the present study were to assess the value of radiopaque materials in the evaluation of stump-socket fit on a broader basis, and to develop a satisfactory procedure for routine clinical use in determining achievement of total contact and in diagnosing pressure problems more accurately.</p> <h3>Sample</h3> <p>The sample for this study consisted of 16 adults (15 males and 1 female), of whom 8 were below-knee and 8 were above-knee amputees. The below-knee prostheses were the patellar-tendon-bearing type, with and without Kemblo inserts. The above-knee prostheses had quadrilateral sockets of various types: wood open end, wood distal air chamber, and plastic total-contact suction socket.</p> <p>Prior to participation in the study, each prospective subject was questioned concerning previous X-ray exposure and allergy to iodine solutions, in order to exclude patients with a history of extensive X-ray exposure or iodine sensitivity. A statement of informed consent was executed by each subject.</p> <h3>Methodology</h3> <p>The study encompassed investigation of the following radiopaque materials and X-ray techniques.</p> <h4>Materials</h4> <ol> <li>Hypaque-M, 90% (Winthrop): An aqueous solution of sodium and meglumine (methylglucamine) diatrizoates, water-soluble organic compounds, used primarily as a contrast medium in studies of the cardiovascular system. Each milliliter supplies 462 mg of iodine.</li><li>Sodium iodide: A saturated solution in absolute alcohol.</li><li>Sodium iodide: A saturated solution (44%) in isopropyl alcohol (70%). Each milliliter supplies 374 mg of iodine.</li></ol> <h4>Procedures</h4> <p>Two or three coats of the contrast medium were applied with a sponge to the entire surface of the stump; the skin was allowed to dry between coats. The procedure was varied by also applying the contrast medium to the inner surface of the socket insert, and by applying lead foil on pressure-sensitive tape to the inner surface of the socket (or socket insert) as a radiopaque marker. The patient then donned his prosthesis, and weight-bearing films were made in the anteroposterior and lateral projections, using either highspeed screens or Kodak Royal Blue Ready-Pack Medical X-ray Film.</p> <p>The X-ray unit used was a Westing-house with an 85-kv peak capacity, and the settings were varied from 100 ma, 1/2sec, 70 kv, 36-in. tube distance, to 100 ma, 1-1/4 sec, 85 kv, 36-in. tube distance, depending on the type of film.</p> <p>Additional films were taken <i>without </i>application of a contrast medium to the stump for half of the subjects. Also, in several instances films were taken while the artificial leg was bearing no weight, <i>i.e., </i>in the mid-swing position.</p> <h3>Results</h3> <p>The techniques used in this study were very satisfactory in providing a definite outline of the periphery of the stump. The films demonstrated a sharp demarcation between the soft tissues of the stump and the inner surface of the insert or socket, thereby clearly indicating the presence or absence of total contact and identifying pressure areas more accurately.</p> <p>With the X-ray equipment used for this study, the optimum settings were determined to be:</p> <p>High-Speed Screens: 100 ma, 75 kv, 1/2sec, 36-in. distance</p> <p>Ready-Pack Film: 100 ma, 85 kv, 1 sec, 36-in. distance</p> <p>Excellent results were obtained with all three of the contrast media, and no significant differences were noted in the films obtained with the three solutions. The saturated solution of sodium iodide in absolute alcohol dries on the skin a little more rapidly than a saturated solution in isopropyl alcohol 70%, but because of Federal regulations, detailed record-keeping is required when absolute alcohol (ethanol) is used. Hypaque-M, 90%, while more expensive than a sodium iodide solution, has the advantage of being commercially available and therefore not requiring the services of a pharmacist for its preparation. Because the iodine compounds are highly water-soluble, they are readily washed off the skin with water after completion of the X-ray exposures. No adverse effects <i>(e.g., </i>skin eruptions) were manifested by any of the patients as a result of these preparations.</p> <p>Application of a contrast medium to the inside of the Kemblo insert (leather backed by rubber) or the inside of the socket (plastic or wood) was not found to be necessary in order to secure satisfactory results. The rubber backing of the Kembio insert and the plastic or wood of the socket are adequately radiopaque for clear demarcation of the inner surface of the prosthesis. The films obtained with the additional step were only marginally superior to those obtained without it, and furthermore, the contrast media tend to stain socket materials, particularly leather.</p> <p>In several instances, lead foil was used successfully as a radiopaque marker of the interface between stump and insert, particularly in cases involving a removable distal-end pad which was not satisfactorily delineated otherwise. This material is available from the Minnesota Mining and Manufacturing Company as Pressure-Sensitive Tape #420-Lead Foil.</p> <p>Examples of films obtained after application of a contrast medium to the stump are shown in <b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>. The periphery of the stump is clearly outlined in the films, so that the accuracy of socket fit may be readily determined: whether there is total contact; whether the suitable weight-bearing areas of the stump, such as the patellar tendon, the popliteal space, and the medial and lateral condyles, are being utilized to the best advantage; and whether adequate reliefs have been provided for the head of the fibula and the tibial tubercle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Left, anteroposterior and right, lateral weight-bearing views of a below-knee stump, coated with contrast material, in a well-fitting PTB socket. Note excellent contact between stump and insert except for small air space posteriorly at distal end. Note also the undesirable space between insert and socket at distal end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Left, anteroposterior and right, lateral weight-bearing views of a below-knee stump, coated with contrast material, in a poorly fitting PTB socket. Note lack of distal contact and inadequate bearing on the patellar tendon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Left, anteroposterior and right, lateral weight-bearing views of a below-knee stump, coated with contrast material, in a hard-socket PTS prosthesis with medial condylar wedge. Note that total contact is satisfactory, except for small air spaces at distal end, but the patellar-tendon bar is too high and the posterior brim is insufficiently flared to provide an adequate shelf in the popliteal area. Note also (right) the apparent increased radiodensity in the patellar-tendon weight-bearing area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Inspection of the contrast-medium films for objective indications of stump-socket pressure gradients tentatively suggests, as also remarked upon by McCollough, that areas of compression <i>(e.g., </i>over the patellar tendon) show increased density of the contrast material. An example of this phenomenon is shown in the lateral view of <b>Fig. 3</b>, where increased radiodensity is apparent in the patellar-tendon weight-bearing area.</p> <p>Although X-ray films obtained by routine methods, without the use of a contrast medium, provide considerable useful information about stump-socket fit, they do not always reveal a clear demarcation between the soft tissues and the socket. This observation was confirmed in the present study on comparing films made with and without a contrast medium taken on the same patient, using the same X-ray settings for both series. With few exceptions, the contrast-medium films were superior to the routine films in outlining the periphery of the stump more sharply. An example of this superiority may be seen in comparing the two views in <b>Fig. 4</b>. This improvement in the delineation of the stump-socket interface makes it easier to read the films and eliminates any doubts that may arise concerning the exact relationship between the stump and the socket at various stump levels.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Left, anteroposterior weight-bearing view of an above-knee stump, coated with contrast material, in a plastic hard-end total-contact suction socket. Note clear delineation of the stump-socket interface, showing excellent total contact. Right, conventional anteroposterior weight-bearing view of same stump and socket, using same X-ray settings. Note blurring of stump-socket interface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li>Clippinger, Frank W., <i>The temporary patellar tendon bearing limb</i>, Inter-Clinic Inform. Bull., 3:8:5-7, June 1964.</li> <li>Clippinger, Frank W., and Bert R. Titus, <i>A "hard socket" patellar tendon bearing below-knee prosthesis</i>, Inter-Clinic Inform. Bull., 4:10:16-18, August 1965.</li> <li>King, Richard E., <i>X-rays as an adjunct to patellar-tendon-bearing fitting</i>, Inter-Clinic Inform. Bull., 2:6:1-8, April 1963.</li> <li>Lambert, Claude N., <i>Applicability of the patellar tendon bearing prosthesis to skeletally immature amputees</i>, Inter-Clinic Inform. Bull., 3:7:7, May 1964.</li> <li>McCollough, Newton C, and Raymond E. Gilmer, Jr., <i>A method of determining total contact in prostheses</i>, Inter-Clinic Inform. Bull., 6:5:9-13, February 1967.</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>5.</b> </td><td class="clsTextSmall">McCollough, Newton C, and Raymond E. Gilmer, Jr., A method of determining total contact in prostheses, Inter-Clinic Inform. Bull., 6:5:9-13, February 1967.</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">McCollough, Newton C, and Raymond E. Gilmer, Jr., A method of determining total contact in prostheses, Inter-Clinic Inform. Bull., 6:5:9-13, February 1967.</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">Clippinger, Frank W., The temporary patellar tendon bearing limb, Inter-Clinic Inform. Bull., 3:8:5-7, June 1964.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Clippinger, Frank W., and Bert R. Titus, A 'hard socket' patellar tendon bearing below-knee prosthesis, Inter-Clinic Inform. Bull., 4:10:16-18, August 1965.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">King, Richard E., X-rays as an adjunct to patellar-tendon-bearing fitting, Inter-Clinic Inform. Bull., 2:6:1-8, April 1963.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Lambert, Claude N., Applicability of the patellar tendon bearing prosthesis to skeletally immature amputees, Inter-Clinic Inform. Bull., 3:7:7, May 1964.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">McCollough, Newton C, and Raymond E. Gilmer, Jr., A method of determining total contact in prostheses, Inter-Clinic Inform. Bull., 6:5:9-13, February 1967.</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>C. B. Taft </b></td></tr><tr><td class="clsTextSmall">Present address: Columbia Medical Center, 630 W. 168th St., New York, N. Y. 10032.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-04.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 Radiographic Evaluation of Stump-Socket Fit Creator An entity primarily responsible for making the resource C. B. Taft * https://staging.drfop.org/files/original/2b79f849d94307f25efd601945ef0c54.png 04f0b384d26021ca2807e73eaa2033ff 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL <a href="http://rompglobal.org">http://rompglobal.org</a> Countries Served Guatemala, Ecuador, United States Organization Type Including ID and tax status 501c3 Contact Name/Title Lauren Panasewicz Director of Development Mission ROMP’s mission is to provide high-quality prosthetic care for underserved people, improving mobility and independence. Tax ID 20-2603927 Address 1474 S Acoma St City Denver State/Province CO Postal Code 80223 Phone (303) 946-7124 Email info@rompglobal.org Services Provided ROMP operates two full time clinics in Guatemala and Ecuador and partners with clinics in the US to provide sustainable care at a low cost to patients. ROMP also operates a US Assistance Program (USAP) that provides access-limited people with amputation in the United States with an affordable, quality option for prosthetic care. Need I Volunteers Need II Donations Additional Info & Comments ROMP Guatemala L Calle, 25-62, Zona 15 Colonia Vista Hermosa 2 Guatemala City, Guatemala Abierto: Lunes a Viernes 9HR - 17HR 502-3049-9471 guatemala@rompglobal.org ROMP Ecuador Madrid y Lugo 24-185, La Floresta, Quito, Pichincha, Ecuador La Floresta, Quito Pichincha, Ecuador Abierto: Lunes a Viernes 9HR - 17HR 593 98 494 3141 ecuador@rompglobal.org LinkedIN Page/Profile https://www.linkedin.com/company/range-of-motion-project/ Facebook Page https://www.facebook.com/ROMPglobal 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 Range of Motion Project Description An account of the resource Prosthetic limbs and orthotic braces are not simply medical devices, but instruments of personal empowerment. https://staging.drfop.org/files/original/aee975bd01e173cadb6bd332d9927ed3.pdf d866aabd179e97ad8f259caadfd4f46d https://staging.drfop.org/files/original/cf7e5a1c10865c7a2f6801745802706f.jpg bfb079830381162d6ce2c95f6c3db913 https://staging.drfop.org/files/original/80177bdc2c6d01dcef1002642392393f.jpg b72fa1e2bc643d38e868474976fab946 https://staging.drfop.org/files/original/d61fadd50e79b7203cb643df570abb42.jpg 50e9ab54ca359ad9fdd2b19c36f7ff32 https://staging.drfop.org/files/original/cabb1a4acfdfba520a78a7dc281f59b0.jpg e6d1577d5fee57ef9520df78f3a2e50d https://staging.drfop.org/files/original/fa7e073d9826e1cc48df65128f65c987.jpg 4e64810dc51607824b7edfab6b000dba https://staging.drfop.org/files/original/cb3215048cf3a11c179f71432884353b.jpg 08d1ecaf1034507e7ae1bb4edb00e1dd https://staging.drfop.org/files/original/8cbb68c28d3f97aca81a578e0068b1b6.jpg 160e3c6521c277fc6bbfc22fb411ad60 https://staging.drfop.org/files/original/ed88f8904d06fe0b726da88a744ab157.jpg f6e276d8e77f1ef1a8b4164aea967c37 https://staging.drfop.org/files/original/499b2d14df818927c677e6ab81294bf3.jpg 8832e1d454749fcb34de722dc4763cd4 https://staging.drfop.org/files/original/f0db8d36bc5ab95237bdaf8b3f0774ad.jpg 00a77b4c33e9d587ebfb6657f4b2f634 https://staging.drfop.org/files/original/ffa5c106a3a94dc6f3ffba57275d427b.jpg 505850a92d9a616c370f7071f20a4962 https://staging.drfop.org/files/original/26a9bc87b04573a87b50af221f53a172.jpg 26d44ea9c02e9b1e215d3cc9777cbbe7 https://staging.drfop.org/files/original/83d1441b01dcdb73ab0174906f56b719.jpg f27a354f95c023f556c00e45b7da38c5 https://staging.drfop.org/files/original/f811aafb32502cadbb7ea0672580e37a.jpg 033ffb96764b132c3b786e618d38b8da https://staging.drfop.org/files/original/68652caa9997d995b4fa091cbbaff9f0.jpg fcf7b1acefad733dab4306d7139d21fc https://staging.drfop.org/files/original/6f10c8ec7cab2b8734bacc6b74dacf84.jpg e11fd3ddf35479f9b8a871e27886d182 https://staging.drfop.org/files/original/d8a9c69caa7a722e6c26cc46a47ca86f.jpg b59874d90b7c956ebbbb4b223045572b https://staging.drfop.org/files/original/78f9d8d11382034703a6765a230cd321.jpg 99cc18ad6bf2cc161fd7ec5e42b8b512 https://staging.drfop.org/files/original/557e4cce203fd0edcfa199807c18deef.jpg 6148afe4dbedeaeeeaefae592b2154bd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_001.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 1 - 27 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/1968_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_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>Recent Advances in Above-Knee Prosthetics</h2> <h5>A. Bennett Wilson, JR.. B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>During the past few years, many innovations have been introduced into the practice of above-knee prosthetics. Most of the literature on the new practices has been provided by the innovators, and therefore the reports and articles on the subject generally are limited to a single approach. It is the purpose of this article to survey past and present practices and to set forth, as accurately as possible, a perspective of procedures and devices available today for the management of the above-knee amputee.</p> <p>Amputation through the thigh results in distinct functional losses. The obvious ones are loss of support by the long bones and loss of joints, resulting in inability to stand and move extensively from place to place. In addition, the appearance of the patient becomes altered from the "normal" in both static and dynamic conditions.</p> <p>Lost support and mobility can be replaced to some extent by the use of a wheelchair or crutches or both, but it has been shown that use of an articulated prosthesis is the most effective means of compensating for these losses. An amputee with a functional prosthesis can negotiate stairs, ramps, and other obstacles and, therefore, can move through areas that would be impracticable if not impossible for a wheelchair. Crutches, properly used, offer a great deal of facility of movement but require the use of considerably more energy than a well-fitted and -aligned above-knee prosthesis, or even a peg leg. <a></a> Also, when crutches are used the hands are not free during ambulation. Another argument for the use of a functional prosthesis is that a fairly normal appearance can be achieved.</p> <p>The basic functional prosthesis for the above-knee amputee consists of a socket, a knee unit, a shank, and a foot-ankle unit. In cases where it is not deemed advisable to keep the socket in place by air pressure (suction socket), suspension must be provided by a belt about the pelvic area or by a shoulder harness.</p> <p>Not so many years ago it was common practice for the prosthetist to make in his shop nearly every part for a prosthesis from basic materials such as wood, steel, and leather. This practice was time-consuming and wasteful. To eliminate as much manual work as possible, the prosthetist today designs and fabricates the socket from basic materials to fit each patient individually, but uses prefabricated components, which he purchases from manufacturers, for the rest of the prosthesis. <a></a></p> <h3>Sockets</h3> <p> Until the introduction of the suction socket in the late 1940's. <a></a> it was common practice to provide the above-knee amputee with a so-called plug-fit socket suspended by a pelvic band connected to the socket by a metal "hip" joint (<b>Fig. 1</b>) <a></a> The plug fit did not provide for a very adequate distribution of forces between stump and socket. There was a tendency for the formation of an adductor roll, and the stability provided between stump and socket left much to be desired. The pelvic belt was heavy. The "hip" joint restricted motion essentially to flexion and extension, and was subject to frequent breakage. Most of the sockets were carved from willow wood and reinforced with rawhide, although sockets formed from aluminum sheet were not uncommon.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical prosthesis for above-knee amputees during the 1940's. Note pelvic band, mechanical "hip joint," carved wooden socket with a "plug fit," and pelvic-control knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The primary purpose of the suction socket (<b>Fig. 2</b>) was to provide increased function and comfort by eliminating the mechanical hip joint and pelvic belt. Pressures between the stump and socket were distributed over wider areas; stability and, therefore, control were improved materially. A socket of the quadrilateral shape <a></a> became standard whether or not suction was used for suspension. The waist belt and Silesian bandage were introduced as more comfortable suspension methods to supplant the pelvic belt and hip joint in some cases. Willow wood remained the material of choice, but plastic laminate (usually nylon stockinet impregnated with a polyester resin) replaced rawhide as a reinforcement material.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. An early version of the suction-socket prosthesis <i>(right), </i>shown in comparison to the so-called conventional above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Experience with problem cases, with the early versions of the suction socket in which a certain amount of air space is left below the distal end of the stump, led the University of California, Berkeley, to develop the modification now known as the total-contact above-knee socket (<b>Fig. 3</b>).<a></a> In a certain number of cases, edema developed in spite of most careful fitting with the "open-end" socket. It was found that the edema could be eliminated by providing a small amount of counter-pressure over the distal end. It was also found that the entire stump must be in contact with the socket in order to keep the circulatory system in balance. The introduction of counterpressure also reduced the unit pressures at the proximal region of the stump, and the contact over the end of the stump seemed to enhance proprioception.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. An above-knee prosthesis with a quadrilateral, total-contact socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide a well-fitting total-contact socket of wood requires a great deal of skill and is quite time-consuming compared with the use of plastic laminates. Plastic laminates, which had proven so useful in the fabrication and fitting of upper-extremity and below-knee prostheses, had not been used for above-knee sockets because of the difficulty encountered in obtaining an adequate cast for preparation of the positive model needed for molding the laminate. A few highly skilled prosthetists had been known to produce adequately formed casts using only their hands, but this achievement was exceptional. To solve this problem, several devices were developed so that casts of above-knee stumps that required a minimum amount of modification could be achieved.</p> <p>The UC-Berkeley device (<b>Fig. 4</b>) <a></a> uses a series of adjustable brims with which the cast is taken under weight-bearing conditions; the Veterans Administration Prosthetics Center device uses a three-part universal jig for holding the stump in position, also under weight-bearing conditions (<b>Fig. 5</b>); <a></a> the New York University casting fixture is a portable device that holds the cast in position but does not require the patient to be in a weight-bearing position (<b>Fig. 6</b>); <a></a> and Northwestern University has developed a modification of the UC-Berkeley technique in which a cast sock is used to suspend the stump and thus assist in forming the desired contours (<b>Fig. 7</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The fixture for the "brim-fitting" technique developed at the University of California Biomechanics Laboratory (San Francisco and Berkeley). Adjustable, easily interchangeable brims are available in a complete range of sizes. The view on the right shows attitude of patient in fixture; right leg is not shown for clarity. See <b>Fig. 7</b> for still another view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The fixture for casting the impression of an above-knee stump developed at the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anterior view of the New York University casting brim in use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. A method, developed at Northwestern University, which uses the University of California casting fixture. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The object of each of these tools is exactly the same: to provide a cast of the above-knee stump that requires the least modification for the fabrication of a well-fitting, quadrilateral, total-contact socket. Each has its advantages and disadvantages. None is superior to the others in all aspects, and selection is based on the personal preferences of the prosthetist. Many facilities have two or even all three devices available for use as circumstances dictate.</p> <h4>Fitting And Alignment</h4> <p> The basic rationale of alignment as set forth by Radcliffe <a></a> in the early 1950's is essentially unchanged, although proper use of some of the hydraulic knee units demands some variations.</p> <p>In order to make it easier for the prosthetist to achieve optimum alignment, the University of California, Berkeley, developed the adjustable leg (<b>Fig. 8</b>) and alignment duplication jig (<b>Fig. 9</b>). <a></a> Dynamic alignment is obtained during amputee ambulation with the adjustable pylon, and the alignment obtained is transferred to the finished prosthesis during fabrication by use of the alignment duplication jig. This procedure proved to be highly satisfactory for use with single-axis, constant-mechanical-friction knee joints, since the adjustable leg also contained this type of joint. Because the functions of the Hydra-Cadence leg demanded that it be aligned somewhat differently, the STAROS-GARDNER coupling (<b>Fig. 10</b>) was designed. <a></a> When placed between the top of the knee block and the thigh piece or socket, the Staros-Gardner coupling provides all the adjustments permitted by the adjustable leg except mediolateral placement of the foot with respect to the knee axis, an adjustment not often used and, then, only to provide better cosmetic appearance. A technique was developed so that when final alignment was achieved a wooden block could be substituted for the coupling, thereby eliminating the need for the alignment duplication jig.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The adjustable above-knee leg developed by the University of California Biomechanics Laboratory (San Francisco and Berkeley). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The alignment duplication jig developed by the University of California Biomechanics Laboratory (San Francisco and Berkeley) to be used in conjunction with the adjustable leg shown in <b>Fig. 8</b>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Staros-Gardner coupling being used to achieve alignment in an above-knee prosthesis. When the desired alignment has been achieved the coupling is replaced with a section of wood. A technique has been developed so that alignment can be maintained without need for the alignment duplication jig. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Components</h3> <p> Components for above-knee prostheses can be obtained from central manufacturers in a number of ways. The most common approach is to purchase "knee-shin set-ups" and foot-ankle units, and to connect these to each other and to the socket in the alignment best suited for the individual patient. The knee-shin set-up usually consists of a wooden knee block, the proximal portion of a hollow wooden shank, and a knee control mechanism (<b>Fig. 11</b>). Excess wood is provided so that the knee and shin can be individually contoured, and in the finished prosthesis the entire unit is reinforced structurally by the application of a plastic laminate over the exterior. Complete wooden set-ups are available, but are seldom used. However, when coordinated motion between knee and ankle is incorporated in the prosthesis, as in the Hydra-Cadence unit, a complete set-up is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical knee-shin wood set-up. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of temporary, or preparatory prostheses, popularly known as "pylons," are available (<b>Fig. 12</b>). Usually these devices are used with an ordinary foot-ankle unit which can be incorporated into the final or definitive prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. "Pylons" for above-knee amputations. <i>Left, </i>U.S. Manufacturing Co.; <i>Center, </i>A. J. Hosmer Corp. unit based on the UCB adjustable leg; <i>Right, </i>VAPC unit designed to accommodate a variety of knee-control devices. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Knee Units</h3> <p> Probably no other component of artificial limbs has received as much attention from designers and "gadgeteers" as the knee joint. Several hundred patents have been issued for knee designs, and many types have been produced and offered to the public, but relatively few designs have been used widely.</p> <p>The primary functions of a knee unit for above-knee prostheses are control of the leg during standing and the stance phase of walking, and control of the shank during the swing phase of walking.</p> <p><i>Swing-Phase Control</i></p> <p>The articulated above-knee prosthesis functions as a compound pendulum. As the thigh stump is brought forward during the latter stages of stance phase, the knee begins to flex and the foot is lifted from the ground because of the effects of inertia. The force propelling the shank acts more or less horizontally through the knee joint, while the center of gravity of the shank is well below this level; thus a moment is created, resulting in rotation of the shank about the knee joint in a backward direction (<b>Fig. 13</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Forces developed during rotation of the shank about the knee joint during forward swing of the thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The less friction there is in the joint, the higher will be the rise of the heel for any given acceleration. Therefore, when a nearly frictionless joint is used, the amputee must use very short steps at a low cadence, so that the shank and foot will return to the proper fully extended position to support him as stance phase is begun. If friction, or some other form of resistance, is introduced, rise of the heel is restrained and shank motion toward full extension is retarded, so that longer steps at higher cadences are possible. When the amount of friction is constant, only one best speed is available to the patient. To overcome this limitation, designers have turned to hydraulic and pneumatic devices to obtain desirable resistance.</p> <p>To guide the design of swing-phase control units, the University of California has plotted knee moments against time for the ideal prosthesis during swing phase (<b>Fig. 14</b>). <a></a> This diagram is based on data accumulated from four normal young males, allowances being made for weight and weight distribution between normal and artificial limbs. The values, of course, will change as cadence is varied and as the height and weight distribution are changed. However, the general pattern should not change.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Knee-moment pattern required for natural swing of an artificial leg. This curve was developed by the University of California Biomechanics Laboratory based on data collected during the study of human locomotion. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Constant Friction (Mechanical)</i></p> <p>Constant friction in a way is a misnomer, because the amount of friction or restraint can be controlled or set, but does not vary in accordance with the needs of the amputee during a given cycle. The amount of friction can be controlled in a number of ways, the most common being the application of a braking surface to the peripheral area of the knee bolt (<b>Fig. 15</b>). The typical knee-moment diagram for a constant-friction knee unit is shown in <b>Fig. 16</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. One type of constant-friction single-axis knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Knee-moment patterns of various swing-phase units in comparison with the ideal curve of <b>Fig. 14</b>. Data were taken at the Veterans Administration Prosthetics Center. The knee units were adjusted for intermediate resistance, and were subjected to 43 cycles per min. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Intermittent Friction</i></p> <p>To more closely approximate the ideal knee-moment diagram, several designs have been made to vary the amount of mechanical friction applied at predetermined points during the swing phase. The Northwestern University Intermittent-Friction Knee Unit (<b>Fig. 17</b>) is one such device that is available commercially. Mechanical friction is provided by pressure between three disks mounted concentrically with the long axis of the knee bolt. The resistance offered by each individual disk is brought into play at varying intervals during the swing phase. The knee-moment diagram of the Northwestern University unit is shown in <b>Fig. 16</b>. The unit is available in a wood set-up, and is delivered with three disks installed. Two additional disks of different configurations are provided for interchange with the regular disks, so that the pattern of resistance about the knee can be changed to suit the amputee on an individualized basis. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Intermittent-Friction Knee Unit developed at Northwestern University, installed in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hydraulic Swing-Phase Control Units</i></p> <p>Because the resistance offered by an orifice to the flow of a fluid increases at a greater rate than the increase in velocity of the fluid, hydraulic systems are ideally suited for control of the shank during swing phase. Thus, heel rise and terminal deceleration can be controlled automatically over a wide range of cadences, giving the amputee much more flexibility in speed of ambulation. <a></a> The value to be obtained by applying these principles has been recognized for many years, but a good deal of engineering was required to develop units that met the exacting demands of limb prosthetics. <a></a></p> <p>The Henschke-Mauch Model "B" unit (<b>Fig. 18</b>) is a very sophisticated device available in a wood set-up to make its use compatible with standard components and practices. A number of orifices are so incorporated into the cylinder wall that the moving piston successively blocks off escape of the fluid and thus varies the resistance throughout the swing phase in order to approximate the ideal moment curve (<b>Fig. 16</b>). Resistance to flexion and to extension may be adjusted independently of each other by the wearer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The Henschke-Mauch "Hydraulik" Knee Unit. <i>Left, </i>Unit installed in a wood set-up; <i>Right, </i>cross-section of the Model "B" (Swing-Phase) Unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a clinical evaluation program conducted by the Veterans Administration, involving more than 30 test subjects, the results were overwhelmingly in favor of the Henschke-Mauch unit in comparison with mechanical friction devices previously worn by the amputees in the study. <a></a></p> <p>The ability to vary gait easily and a reduction in effort required and fatigue produced were the advantages most frequently cited. The last two advantages are particularly noteworthy, since the experimental prostheses were heavier than the prostheses worn previously.</p> <p>The DuPaCo "Hermes" Knee (<b>Fig. 19</b>) is quite similar in design and function to the Henschke-Mauch Model "B" unit and is also available in a wood set-up. Resistance to flexion and to extension may be adjusted independently of each other by the amputee. A clinical study of the DuPaCo knee by the Veterans Administration resulted in very positive reactions, strikingly similar to those obtained in the study with the Henschke-Mauch Model "B" unit. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. DuPaCo "Hermes" Hydraulic Swing-Phase Control Unit mounted in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unlike the Henschke-Mauch and DuPaCo units, the "Hydra-Cadence" hydraulic leg (<b>Fig. 20</b>) is an integrated system incorporating some ankle control as well as swing-phase control. This system is available only in a metal frame, with a specially designed foot-ankle assembly. For appearance, the metal frame that constitutes the shank is covered with a cosmetic cover of a relatively thin, semirigid plastic cast to resemble an average normal shank. The swing-phase unit is a relatively simple piston type and does not offer quite as precise control of function as the more sophisticated units. In addition to control of the shank during swing phase, resistance to plantar flexion is controlled hy-draulically, and motion between the ankle and knee are coordinated so that dorsi-flexion of the ankle takes place after the knee has been flexed 20 deg. The object of the coordinated motion feature was to provide additional toe clearance during the swing phase, but unfortunately the motion does not take place at the time when it is needed most. Nevertheless, as in many other instances, the side effects are highly useful. One advantage of coordinated motion appreciated by amputees is that during sitting dorsiflexion of the foot allows the wearer to draw his artificial foot comfortably under his knee, thus keeping it out of the way when he is seated in a theater or bus. In clinical tests conducted by the Veterans Administration, the overwhelming majority of test subjects preferred the "Hydra-Cadence" unit to their conventional limbs. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. "Hydra-Cadence" Artificial Leg with cosmetic cover removed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The swing-phase control system of the "Hydra-Cadence" unit is offered in a wood set-up or separately for use in a pylon as the "Hydra-Knee" (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. "Hydra-Knee" installed in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the problems of leakage and high maintenance costs have been overcome to a point where hydraulic devices are practical, pneumatic systems also have appeal since manufacturing costs should be materially lower. Pneumatic systems are not apt to produce a knee-moment curve as smooth as those obtained with hydraulic units, but many feel that they offer an excellent compromise suitable for many amputees.</p> <p>One such device nearly ready for commercial distribution is the University of California Pneumatic Swing-Phase Unit. <a></a> Like the Henschke-Mauch and DuPaCo units, the UCB device consists essentially of a moving piston in a cylinder (<b>Fig. 22</b>). It will be available initially in a pylon-type shank and wooden knee block.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Pneumatic Swing-Control Unit developed at the Biomechanics Laboratory, University of California (San Francisco and Berkeley). <i>Left, </i>Cutaway view; <i>Center, </i>complete unit; <i>Right, </i>pylon and cosmetic cover designed especially for the pneumatic unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Stance-phase Units</h3> <p>Increased understanding of fitting and alignment has alleviated many of the former problems of stability control of the leg during stance phase, especially for those patients with relatively strong stumps. Nevertheless, there appears to be a real need for knee units that provide assurance against buckling yet do not interfere with other functions of the leg. The increase in the number of "geriatric" patients in recent years has tended to highlight this need. Patents have been granted for many ways of stabilizing the knee, but few have been found practical. Doubtless the most widespread stance-phase control device in use today is the Otto Bock knee (<b>Fig. 23</b>). Purely mechanical in action, the Bock knee provides resistance to flexion by a friction braking action effected by weight-bearing. When weight is placed on the prosthesis, the knee block moves slightly toward the shank to engage a "V"-type brake. Swing-phase control consists of constant friction and a spring-biased extensor mechanism.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The Otto Bock Safety Knee Unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Henschke-Mauch Model "A" unit (<b>Fig. 24</b>), currently in an advanced experimental stage, consists essentially of the Model "B" unit (<b>Fig. 18</b>) with provisions for stance-phase control added. Braking of the knee joint is controlled by the complex interaction of a pendulum and a counterweight suspended in hydraulic fluid. <a></a> The braking action is brought into play whenever required to arrest buckling action, and is removed only by the prolonged hyperextension moment typical of late stance phase, so theoretically there should be a smoother transition between stance phase and swing phase than that provided by other units. Moreover, for special tasks, the amputee can set the knee either in "freewheeling" or almost fully locked position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Henschke-Mauch "Hydraulik" Model "A" (Swing and Stance Control) Unit. <i>1, </i>Cylinder; <i>2. </i>piston; <i>3, </i>piston rod; <i>4, </i>hydraulic fluid; 5<i>, </i>accumulator piston; <i>6, </i>dashpot; 7, dashpot piston; <i>8, </i>control bushing; <i>9, </i>swing adjustment screw; <i>10 </i>and <i>11</i>. check valves; <i>12 </i>and <i>13. </i>channels: <i>14, </i>pendulum; <i>15, </i>valve; <i>16, </i>counterweight; <i>17, </i>spring; <i>18, </i>stance adjustment screw; <i>19, </i>selector switch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A clinical evaluation by the Veterans Administration involving 50 units has nearly been completed. It is expected that the Henschke-Mauch Model "A" unit will be available for general use in the near future.</p> <h3>Foot-ankle Units</h3> <p> Many attempts have been made to develop foot-ankle units that offer more than the minimum function required, which is controlled plantar flexion. Through the years several designs have been manufactured and made available, but none has found widespread use, usually because the maintenance requirements of the units have outweighed any functional gain they offered. Thus, today, nearly every artificial leg (except the "Hydra-Cadence") incorporates either a SACH (solid-ankle cushion-heel) foot (<b>Fig. 25</b>) or a so-called conventional foot (<b>Fig. 26</b>). Both designs provide controlled resistance to plantar flexion, firm resistance to dorsi-flexion, and limited toe motion, but little else. Resistance to plantar flexion can be adjusted more easily in the conventional foot by introducing rubber bumpers of different densities. The absence of parts in the SACH foot which rotate or rub and its resistance to moisture make its use attractive. Since its introduction in 1958, the design of the SACH foot has been refined in a number of ways. Initially the SACH foot was made by laminating layers of foam rubber around a wooden keel. Later, techniques for molding the rubber were developed and most units are manufactured in this manner. However, the laminated type is available for special applications where shaping to unusual sizes and configurations is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. The SACH (solid-ankle, cushion-heel) Foot. <i>Upper, </i>Laminated type; <i>Lower, </i>molded type. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Cross-section of a typical "conventional" foot-ankle unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Very recently, a special SACH foot has been made available by Kingsley Manufacturing Co. for use in immediate postsurgical fitting procedures (<b>Fig. 27</b>). This version has a flat, wide sole designed for use without a shoe while the patient is in the hospital. This permits equal leg length when the natural foot of the patient is bare or is covered simply with a sock or slipper. It is also about 20 per cent lighter than the conventional SACH foot, and resistance to toe break is less.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Special SACH foot for use in immediate postsurgical fitting procedures. <i>Courtesy Kingsley Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Veterans Administration Prosthetics Center is responsible for updating the specifications for the SACH foot, and makes periodic checks of mass-produced units on a random basis.</p> <p>At the present time, development of a more functional foot-ankle unit using hydraulic principles is under way.</p> <table> <tbody><tr><td> <h3><i>Definitions</i></h3></td> </tr> <tr><td> <p><i>Preparatory Prosthesis</i></p> </td> </tr> <tr><td> <p>A cosmetically unfinished functional replacement for an amputated extremity, fitted and aligned in accordance with sound biomechanical principles, which is worn for a limited period of time to expedite prosthetic wear and use and to aid in the evaluation of amputee adjustment.</p> </td> </tr> <tr><td> <p><i>Pylon</i></p> </td> </tr> <tr><td> <p>A rigid supporting member, usually tubular, that is attached to the socket or knee unit of a prosthesis. The lower end of the pylon should be connected to a foot-ankle assembly.</p> </td> </tr> <tr><td> <p><i>Rigid Dressing</i></p> </td> </tr> <tr><td> <p>A plaster stump wrap, usually applied in the operating or recovery room immediately following operation, for the purpose of controlling edema and pain. It is preferably shaped in accordance with the basic patellar-tendon-bearing (PTB) or quadrilateral designs, but is not necessarily so.</p> </td> </tr> <tr><td> <p><i>Immediate Postsurgical Prosthetic Fitting</i></p> </td> </tr> <tr><td> <p>A procedure wherein a functional socket, designed for weight bearing and walking, is fitted to the patient immediately after operation in the operating or recovery room, or at some time prior to removal of sutures. As distinct from the rigid dressing, referred to above, this socket should be shaped in accordance with the basic PTB or quadrilateral design; it incorporates provision for easy attachment and detachment of a pylon and foot-ankle assembly.</p> </td> </tr> <tr><td> <p><i>Early Prosthetic Fitting</i></p> </td> </tr> <tr><td> <p>A procedure wherein a preparatory prosthesis, as defined above, is provided for the amputee immediately following removal of sutures.</p> </td> </tr> <tr><td> <p><i>Permanent Prosthesis</i></p> </td> </tr> <tr><td> <p>A replacement for a missing limb, which meets accepted checkout standards for comfort, fit, alignment, function, appearance, and durability.</p> </td> </tr> </tbody></table> <h3>Pylons</h3> <p> Recently a number of devices known as pylons have been developed to meet the requirements imposed by immediate and early postsurgical fitting, namely, functional devices that contain built-in alignment features but are light enough for use throughout the day. Also, devices used in fitting immediately postoperatively should be easily removable from the socket so that the device may be disconnected when the patient is sleeping. Provision for locking the knee joint manually is desirable for use with infirm patients.</p> <p>The Hosmer Above-Knee Temporary Leg (<b>Fig. 28</b>) is a modification of the adjustable leg originally designed by the University of California Biomechanics Laboratory for alignment adjustment during walking trials.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. The Hosmer Above-Knee Temporary Leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The U.S. Manufacturing Co. above-knee constant-friction pylon (<b>Fig. 29</b>) is simple, is light in weight, and provides all adjustments necessary in aligning a leg. However, the wedge disks used to change the adduction-abduction and flexion-extension attitudes of the socket require compensatory adjustments to maintain position in one while the other is changed. Hence some degree of skill in using this unit is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. The U.S. Manufacturing Co. Above-Knee Constant-Friction Pylon. The expanded metal straps at the top are provided for use with plaster-of-Paris sockets. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The U.S. Manufacturing Co. also provides an above-knee temporary prosthesis with the "Hydra-Knee" unit installed (<b>Fig. 30</b>). Alignment adjustment is provided in the same manner as in the above-knee unit shown in <b>Fig. 29</b>. Cosmetic covers similar to those used with "Hydra-Cadence" units are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. The Hydra-Knee Pylon. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide for independent adjustment in the adduction-abduction and flexion-extension planes, the Veterans Administration Prosthetics Center designed a unit (<b>Fig. 31</b>) in which threaded "disks" are used to provide a wedging action between two conical surfaces placed apex to apex. This device is incorporated in the VAPC "Standard" above-knee pylon which permits the interchange of several knee mechanisms including various constant friction knees, the DuPaCo swing-control unit, both of the Henschke-Mauch knee units, and the UCB pneumatic device. This very desirable interchangeability feature permits the patient to try out a number of swing-control devices at a minimum cost.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Pylon developed at the Veterans Administration Prosthetics Center. This unit will accommodate a number of different standard mechanisms for control of the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is feasible and practical to use any of these prostheses for indefinite periods. Thus, changes in alignment can be made if they are needed. A comparison of the major features and characteristics of the various pylons is given in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Use of the Prosthetics Research Study (Seattle) casting fixture to form socket in fitting above-knee case with prosthesis immediately after operation. <i>Courtesy Prosthetics Research Study, Seattle, Wash.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Time of Fitting</h3> <p> From time to time through the years, a few clinicians have argued for fitting new amputees with temporary or "training" limbs, either for acceleration of the rehabilitation process or to evaluate the patient's potential for use of a prosthesis if there is doubt about his ability to use one. No one argued against this approach provided the temporary limb was properly fitted and aligned. However, when fitting was done before the stump had stabilized the frequent socket changes that were necessary resulted in high costs. If poorly fitted and aligned prostheses were used, more harm than good could result.</p> <p>The introduction of improved casting methods, improved fabrication techniques, and adjustable pylons led the Orthopaedic Department at Duke University to conduct a series of experiments, beginning about 1960, in which it was demonstrated that it is feasible and, indeed, desirable to fit amputees as soon as the wound has healed. <a></a> In 1963, several groups in the United States began experimenting with the concept of fitting the patient immediately after operation and allowing some degree of ambulation very soon thereafter, a technique that had achieved some success in a rather crude way in France and Poland.<a></a></p> <p>By 1967 the technique had been developed in sufficient detail at the Prosthetics Research Study, Seattle, Washington, and experience with experimental cases was such that it seemed warranted to offer special courses in the Prosthetics Education Program in immediate postsurgical fitting of prostheses. The technique applies to all levels of lower-extremity amputation. Experience has shown that the formation of edema is materially reduced, postoperative pain is reduced, development of contractures is avoided, stump bandaging is unnecessary, and the general well-being of the patient is better than when he is treated in the conventional manner. The procedure obviously reduces both time of hospitalization and time required for rehabilitation, and it is appropriate for use in virtually all types of cases except where an open amputation is indicated. More time is required by the surgeon and prosthetist in the management of the patient during the first two weeks, but substantial savings are effected in the over-all treatment program.</p> <p>For the above-knee case, immediate postsurgical fitting consists essentially of providing the patient with a quadrilateral total-contact socket of plaster-of-Paris bandage (<b>Fig. 32</b>) and an easily detachable functional pylon, allowing him to begin weight-bearing about 24 hours after amputation (<b>Fig. 33</b>). No special surgical techniques are needed. Myoplasty, consisting of some method to ensure reattachment of the cut muscles about the thigh, is recommended in any case. <a></a> The cast-socket is left in place for 8 to 12 days, at which time the sutures can usually be removed. A new cast socket is applied immediately and is kept in place until measurements and a cast can be made for the definitive prosthesis, usually 10 to 12 days later. If some other condition precludes the patient from walking, a rigid dressing of plaster of Paris should be used, rather than conventional dressings, to keep formation of edema to a minimum and thus provide a stump that will cause the pros-thetist less trouble.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Above-knee amputation patient fitted with a prosthesis immediately after amputation. <i>Courtesy Prosthetics Research Study, Seattle, Wash.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Immediate postsurgical fitting and early fitting have been very successful in the hands of competent surgeon-prosthetist teams, and are routine procedures in many centers today. Research in this area is continuing in order to refine the methods still further.</p> <h3>Above-Knee Prosthetics for Children</h3> <p> Amputation in children can be classified as either acquired or congenital. The acquired amputation is the result of trauma or of disease, usually a malignant tumor. The congenital type is the result of a malformation occurring during embryonic development.</p> <p>Management of the acquired amputation in children is essentially the same as that for the adult. Because wounds in children tend to heal faster than they do in adults, immediate postsurgical fitting and early fitting techniques are most appropriate. Usually care must be taken to keep the child patient from being too active. The quadrilateral, total-contact, plastic, suction socket is nearly always indicated. A Silesian bandage may be used, but is usually not needed. For patients below the age of puberty, the only knee unit available is the constant-friction type. SACH and conventional feet are available in sizes suitable for children of all ages.</p> <p>Children with congenital malformations of the lower extremities usually offer a greater challenge. Many times the stump and proximal anatomy are abnormal in structure, and these features must be taken into account in design of the socket and suspension. For guidelines and suggestions for treatment of unusual and bizarre cases, the reader is referred to <i>The Limb-Deficient Child</i>. <a></a></p> <p>For the high, bilateral above-knee case where conventional above-knee or knee-disarticulation prostheses are not suitable, <i>i.e., </i>the patient is unable to use crutches, the use of the swivel walker is recommended (<b>Fig. 34</b> and <b>Fig. 35</b>). <a></a> Designed at the Ontario Crippled Children's Centre for use by patients with severe involvement of all four limbs, the swivel walker has met with success wherever it has been used. Motion is effected by displacement of the center of gravity of the body. Although movement is restricted to smooth, level surfaces, the swivel walker offers an effective means of mobility, and the psychological benefits to be gained from it are quite rewarding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Principle of the "Swivel Walker" developed at the Ontario Crippled Children's Centre, Toronto, Canada, for very high, bilateral, lower-extremity cases. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. The OCCC swivel walker with articulated joints that permit a sitting position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Above-Knee Prosthetics for Geriatric Cases</h3> <p> At one time it was an almost universal rule to amputate through the thigh in cases of peripheral vascular disease when limb ablation was indicated. However, since it has been shown that many knee joints can be saved in spite of what appear to be overwhelming odds, the ratio of above-knee to below-knee amputations is decreasing. Unfortunately, however, there will always be a certain number of above-knee cases.</p> <p>Immediate postsurgical and early fitting practices should be used whenever possible. Proper use of these procedures reduces the mortality rate drastically and permits the fitting of definitive prostheses considered impossible, or at least impractical, only a few years ago. The use of provisional prostheses permits the clinic team to determine, without question, whether or not a definitive prosthesis is indicated. The VAPC "Standard" AK Pylon permits experimentation with several hydraulic units as well as with mechanical friction knee control.</p> <p>In spite of the many useful innovations that have been introduced into the practice of above-knee prosthetics through the years, there is still room for further improvement. Among the developments needed are more foolproof methods of obtaining optimum fit and alignment. Sockets that can be adjusted to meet the constantly changing cyclical demands of the amputee are certainly desirable and possible. Indeed, it might be feasible to provide a socket that is adjusted automatically to meet the needs of the patient constantly throughout the day. In any event, studies of the effect of pressure on human tissues must lead eventually to a better application of limb prostheses.</p> <p>Needed also are methods for fitting and fabrication of limbs in even less time than is presently required. Materials that can be formed at temperatures safe to human tissues are now becoming available, and it is hoped that a useful socket can be molded over the stump, eliminating the need for plaster of Paris in taking impressions and making models of the stump. Such a technique, when used with adjustable pylons that are cheap enough and light enough to leave as the "permanent" prosthesis, should permit fast, economical service.</p> <p>Concurrently with studies designed to point the way to more functional prostheses and more efficient service, a number of surgeons are studying and trying to devise methods for providing more functional stumps. In recent years the techniques of amputation have taken on more significance in the minds of surgeons and, consequently, prosthetists have been seeing stumps that are more functional than has been the case in the past. Further research and a continuation of educational programs should result in even more improvement.</p> <h3>Acknowledgment</h3> <p>Special appreciation is due the Prosthetic and Sensory Aids Service of the Veterans Administration for providing nearly all of the illustrations for this article.</p> <p><b>References:</b></p> <ol> <li>Anderson, M. H., J. J. Bray, and C. A. Hennessy,<i>The construction and fitting of lower-extremity prostheses</i>, Chap. 6 in Orthopaedicappliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 263-312.</li> <li>Bard, Gregory, and H. J. Ralston, <i>The measurment of energy expenditure during ambulation, with special reference to evaluation of assistive devices</i>, Arch. Phys. Med., 40:415-420, October 1959.</li> <li>Blakeslee, Berton, ed.,<i>The limb-deficient child</i>, University of California Press, Berkeley and San Francisco, 1963.</li> <li>Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, Veterans Administration, Washington, D.C., 1967.</li> <li>Foort, J.,<i> Adjustable-brim fitting of the total-contact above-knee socket</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</li> <li>Foort, J., and N. C. Johnson, <i>Edema in lower-extremity amputees</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1962.</li> <li>Golbranson, F. L., Charles Asbelle, and Donald Strand,<i> Immediate postsurgical fitting and early ambulation</i>, Clin. Orth., 56:119-131, 1968.</li> <li>Goldner, J. Leonard, Frank W. Clippinger, Jr., and Bert R. Titus, <i>Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis</i>, Final Report of Project 1363 to (U.S.)</li> <li>Vocational Rehabilitation Administration by Duke University Medical Center, Durham, N.C., 1967. 9. Haddan, Chester C, and Atha Thomas,<i> Status of the above-knee suction socket in the United States</i>, Artif. Limbs, 1:2:29-39, May 1954.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations</i>, Artif. Limbs, 10:2:5-26, Autumn 1966.</li> <li>Hanger, H. B.,<i>Above-knee socket shape and clinical considerations</i>, Committee on Pros-thetic-Orthotic Education, National Research Council, August 1964.</li> <li>Kay, Hector W., K. A. Cody, and H. E. Kramer, <i>Total contact above-knee socket studies</i>, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</li> <li>Lewis, Earl A., <i>Fluid controlled knee mechanisms, clinical considerations</i>, Bull. Pros. Res., 10:3:24-56, Spring 1965.</li> <li>Motloch, W. M., and Jane Elliott, <i>Fitting and training children with swivel walkers</i>, Artif. Limbs, 10:2:27-38, Autumn 1966.</li> <li>Murphy, E. F., <i>The swing phase of walking with above-knee prostheses</i>, Bull. Pros. Res., 10:1:5-39, Spring 1964.</li> <li>Murphy, Eugene F., <i>Lower-extremity components</i>, Chap. 5 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</li> <li>Radcliffe, C. W., <i>Functional considerations in the fitting of above-knee prostheses</i>, Artif. Limbs, 2:1:35-60, January 1955.</li> <li>Radcliffe, C. W.,<i> Biomechanical design of an improved leg prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 1957.</li> <li>Radcliffe, C. W., and H. J. Ralston, <i>Performance characteristics of fluid-controlled prosthetic knee mechanisms</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 1963.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial legs with the adjustable coupling</i>, Artif. Limbs, 7:1:31-43, Spring 1963.</li> <li>Staros, Anthony, and Eugene F. Murphy, <i>Properties of fluid flow applied to above-knee prostheses</i>, Bull. Pros. Res., 10:1:40-65, Spring 1964.</li> <li>Staros, Anthony, and Edward Peizer, <i>Northwestern University intermittent mechanical friction system (disk-type)</i>, Artif. Limbs, 9:1:45-52, Spring 1965.</li> <li>Thomas, Atha, and C. C. Haddan, <i>Amputation prosthesis</i>, Lippincott, Philadelphia, Pa., 1945.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the Hydra-cadence above-knee prosthesis</i>, TR-2, Nov. 1, 1963.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the Henschke-Mauch "Hydraulik" swing control system</i>, TR-3, Dec. 1, 1964.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the DuPaCo "Hermes" hydraulic control unit</i>, TR-4, Jan. 4,1965.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, 11:1:47-50, Spring 1967.</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>14.</b> </td><td class="clsTextSmall">Motloch, W. M., and Jane Elliott, Fitting and training children with swivel walkers, Artif. Limbs, 10:2:27-38, Autumn 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Blakeslee, Berton, ed.,The limb-deficient child, University of California Press, Berkeley and San Francisco, 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>4.</b> </td><td class="clsTextSmall">Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, Veterans Administration, Washington, D.C., 1967.</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">Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, Veterans Administration, Washington, D.C., 1967.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Golbranson, F. L., Charles Asbelle, and Donald Strand, Immediate postsurgical fitting and early ambulation, Clin. Orth., 56:119-131, 1968.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, 11:1:47-50, Spring 1967.</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">Goldner, J. Leonard, Frank W. Clippinger, Jr., and Bert R. Titus, Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis, Final Report of Project 1363 to (U.S.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</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>15.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking with above-knee prostheses, Bull. Pros. Res., 10:1:5-39, Spring 1964.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Staros, Anthony, and Eugene F. Murphy, Properties of fluid flow applied to above-knee prostheses, Bull. Pros. Res., 10:1:40-65, Spring 1964.</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>24.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the Hydra-cadence above-knee prosthesis, TR-2, Nov. 1, 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>26.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the DuPaCo 'Hermes' hydraulic control unit, TR-4, Jan. 4,1965.</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>25.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the Henschke-Mauch 'Hydraulik' swing control system, TR-3, Dec. 1, 1964.</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>13.</b> </td><td class="clsTextSmall">Lewis, Earl A., Fluid controlled knee mechanisms, clinical considerations, Bull. Pros. Res., 10:3:24-56, Spring 1965.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Staros, Anthony, and Eugene F. Murphy, Properties of fluid flow applied to above-knee prostheses, Bull. Pros. Res., 10:1:40-65, Spring 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and H. J. Ralston, Performance characteristics of fluid-controlled prosthetic knee mechanisms, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 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>22.</b> </td><td class="clsTextSmall">Staros, Anthony, and Edward Peizer, Northwestern University intermittent mechanical friction system (disk-type), Artif. Limbs, 9:1:45-52, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Biomechanical design of an improved leg prosthesis, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 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>18.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Biomechanical design of an improved leg prosthesis, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 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>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking with above-knee prostheses, Bull. Pros. Res., 10:1:5-39, Spring 1964.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, Spring 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>20.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, Spring 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>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Functional considerations in the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artif. Limbs, 10:2:5-26, Autumn 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 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>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 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>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1962.</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>11.</b> </td><td class="clsTextSmall">Hanger, H. B.,Above-knee socket shape and clinical considerations, Committee on Pros-thetic-Orthotic Education, National Research Council, August 1964.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Functional considerations in the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Thomas, Atha, and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, Pa., 1945.</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>9.</b> </td><td class="clsTextSmall">Vocational Rehabilitation Administration by Duke University Medical Center, Durham, N.C., 1967. 9. Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artif. Limbs, 1:2:29-39, May 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, M. H., J. J. Bray, and C. A. Hennessy,The construction and fitting of lower-extremity prostheses, Chap. 6 in Orthopaedicappliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 263-312.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</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>2.</b> </td><td class="clsTextSmall">Bard, Gregory, and H. J. Ralston, The measurment of energy expenditure during ambulation, with special reference to evaluation of assistive devices, Arch. Phys. Med., 40:415-420, October 1959.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and H. J. Ralston, Performance characteristics of fluid-controlled prosthetic knee mechanisms, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 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>A. Bennett Wilson, JR.. B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-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 Recent Advances in Above-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, JR.. B.S.M.E. * https://staging.drfop.org/files/original/563b7e3d5e654828605f04deb909797d.pdf bdd8ac1d4ea751b6467591119d581c32 https://staging.drfop.org/files/original/06192bdad0f19b8b8f1a62b6de034970.jpg b1d165ad8953da55d9ae82c37eb333fa https://staging.drfop.org/files/original/11faed39014403a6dc246e19447a1e04.jpg e053bf6273abb66dfc3e4b534d6f0ef2 https://staging.drfop.org/files/original/ab3f22ae3bf0b961414fc0148beb8ad2.jpg c8cc8b308e2f932c66508ebcb3918fe5 https://staging.drfop.org/files/original/a98488decd50e21af69363b9e67475e2.jpg 8ae2865195228b7aca7c75f753e4584b https://staging.drfop.org/files/original/3104c38e2e1fdde67ea076415c929bf7.jpg ce62f98c13cdfb73a43c7b2f673348df https://staging.drfop.org/files/original/1bfb3db8f0a4653731d81faa29559635.jpg bc64124b91d9ba11eef6f8356c5d0319 https://staging.drfop.org/files/original/1a846b2a0fe0a6fddc0540823690ccff.jpg d1f0c1cb1a48e93b1be62020126a530d https://staging.drfop.org/files/original/54f4c041c313324c6dd89aba4c7335e8.jpg 1a38657457516471793399d4f2ade79f https://staging.drfop.org/files/original/c5555a3c031f1ad854aeee2c5fbd1376.jpg 836517a1021bc3d397aab93236925ba2 https://staging.drfop.org/files/original/ddd6cf419da77ba7ed5f5f1bcf7c62b3.jpg adca9e2f32b00a97ee7de032d4c3efc4 https://staging.drfop.org/files/original/8a780fa990993d128a1889acb02fe387.jpg a021a16bcf45de281a02a47e05ebe5a8 https://staging.drfop.org/files/original/1657876e7ff4af53ca8144dee7ddb077.jpg 9dd2ddab021621e602392a91ed65eae6 https://staging.drfop.org/files/original/7da95365c1b01ff987fb41f4868ee168.jpg e09de561d7cb9a7fe09ddbb9766aafe6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_001.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 1 - 12 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/1969_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_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>Recent Advances in Below-Knee Prosthetics</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>The concept of constructing a below-knee prosthesis with side joints and a thigh lacer was set forth by the Dutch surgeon Verduin in 1696 (<b>Fig. 1</b>) and followed universally until the advent of the patellar-tendon-bearing prosthesis in the late 1950's. <a></a> Although other innovations such as contact over the distal end of the stump, suction suspension, and "muley" sockets were introduced from time to time, they were never widely used, possibly because principles governing their use were not set forth in a systematic manner.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Verduin leg (1696). From MacDonald, J., Amer.J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In 1957, the predecessor of CPRD, the Advisory Committee on Artificial Limbs, encouraged the University of California at Berkeley to study the problems of the below-knee amputee and to improve the then current management practices. As a result, some of the leading prosthetists in this country were invited to Berkeley later in 1957 for the express purpose of examining in detail the prosthetics practices for BK amputees and rationales for those practices. <a></a> An analysis of the findings of that conference led to the development of the patellar-tendon-bearing prosthesis, known now as the PTB prosthesis.</p> <p>The original version of the PTB prosthesis was a plastic laminate socket which was formed over a modified plaster-of-Paris model of the stump, and which contained a soft inner liner that contacted the entire surface of the stump. <a></a> The major weight was borne by the medial flares of the tibia and the patellar tendon. No knee joints or thigh corsets were used, suspension being effected by a fabric strap around the thigh just above the femoral condyles (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Cutaway view of the original patellar-tendon-bearing (PTB) prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The PTB concept was offered in formal education programs in this country and gradually gained acceptance, so that by 1961 slightly more than half of the below-knee prostheses provided in the United States were of that type. <a></a> The concept also has been accepted widely in other countries, and the PTB now is generally considered to be the standard prosthesis for below-knee amputations.</p> <p>In recent years, research groups and individual prosthetists have introduced improvements to the basic concept. <a></a> This article describes the advanced practices in the management of the below-knee amputee that have been developed since the introduction of the PTB prosthesis.</p> <h3>The Hard Socket</h3> <p>The original PTB socket design called for a lining of leather or Naugahyde backed by sponge rubber. Perspiration caused problems in many instances, however, because Naugahyde does not "breathe" and leather deteriorates rapidly in the presence of sweat. This problem prompted some prosthetists to eliminate the liner, and the "hard" PTB socket has become increasingly popular.</p> <h3>The PTS Socket</h3> <p>The suspension strap for the PTB prosthesis, as designed originally, was usually satisfactory, but there were enough dissatisfied amputees to prompt a number of prosthetists to seek improved suspension methods. In addition to developing different strap designs (<b>Fig. 3</b>) <a></a>, several groups experimented with new configurations for the proximal border of the socket. The research team at Nancy, France, introduced the "prothese tibiale a emboitage supracondylien," popularly known as the PTS, in which the proximal border extends above the patella and the femoral condyles (<b>Fig. 4</b>), <a></a> thus holding the socket on the stump. This concept was introduced into the United States by Nitschke and Marschall <a></a> and the PTS prosthesis is being used at an increasing rate in the United States. The technique may be used with or without a liner. Hamontree <a></a>, in reporting his experiences with 94 cases, noted that, although he believed that the majority of the patients could have been satisfied with the original version of the PTB, a certain percentage could have been successfully fitted only with the PTS version.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Left, continuous-strap suspension arranged in a figure eight with Velcro for adjustment; right, anterior view of two inverted V-straps looped through a ring and attached inside a hard socket close to the brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. A right, below-knee stump and the amputee wearing a PTS-socket prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Wedge Suspension Socket</h3> <p>Another attempt to improve upon the strap type of suspension resulted in the KBM (Kondylen Bettung Munster) prosthesis <a></a>, in which a small wedge is inserted between the proximal area of the socket and the area of the stump along the medial condyles of the femur (<b>Fig. 5</b>). Developed at the University of Munster, this concept was introduced into the United States by Fillauer <a></a> and is now known as the supracondylar-wedge suspension system. The wedge system may be used with or without a socket liner, but generally no liner is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The supracondylar-wedge suspension method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Air-Cushion Socket</h3> <p>In an effort to develop a socket that would permit the stump to bear the optimum amount of the weight load over its distal end, Wilson and his associates <a></a> designed and developed the "air-cushion socket" (<b>Fig. 6</b>), which reduces the magnitude of the vertical components of weight-bearing forces at other points on the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Cutaway view of the air-cushion socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The air-cushion PTB consists of an elastic inner sleeve (stockinet impregnated with silicone rubber) suspended from the level of the tibial tubercle in a rigid outer shell that is closed distally. Stump support is provided by the tension of the sleeve itself and by the compression of the air in the chamber between the inner sleeve and outer cap.</p> <p>Trials in the United States, Denmark, and Yugoslavia <a></a> have shown that the air-cushion version of the PTB is particularly useful for patients with very sensitive stumps. In fact, there appear to be few, if any, contraindications to the use of the air-cushion socket, the only disadvantages being that slightly more time is required to fabricate the socket and that few modifications can be made after it has been fabricated.</p> <h3>Porous Socket</h3> <p>In seeking ways to alleviate the problems caused by perspiration, the U. S. Army Medical Biomechanical Research Laboratory developed a porous plastic laminate. <a></a> Conventional epoxy resins and filler materials are used in the fabrication, but special care must be taken in controlling the proportions of the ingredients and in curing. The first porous laminates developed by AMBRL were satisfactory for upper-extremity sockets, but they were not strong enough for routine use in lower-extremity sockets. Subsequently, the technicians developed a fabrication technique using epoxy resins that overcame the major shortcomings of the earlier laminates. <a></a> New York University, after studying 20 children and young adults, reported that the porous-laminate socket appeared to be a "significant and worthwhile addition" to below-knee prosthetics specifically and to limb prosthetics generally. <a></a> There were fewer problems with perspiration, and skin eruptions were ameliorated. In addition, the prostheses with porous-laminate sockets weighed less. When perspiration was a major problem, the two disadvantages cited-slightly increased fabrication time and greater difficulty in maintaining socket cleanliness-were far outweighed by the advantages.</p> <p>Because most of the innovations to the original PTB design are not mutually exclusive, it was possible to develop a chart showing the combinations of features that can be used to devise a below-knee prosthesis that best meets the needs of the individual patient (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Casting Methods</h3> <p>The method for obtaining a model of the stump for fabrication of the PTB socket, as described in the original manuals, consisted of wrapping the stump with plaster-of-Paris bandages, shaping the wrap with the fingers, and subsequently modifying the male mold produced from the female cast, or wrap. Any number of attempts have been made to devise a procedure that would require less skill. One such method that has been accepted by many prosthetists is the sling-casting, or suspension-casting, technique developed by Hampton <a></a> (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Ring and sock for suspension casting of the below-knee stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the suspension-casting technique, the stump is wrapped while it is held in a vertical position that simulates weight-bearing during standing. Felt patches to provide relief for sensitive areas of the stump can be applied directly to the stump, and a minimum amount of modification is necessary, although the need for modification is not eliminated entirely.</p> <p>Research workers and clinicians have been searching for years for a material that will enable the prosthetist to form a socket directly over the stump, thereby eliminating the need for plaster wraps and male molds. Experience with a synthetic rubber, Polysar<a style="text-decoration:none;">*</a> X-414, has shown that this material definitely has a place in the fabrication of sockets. <a></a> Temporary, or provisional, below-knee prostheses consisting of a synthetic-balata socket and pylon-type components are proving to be useful. Because it becomes pliable at temperatures easily tolerated by the skin, synthetic balata can be applied directly over the stump. Extruded tubing of various diameters with walls 1/4-in. thick is available. A piece of tubing slightly smaller in diameter than the stump is heated in water to about 160 deg F, then forced over the stump, which has been padded in appropriate areas (<b>Fig. 9</b>). To give proper shape to the socket, a length of pressure-sensitive tape, 1 in. wide, is wrapped over the outside, and final forming is carried out manually. To provide total contact, the distal end is filled with "foam-in-place" silicone. The socket is easily mounted on a pylon unit for use as a temporary prosthesis, or a more permanent one if desired. The prosthesis can be given a natural appearance by applying and shaping semirigid blocks of Koroseal "Spongex"<a style="text-decoration:none;">*</a> (<b>Fig. 10</b>). Contours of the socket can be changed at any time by heating the area with a heat gun and reshaping it manually.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Top, application of socket tube to the stump; bottom, trimming of socket brim prior to final molding. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Foam blocks for fitting over pylon and socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Time of Fitting</h3> <p>During the past decade, the advantages of fitting a prosthesis as soon after amputation as possible have been demonstrated repeatedly. Goldner and his associates <a></a> demonstrated that "early" fitting-that is, providing the patient with a temporary prosthesis as soon as the wound has healed rather than waiting for a maximum amount of shrinkage to take place-could drastically reduce time and costs of rehabilitation. Even more dramatic results have been obtained by fitting artificial limbs immediately after surgery, especially with below-knee amputees <a></a> (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Schematic cross section showing the major elements of a prosthesis as applied immediately following surgery to a below-knee amputee. The suture line, silk dressing, and drain are not shown. The fluffed gauze does not extend beyond the area indicated in "A." Inset: A below-knee amputee fitted with the immediate postsurgical prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The technique of immediate postsurgical fitting was originated in France by Berlemont, was carried further by Weiss in Poland, and, after a considerable experimentation period in the United States, is now being taught routinely in the prosthetics education programs in this country. <a></a> The technique consists of applying a rigid dressing over the stump and attaching an adjustable pylon and foot. Standing and ambulation is begun as soon as the patient's condition permits. For young, otherwise healthy patients, some ambulation can begin on the day following amputation.</p> <p>Usually the rigid dressing is left in place until the wound has healed and the sutures can be removed-about 10-14 days postoperatively. A second rigid dressing is provided for another 10- to 14-day period, at which time a "permanent," or definitive, limb can be provided. The advantages of immediate postsurgical fitting include reduction of edema, less pain, shorter periods of hospitalization and therapy, and fewer contractures. The technique has become standard practice in many centers with trained teams. <a></a></p> <h3>Hardware</h3> <p>To make early fitting and immediate postsurgical fitting easier, a number of adjustable pylons have been developed. Those currently available are shown in <b>Fig. 12</b>. Some of their characteristics are given in <b>Table 1</b>. These units are strong enough and light enough for extended usage with or without some sort of cosmetic cover. A number of approaches to cosmetic treatment such as the use of Spongex, mentioned above, have been offered, but none have been accepted widely by prosthetists. Work on this problem is continuing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Below-knee pylon-type prostheses that can be used for fitting immediately after surgery. A, Hosmer Postoperative Pylon; B, Northwestern Pylon (Hosmer); C, Veterans Administration Prosthetics Center (VAPC) "Standard" Pylon; D, Canadian "Instant" Prosthesis (Hosmer); E, United States Manufacturing Co. Pylon; F, Finnie-Jig (Arthur Finnieston Co.). Metal straps for attachment to a plaster-of-Paris socket are available, but not shown. Courtesy of Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Education and Research Needs</h3> <p>At the December 1968 "Symposium on Below-Knee Prosthetics", <a></a> sponsored by the Committee on Prosthetics Research and Development, a number of suggestions for improving prosthetics education and practice were offered.</p> <ol> <li>The body of knowledge about BK prosthetics that has been developed in recent years should be made available to practicing prosthetists and other clinicians.</li><li>All institutions offering prosthetics-education courses should include the information presented at the symposium in their curricula.</li><li>Opportunities for continuing education, such as postgraduate-type courses for clinic teams in the latest prosthetics techniques, should be provided.</li><li>Additional manuals and other instructional materials should be prepared. In addition, a central group that would be responsible for the orderly preparation and dissemination of technical information is needed.</li><li>Current research efforts in BK prosthetics should be continued, but with emphasis placed on the development of a truly refined theory of fitting.</li></ol> <p>Because most of the recent improvements to the design of the below-knee socket, especially in suspension techniques, have been accomplished by practicing prosthetists, there is little need for the research centers to devote their time to developing additional improvements. On the other hand, there is very little knowledge about the basic principles underlying optimum fitting of prostheses. Therefore, the research centers should be encouraged to obtain basic information about the effects of pressure and shear forces on tissues, and to more clearly indicate the biomechanical forces required in the various phases of walking. Following that work, methods by which those principles could be put into practice should be developed, including the use of hydrostatic sockets and other methods that might provide automatic adjustment.</p> <p>As a result of these suggestions, a pilot course in advanced below-knee prosthetics practices was held at Northwestern University (see "News and Notes") on August 4-13, 1969, for prosthetist instructors from the University of California at Los Angeles, New York University, and Northwestern University. The University Council on Prosthetics Education is now developing a curriculum for short-term postgraduate courses in below-knee prosthetics. The advanced techniques will also be offered in regular courses in below-knee prosthetics.</p> <p><b>References:</b></p> <ol> <li>The American Academy of Orthopaedic Surgeons, Inc.,<i> Historical development of artificial limbs</i>, Chap. 1 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Burgess, Ernest M., <i>The below-knee amputation</i>, Inter-Clinic Inform. Bull., 8:4:1-22, January 1969.</li> <li>Burgess, Ernest M., and Joseph H. Zettl, <i>Amputations below the knee</i>, Artif. Limbs, 13:1:1-12, Spring 1969.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D. C, April 1967.</li> <li>Caldwell, Jack L., <i>Inverted V-strap suspension for PTB prosthesis</i>, Artif. Limbs, 9:1:23-26, Spring 1965.</li> <li>Committee on Prosthetics Research and Development, <i>Below-knee prosthetics</i>, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</li> <li>Committee on Prosthetics Research and Development, <i>Immediate postsurgical fitting of prostheses</i>, A report of a workshop, National Academy of Sciences, Washington, D. C, May 1968.</li> <li>Compere, Clinton L., <i>Early fitting of prostheses following amputation</i>, Surg. Clin. N. Amer., 48:1:215-226, February 1968.</li> <li>Dolan, Clyde M. E., <i>The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis</i>, Artif. Limbs, 12:1:25-34, Spring 1968.</li> <li>Fillauer, Carlton, <i>Supracondylar wedge suspension of the P T.B. prosthesis</i>, Orth. and Pros., 22:2:39-44, June 1968.</li> <li>Goldner, J. Leonard, Frank W. Clippinger, and Bert R. Titus, <i>Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis</i>, Final Report of Project RD-1363-M, Duke University Medical Center, Durham, N. C, circa 1967.</li> <li>Hamontree, Sam E., Howard J. Tyo, and Snowdon Smith, <i>Twenty months experience with the "PTS"</i>, Orth. and Pros., 22:1:33-39, March 1968.</li> <li>Hampton, Fred, <i>Suspension casting for below knee, above-knee, and Syme's amputations</i>, Artif. Limbs, 10:2:5-26, Autumn 1966.</li> <li>Hill, James T., Henry Mouhot, and Robert E. Plumb, <i>Manual for preparation of a porous PTB socket with soft distal end</i>, Tech. Rep. 6804, U. S. Army Medical Biomechanical Research Laboratory, Washington, D. C, May 1968.</li> <li>Kuhn, G. G., S. Burger, R. Schettler, and G. Fajal, <i>Kondylen Bettung Munster am Unter-schenkel Stumpf</i>, "KBM-Prothese," Atlas d'Appareillage Prothetique et Orthopedique, No. 14, 1966.</li> <li>Litt, Bertram D., and LeRoy Wm. Nattress, Jr., <i>Prosthetic services USA-1961</i>, American Orthotics and Prosthetics Association, Washington, D. C, October 1961.</li> <li>Lower-Extremity Amputee Research Project, Minutes of symposium on BK prosthetics, University of California, Berkeley, April 1957.</li> <li>Marschall, Kurt, and Robert Nitschke, <i>Principles of the patellar tendon supra-condylar prosthesis</i>, Orthop. Pros. Appl. J., 21:1:33-38, March 1967.</li> <li>Marschall, Kurt, and Robert Nitschke, <i>The P.T.S. prosthesis (Complete enclosure of patella and femoral condyles in below knee fittings)</i>, Orthop. Pros. Appl. J., 20:2:123-126, June 1966.</li> <li>Pierquin, L., G. Fajal, and J. M. Paquin, <i>Prothese tibiale a emboitage supracondylien</i>, Atlas d'Appareillage Prothetique et Orthopedique, No. 1, January 1964.</li> <li>Plumb, Robert E., and Fred Leonard, <i>Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 1963.</li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-bearing below-knee prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</li> <li>The Staff of the Prosthetics Research Group, Biomechanics Laboratory-University of California, <i>Manual of below knee prosthetics</i>, The Regents of the University of California, November 1959.</li> <li>The Staff, Veterans Administration Prosthetics Center, <i>Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material</i>, Orth. and Pros., 23:1:36-61, March 1969.</li> <li>Wilson, L. A., E. Lyquist, and C. W. Radcliffe, <i>Air-cushion socket for patellar-tendon-bearing below-knee prosthesis</i>, Tech. Rep. 55, Department of Medicine and Surgery, Veterans Administration, Washington, D. C, May 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</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">Committee on Prosthetics Research and Development, Immediate postsurgical fitting of prostheses, A report of a workshop, National Academy of Sciences, Washington, D. C, May 1968.</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">Committee on Prosthetics Research and Development, Immediate postsurgical fitting of prostheses, A report of a workshop, National Academy of Sciences, Washington, D. C, May 1968.</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>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., The below-knee amputation, Inter-Clinic Inform. Bull., 8:4:1-22, January 1969.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Burgess, Ernest M., and Joseph H. Zettl, Amputations below the knee, Artif. Limbs, 13:1:1-12, Spring 1969.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D. C, April 1967.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Compere, Clinton L., Early fitting of prostheses following amputation, Surg. Clin. N. Amer., 48:1:215-226, February 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Frank W. Clippinger, and Bert R. Titus, Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis, Final Report of Project RD-1363-M, Duke University Medical Center, Durham, N. C, circa 1967.</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">Sockets of this material should not be left near radiators or in an abnormally warm environment, such as the interior of a closed automobile parked in sunlight on a warm day, because synthetic balata becomes pliable at temperatures as low as 120 deg F.</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">B. F. Goodrich Co.</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>24.</b> </td><td class="clsTextSmall">The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, Orth. and Pros., 23:1:36-61, March 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of Polymer Corporation Limited.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below knee, above-knee, and Syme's amputations, Artif. Limbs, 10:2:5-26, Autumn 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Dolan, Clyde M. E., The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis, Artif. Limbs, 12:1:25-34, Spring 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 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>9.</b> </td><td class="clsTextSmall">Dolan, Clyde M. E., The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis, Artif. Limbs, 12:1:25-34, Spring 1968.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Hill, James T., Henry Mouhot, and Robert E. Plumb, Manual for preparation of a porous PTB socket with soft distal end, Tech. Rep. 6804, U. S. Army Medical Biomechanical Research Laboratory, Washington, D. C, May 1968.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 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">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</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>25.</b> </td><td class="clsTextSmall">Wilson, L. A., E. Lyquist, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Tech. Rep. 55, Department of Medicine and Surgery, Veterans Administration, Washington, D. C, May 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Fillauer, Carlton, Supracondylar wedge suspension of the P T.B. prosthesis, Orth. and Pros., 22:2:39-44, June 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Kuhn, G. G., S. Burger, R. Schettler, and G. Fajal, Kondylen Bettung Munster am Unter-schenkel Stumpf, 'KBM-Prothese,' Atlas d'Appareillage Prothetique et Orthopedique, No. 14, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hamontree, Sam E., Howard J. Tyo, and Snowdon Smith, Twenty months experience with the 'PTS', Orth. and Pros., 22:1:33-39, March 1968.</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>18.</b> </td><td class="clsTextSmall">Marschall, Kurt, and Robert Nitschke, Principles of the patellar tendon supra-condylar prosthesis, Orthop. Pros. Appl. J., 21:1:33-38, March 1967.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Marschall, Kurt, and Robert Nitschke, The P.T.S. prosthesis (Complete enclosure of patella and femoral condyles in below knee fittings), Orthop. Pros. Appl. J., 20:2:123-126, June 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Pierquin, L., G. Fajal, and J. M. Paquin, Prothese tibiale a emboitage supracondylien, Atlas d'Appareillage Prothetique et Orthopedique, No. 1, January 1964.</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">Caldwell, Jack L., Inverted V-strap suspension for PTB prosthesis, Artif. Limbs, 9:1:23-26, Spring 1965.</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">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Litt, Bertram D., and LeRoy Wm. Nattress, Jr., Prosthetic services USA-1961, American Orthotics and Prosthetics Association, Washington, D. C, October 1961.</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>22.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">The Staff of the Prosthetics Research Group, Biomechanics Laboratory-University of California, Manual of below knee prosthetics, The Regents of the University of California, November 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Lower-Extremity Amputee Research Project, Minutes of symposium on BK prosthetics, University of California, Berkeley, April 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>1.</b> </td><td class="clsTextSmall">The American Academy of Orthopaedic Surgeons, Inc., Historical development of artificial limbs, Chap. 1 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 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>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N. W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-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 Recent Advances in Below-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/9efbf424d1bfe2b5b84fe13f0d2fd516.pdf 0bcf1c41627ab178388a24b6e69db174 https://staging.drfop.org/files/original/9811319d59776c370a44ed906f991cfd.jpeg 00380d4a6a0059f69700b9ea0c517dc3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_04_001.pdf Text Any textual data included in the document <h2>Rehabilitation Engineering and Prosthetics/Orthotics</h2> <h5>Anthony Staros, MSME, PE&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The words "Rehabilitation Engineering" are now commonly used to mean a paramedical practice which in its job characteristics and their demands, in the basic technical background needed, in its high activity level, and in its human service slant, is an extrapolation of professional prosthetics and orthotics. Prosthetics and orthotics are in fact very significant components.</p> <p>Rehabilitation engineering is defined as that broad discipline having as its ultimate objective the <i>application</i> of technology to enhance life's quality for the disabled. It includes subsidiary goals in research, development and education. But one doesn't need to be an engineer to <i>practice</i> rehabilitation engineering!</p> <p>With the recent advances in technical aids, prosthetics and orthotics included, there has been increasing need for those who currently serve the disabled with technology to expand the range of their commitment requiring a persistent demand for more knowledge. At the same time, there are counterpressures:—the potentially harmful low rates of increase in the numbers of practitioners. Fewer people are trying to do more while also needing more information for what they do. The effects that Government budget restraints will produce in this situation are difficult to predict, but clearly seen is that the pressures will be greater, that there will be real need for increased efficiency in all parts of society and more so for us committed to the delivery of high quality service to the disabled: increased productivity and more knowledge are conjointly required.</p> <p>Much of what rehabilitation engineering means in real practice is the selection of devices, the making of special systems, or the design of environments, and then the delivery of these, customizing them even further when necessary, and applying them to assist the disabled. Demanded is the achievement of independence through function and/or access with both comfort and control maximized. Training of the client is essential. These efforts are effected in a precise and deliberate process with full understanding of the patterns of disability presented and a substantial awareness of the personal wishes of the disabled person being served (and his/her family).</p> <p>Rehabilitation engineering includes aids fitted directly to the client as in prosthetics and orthotics, tools such as communication devices, and adaptations to environment, to work sites, to the home, or to the vehicles used to reach one or the other or to those mobility devices operated within an environment. Some of the technical aids may be very simple in design; most of those which are custom-made require biomechanically sound, creative, and often inventive approaches. The simplest may require the most creativity.</p> <p>In the rehabilitation engineering applications process, in supporting the physician's role in prescription or in the selection of aids and then in their application, the knowledgeable and interested prosthetist, orthotist, and therapist (physical, occupational, speech) can play the key roles. Especially <i>productive</i> and <i>cost effective</i> is the involvement of the skilled technician, an essential member of the rehabilitation engineering team. The team concept is crucial in that the knowledge needed comes out of the sharing of training and experience—and the creativity sought can usually come from the synergism in the group, especially including the client. The actual "making" although involving all to various degrees becomes the special province of the technician, with the "fitting" itself being a product of the team. The required contribution to benefit the patient will be a scenario of analysis and synthesis, idea and response, search and research, give and take, and then plain work.</p> <p>That which is rehabilitation engineering has been performed for many years, before it became stylish to use this expression to represent a special technology. But there is now in place an acceleration in the development of new technology in products and processes, many so recent that they are not known to members of the rehabilitation team who received preparatory training or post-graduate courses years earlier. Even now the newer information needed is not obtained in structured formats. Pathways should be constructed for each member of the team to broaden his/her own discipline to include constantly updated knowledge about all technology necessary for his/her personal professional contribution to the rehabilitation engineering team. And not to be overlooked is that the payers for services need to be instructed on the cost benefits of rehabilitation engineering.</p> <p>We recommend that these professionals (the prosthetist, orthotist, and therapist) have their own societies' publications and conferences include the information about the advance in rehabilitation engineering. They should also participate in those societies which meld the team, the <i>Rehabilitation Engineering Society of North America</i> and the <i>International Society for Prosthetics and Orthotics</i>, thereby advancing the practice of rehabilitation engineering through contacts with the other team members. Special seminars need to be structured for the 3rd party payers.</p> <p>In the team, or even in the individual practices, the added knowledge about rehabilitation engineering aids can only benefit. If the prosthetist or orthotist fitting a patient with an <i>upper-limb</i> deficit relates his fitting in part to the vehicle controls the disabled person may need to use, shouldn't he or she be knowledgeable about such controls and their installation? Beyond that, shouldn't both (prosthesis or orthosis <i>and control</i>) be "installed" under such professional supervision? Yet still, in this decade of rapidly advancing technology and of certification of those who dispense it, ordinary automobile repair garages install hand controls for licensed vehicles for disabled drivers. Why not the orthotist or prosthetist overseeing his/her technician?</p> <p>There are often frustrating limits to the mobility which can be provided in lower limb orthotic or prosthetic care. Under what circumstances does one use a wheelchair as a supplement or as a last resort? How is it selected? In what way should it be modified if at all? What kind of buttock and trunk support are required? Here the prosthetist, the orthotist, and the therapist should be involved for aren't these the professionals who can be and should be closely associated with wheelchair prescription and modification? In a national workshop held in 1978, WHEELCHAIR I,<a style="text-decoration: none;">*</a> mention was repeatedly made about the need for a "wheelchairist", a person to be concerned exclusively with wheelchair prescription and fitting. If prosthetists, orthotists, and therapists are indeed responsible for other aids for mobility, why not then the wheelchair? Isn't a functioning rehabilitation engineering team the "wheelchairist" sought?</p> <p>From the clinic team setting or from the counselor's desk, the usual site for the final selection and customization of technical aids and then their application is not unlike a prosthetics/orthotics laboratory, there blessed with talented technician support. In a recent paper,<a style="text-decoration: none;">*</a> we recommended that the prosthetics/orthotics profession develop the practice of rehabilitation engineering:</p> <p>"Recommended is that prosthetics and orthotics, with their foundation in clinical technology, constitute the basis for the establishment and certification of a broadly based rehabilitation engineering capability in the United States. Indeed, it would be well for prosthetists and orthotists to start expanding their scope to include the other technical aids in rehabilitation engineering and in collaboration with other members of the rehabilitation team, especially the orthopedic surgeon, provide the means for a wider coverage in the delivery of technology to restore independence and function to many handicapped individuals who are not now receiving the full, broad spectrum services they deserve."</p> <p><a href="/files/original/9811319d59776c370a44ed906f991cfd.jpeg"><b>Figure 1</b></a></p> <p>Is there then really need for the engineer, the graduate of a formal engineering curriculum to be the <i>applier</i>, the "clinical" practitioner of rehabilitation engineering? The rehabilitation <i>engineer</i> has a role: in design, development, research, and perhaps in management. The prosthetist, orthotist and therapist especially with technician support, as a team and as individuals can and should respond to the total technical needs of the patients presented to them; rehabilitation engineers should identify with the other (consulting) members of the medical-technical professional structure in the overall rehabilitation effort. To be called on only in the case of <i>special</i>, more complex problems, the engineer should be mostly involved in leading generalized design and development efforts, these to include others of the team as well.</p> <p>Total need, as the prosthetist, orthotist, and therapist well know, includes "tender loving care," this in the past demonstrated by the experiences of these professionals in analyzing then defining the problems of the disabled. For patients with the severer disabilities, those requiring broader rehabilitation engineering efforts, good practice requires more of such empathic yet deliberate reasoning to seek solutions: devices which yield function in a real sense and are more than just tolerated, used for their novelty, or accepted to please someone else. Seating, wheelchair designs, licensed vehicle modifications, electrical stimulation for pain relief or function, and home and job modifications are all parts of an armamentarium which spans the spectrum from modifications to the shoe to those to the motorcar, for mobility; from a mouth stick to a robotic system, for independent "prehensile" function; from a simple word-display board to synthetic speech, for communciation.</p> <p>Then, do we really need to cultivate large numbers of graduate engineers for rehabilitation engineering practices (other than for the employment of some smaller number in research and development)? Yes, if the prosthetist/ orthotist does not accept the alternative recommended: proper management of his/her practice integrating it with those of other team members and with the very significant role of their skilled technicians who become key constituents in that practice.</p> <p>Apparently some prosthetists and orthotists see an expanding future. The excellent document describing the professions of prosthetics and orthotics and recently published by the American Academy of Orthotists and Prosthetists<a style="text-decoration: none;">*</a> refers to the directions being taken by its professions, based for now on "bionics" referring specifically to automatic control of knee function and myoelectric control of powered upper-limb prostheses. These are presented as steps toward encompassing more and more technology, components of a rehabilitation engineering commitment. In fact the logo of this publication (shown here) presents the transition from orthotics and prosthetics to rehabilitation engineering over a natural pathway (or track) for growth.</p> <p>The essential initiatives now have to come from the current practitioners. In fact they could also abdicate their "clinical" role to the rehabilitation engineering equipment dealers!</p> <b>Footnote</b>The Academy brochure can be ordered from the National Office for $1.25 each.<b><br /><br />Footnote</b> Staros, A. and G. Rubin, The Orthopedic Surgeon and Rehabilitation Engineering in Orthopedics, March/April 1978, Volume 1/Number 2, Charles B. Slack, Inc., Thorofare, N.J.<br /><br /><b>Footnote</b> Moss Rehabilitation Hospital (REC) Wheelchair I; Report of a Workshop sponsored by RSA and VAPC, Dec. 6-8, 1977, Philadelphia, Pa.<br /><br /><em><b>*Anthony Staros, MSME, PE </b> Director, VA Rehabilitation Engineering Center New York, N.Y.</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 1 - 3 Year 1981 Volume 5 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1981_04_001/1981_04_001-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Rehabilitation Engineering and Prosthetics/Orthotics Creator An entity primarily responsible for making the resource Anthony Staros, MSME, PE * https://staging.drfop.org/files/original/c9a1d6e7671d63f3fcd52fc82276041f.pdf 7dc5a6a86a368317cbf6867d2a17b66e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_055.pdf Text Any textual data included in the document <h2>Rehabilitation: Goals or Shoals?</h2> <h5>Samuel A. Weiss, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In the pre-1960 period, the dominant aim of rehabilitation personnel working with amputees was the restoration of the amputee to maximum pre-morbid functioning. Lower-extremity amputees had little choice. A degree of prosthetic restoration consonant with some ambulation was necessary in order to provide some independence and self-sufficiency. Upper-extremity amputees were also presented with the goal of maximum functional restoration. While comfort and cosmesis were given their due, the explicit dogma was restoration to as much premorbid functioning as was mechanically feasible. The writer remembers the dictum of one expert, "a hook for work and a functional, cosmetically acceptable hand for recreation." An upper-extremity amputee might plead that he had learned to "manage" with his intact hand and was, therefore, interested only in an acceptable, passive appendage to fill a sleeve and allow him to mix in society inconspicuously. All in vain. He was regarded virtually as a self-denigrating quitter who was undermining his own livelihood, as well as a heretic in our work ethic society. To an appreciable extent this pejorative judgment was then true because in the pre-60's period there were, as yet, no "Great Society" programs which were to introduce alternative means of financial support. To a worker in the pre-60's period, functional restoration was the life raft which prevented him from sinking unless he was content to gasp through life on the dole and undergo the psychological angina pains of conscience.</p> <p>When the "Great Society" programs were introduced, the work ethic, for better or worse, was to a considerable extent attenuated. Moreover, improvements in technology, reduction in the need for manual labor, and the proliferation of new types of jobs allowed amputees better viability because an entirely intact body was no longer necessary for self-support. Yet the dogma of total, functional restoration hovered in the consciousness of rehabilitation personnel. While society in the 60's became more interested in immediate self-gratification, rehabilitation experts, who had been trained to make men and things "work," retained their pure work ethic consciousness. Physicians desired that body functioning become normal; physical and occupational therapists knew that somatic improvement required vigorous exercise; psychologists believed in maximum self-realization; and engineers and prosthetists yearned for more powerful mechanisms to provide normality. The old-fashioned work ethic had, to a considerable extent, been replaced by a new pay ethic—more pay for less work and poorer service for higher fares. We rehabilitation workers, however, remained aloof on Mt. Sinai, in our pristine innocence, proclaiming the Ten Commandments to stiff-necked and stiff-limbed rehabilitants who preferred to dance around the golden calf of entitlements.</p> <p>While recent political changes are striving to restore the work ethic to its former glory, the average person does not readily relinquish the desire to be presented with a set of options from which to choose. Attempts to enforce one set of standards or goals equally on all rehabilitants are doomed to fail.</p> <p>Perhaps some examples of individual personality types I have encountered among amputees seen at NYU Medical Center and in private practice will illustrate the distinctive rehabilitation goals of different people.</p> <h3>Case Studies</h3> <p>"A" applied as a volunteer experimental prosthesis wearer. He had lost his non-dominant hand in an accident. During the interview, he impressed the writer with his stability. His psychological test profile was exceptional. The writer remembered "A's" well-executed and orderly Bender-Gestalt drawings and recommended him for a position at an agency where he is still employed. I never saw "A" wear anything but a hook when I visited the agency. He never attempted to emphasize his functional restoration goal. His good-natured and efficient performance with his hook spoke for itself. In my conversations with him on various topics, both vocational and personal, he would often become enthusiastic and wave his hook in front of my eyes to emphasize a point. I never "saw" the hook. His efficiency and personality preempted his amputation. All I saw was the person, not the disability.</p> <p>"B" was a double hand amputee volunteer. He was gainfully employed and wished to contribute to amputee rehabilitation. "B" underscored his conviction of absolute normality. He wished to demonstrate this to the staff by maneuvering his two prostheses and a sheet of paper to pick up a dime. He failed a number of times before succeeding, but the note of triumph in his eye compensated for the failures. "B" had convinced himself that he was normal and who were we to question him? He was gainfully employed, easy to deal with, and adjusted to his environment. His "super normality" was irrelevant since this illusion did not interfere with his various roles as a human being.</p> <p>"C" did not require functional restoration for his work. He wore an active, cosmetic hand because of his desire not to attract attention to his disability, and his prosthesis was useful for minor tasks. He refused to wear a hook for more inclusive manual functioning. His goal was mainly cosmetic. The limited function of the type of prosthetic hand then available was satisfactory to him.</p> <p>"D" wore a passive hand with no function. His main goal was to appear normal to the casual observer. To some work ethicists on our staff "D" was regarded as an unactualized individual, but "D's" goals were not the attainment of complete self-actualization, but merely a wish to blend with the crowds on the trains and street.</p> <p>"E" was a prosthesis wearer interviewed for phantom limb experience. Our explanation as to the potential value of the study was misinterpreted by him. He somehow gained the impression that further knowledge about phantom limb sensation and neurological functioning would enable scientists to grow a new, natural limb on his amputation stump (as is the case with some lower animals). He nervously inquired "Will I lose my pension?" This veteran was so satisfied with his prosthesis (and disability pension) that he seemingly rejected the ultimate restoration, a reborn limb!</p> <p>"F" lost his left hand in an accident. He absolutely refused to wear his prosthesis because of discomfort and because he functioned adequately with his intact limb. His empty sleeve was virtually "filled" by his outgoing and warm personality. His interpersonal behavior was the best camouflage for his amputation. He was an amputee who had the best prosthesis of all—his total personality. Unfortunately, he later died, following a disease unrelated to his amputation. The large funeral chapel was packed with people from numerous walks of life.</p> <p>Each of these individuals represents a different personality type with distinctly different goals and levels of achievement, satisfactory to each if not to rehabilitation personnel.</p> <p>My experience as a psychologist has convinced me that different patients are ready for varying levels of growth. Some patients who have made appreciable, but not optimal gains in psychotherapy will leave. A percentage of these will return months or years later, after they have assimilated their original gains, to strive for a higher level of achievement. The choice must be voluntary.</p> <b>*Samuel A. Weiss, Ph.D. </b><span>Dr. Samuel A. Weiss can be contacted at 7 Park Avenue, Suite 66, New York, New York 10016; tel. 212-686-8324.<br /><br /><br /></span> Page Number(s) 55 - 56 Year 1986 Volume 10 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 Rehabilitation: Goals or Shoals? Creator An entity primarily responsible for making the resource Samuel A. Weiss, Ph.D. * https://staging.drfop.org/files/original/d49da90fa9f0c0ee8147b96e291908d3.pdf 7f08e42eea8bbbd23d3d4d6b91d0a0d2 https://staging.drfop.org/files/original/943afc173437b395a3f94b4ff2659a5e.jpg aa7edcef18db620b1fa2f490e5abf250 https://staging.drfop.org/files/original/e5efcf538172dab88f36c526b06a5f91.jpg aba531f72f2e4837c3a0a0b0996a73b8 https://staging.drfop.org/files/original/4ccde9a701dd6d5771ce107d46ac1bc2.jpg 5982b814b207265768b8e8750f90685f https://staging.drfop.org/files/original/aa05931a1d684780719bffdfc3498e7a.jpg b880cef406760c7ee2e1a038abc28149 https://staging.drfop.org/files/original/421de63be1138b2062533ad526050cd9.jpg 88152a35fb9192cc5d5b0a5e982bf642 https://staging.drfop.org/files/original/f4ec3d7373a8b0783fac25fe09b090b3.jpg 3f7eebb64f66e1965cf88142303178ed https://staging.drfop.org/files/original/f65c0df2d21adfa0a03a47a88fbf4c89.jpg d1a7c7c76a17d4b01701aa2a3b301a19 https://staging.drfop.org/files/original/4d3edf70ddb64346ebd926f557b44423.jpg df371f26240fe9a9af112a646a920e90 https://staging.drfop.org/files/original/130be2ed482165f3c83e4db139d76775.jpg 1e67cc03d90ff9c36c754e076e4cf71d https://staging.drfop.org/files/original/7559e1b4fd16d73a7c5698a4499dd5a7.jpg 225d1d21859fd91c9ebad5bc7191a4ed https://staging.drfop.org/files/original/08cd8d811779f982414986d31a527e19.jpg d3771dbd56799b33182af35d1c92d2ae https://staging.drfop.org/files/original/0939223082872fe05d76f44303b19cca.jpg 93a3a96df839aeb10aef4f65b4baf868 https://staging.drfop.org/files/original/df210d8c1bc8a0526c3cc9c380a65f3b.jpg ab58e114ecbeb9a449d2ccc395937275 https://staging.drfop.org/files/original/95e5e807e78ed5211798f516f1166caa.jpg 788a7ede4aa0a25137bd4a58b820245d https://staging.drfop.org/files/original/a0b47ea6e200a0bd2d2c28ae25937015.jpg 866795b24cb4c9e1f5970dc549e5e4dc Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_033.pdf Text Any textual data included in the document <h2>Removable Rigid Dressing for Below-knee Amputees</h2> <h5>Yeongchi Wu, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Harold Krick, CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Background</h3> <p>According to the National Center For Health Statistics, there were 274,000 patients with amputations of major limbs in 1971 in the United States. This number rose to 358,000 in 1977. Kay in 1975 reported 53.8 percent of the 6,000 reviewed new patients had had amputations at the below-knee level.<a></a> If the percentage and the number of amputees remained unchanged, there would be at least 200,000 below-knee amputees in this country at any given time. It is possible that this number could have been doubled in the past ten years. The most recent information regarding amputation available to the authors was the Vital and Health Statistics published by the U.S. Department of Health and Human Services in April, 1986. A review of 192,000 medical records from the 407 hospitals that participated in the 1984 National Hospital Discharge Survey showed an estimated 32,000 below-knee amputations alone. Therefore, improvement in the management of below-knee amputees will certainly benefit a significant number of patients.</p> <p>At the V.A. Lakeside Medical Center (VALMC) and Rehabilitation Institute of Chicago (R.I.C.), members of Northwestern University-McGraw Medical Center, Chicago, three techniques have been developed for treatment of below-knee amputees. These include the Removal Rigid Dressing (R.R.D.), Scotch-cast™ preparatory prosthesis, and the "one-step socket lamination definitive prosthesis." These approaches have been invaluable in the management of below-knee amputees.</p> <p>This paper describes the Removal Rigid Dressing for postoperative management of the below-knee amputee. Clinical experiences since 1977 have shown the benefits of the R.R.D. to be the following:</p> <ol> <li> <p>Rapid residual limb shrinkage</p> </li> <li> <p>Prevention of edema</p> </li> <li> <p>Possibility of frequent residual limb observations</p> </li> <li> <p>Soft tissue immobilization to facilitate wound healing</p> </li> <li> <p>Elimination of skin breakdown commonly seen in elastic bandaging</p> </li> <li> <p>Simplicity of donning and doffing</p> </li> <li> <p>Development of tolerance to weight bearing</p> </li> <li> <p>Prevention of residual limb trauma</p> </li> <li> <p>Reduction of wound pain</p> </li> </ol> <p>With nine years clinical experience at this university medical center and dissemination through the Northwestern University Prosthetic School, it appears to us that this technique has its merits in the postoperative and pre-pros-thetic management of the below-knee amputee.</p> <p>In a study done in 1977, the average hospital stay for amputees at VALMC was reduced by 90 days after the development of the R.R.D.<a></a> This was achieved primarily by complete elimination of skin breakdown seen previously from elastic bandaging and by speeding stump shrinkage with the R.R.D.<a></a></p> <p>In the 1970s, at the VALMC in Chicago, there were many problems in postoperative below-knee residual limb care. For many years, the below-knee amputees were managed with a soft dressing or thigh high cast, i.e. Immediate Post-Surgical Fitting (IPSF) without pylon, followed by elastic bandaging, as many hospitals did at that time. The technique was done by the therapists, nurses, and patients, following the procedure learned directly or indirectly from the Northwestern University Prosthetic/Orthotic School. There was no special team or particular therapists assigned to amputee care. Inevitably, many techniques differing from the original were used by different individuals. For a long time, the staff was puzzled by the very high frequency of skin breakdown and distal edema (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg"><b>Fig. 1</b></a>). At times, it was a surprise at the V.A. Prosthetic Clinic when a patient presented who was free of any residual limb complications.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg"><strong>Figure 1. A typical pressure sore over the tibial tubercle and distal edema from conventional elastic bandaging.</strong></a><br /> <p>It was apparent that inconsistent limb care techniques by the staff and the patient himself was a contributing factor (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg"><b>Fig. 2</b></a>). Many thoughts came to mind and many attempts were made to remedy this problem, such as using a protective covering made of thermoplastic or a donut shaped sponge over the tibial tubercle to prevent skin breakdown. Nothing was promising until one afternoon in early 1977 when the idea of the R.R.D. came to light.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg"><strong>Figure 2. A conventional elastic bandage is an unreliable technique in a patient's hand.</strong></a><br /> <p>This happened after seeing a 90 year old man develop a tibial pressure sore on his well healed limb only three hours following the change from a thigh high plaster cast to an elastic bandage. We decided that the elastic bandage was guilty and should never be used for below-knee amputees again, and the thigh high cast could be modified to continue the excellent results. We analyzed the principles behind the thigh high plaster cast and incorporated them into the R.R.D. system.</p> <p>The design was completed on the same day and the same principles have been kept until this date without any further modifications. This system is a below-knee plaster cast suspended by a stockinette to a supracondylar suspension cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg"><b>Fig. 7</b></a> (a, b, c) and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg"><b>Fig. 7</b></a> (d, e, f)). Underneath the below-knee plaster cast, sport tube socks are added to provide-continuous controlled compression.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg"><strong>Figure 7 d, e, and f. Application of the Removable Rigid Dressing: d) the supracondylar cuff, e) pull the stockinette, and f) fold the suspension stockinette to make sure the cast is secured over the supracondylar cuff.</strong></a><br /> <h3>Why Does R.R.D. Work?</h3> <p>No matter how successful this method has been, we certainly were inspired by the important pioneer work by Dr. Weiss in Poland, and later by Dr. Burgess<a></a> in this country. A few of the principles that made the R.R.D. an effective procedure were originally utilized in the IPSF system:</p> <ol> <li> <p>Use of a non-expandable dressing prevents the development of edema following amputation.</p> </li> <li> <p>Use of supracondylar suspension keeps the cast in place.</p> </li> <li> <p>Rigid dressing is effective in immobilization of soft tissue, which is essential for wound healing and pain control as well as trauma prevention.</p> </li> <li> <p>Controlled compression of the residual limb avoids skin breakdown and facilitates shrinkage.</p> </li> </ol> <h3>Fabricating The R.R.D.</h3> <p>The R.R.D. consists of four components: a) tube socks, b) below knee plaster cast, c) suspension stockinette, and d) supracondylar cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><strong>Figure 3. Components of the Removable Rigid Dressing: a) athletic tube socks with the elastic band removed, b) below-the-knee cast, c) suspension stockinette, and d) thermoplastic supracondylar suspension cuff.</strong></a><br /> <p><i>Tube Socks</i></p> <p>The idea of using tube socks arose because of the difficulty in obtaining wool socks from the V.A. supply center in early 1977 and the necessity of hand care of wool socks. By replacing the elastic bandaging with R.R.D., we noted that below-knee residual limbs changed from their previous conical shapes to cylindrical contours. The measurements of properly fitted wool socks for our patients differed from those supplied by the V.A. supply center. For a while there was a shortage of socks for our patients. This led to the need for alternatives. One day, we tried a large size tube sock on sale at the V.A. canteen store.</p> <p>To this date, we still use tube socks routinely at the V.A. hospital and R.I.C. They can be changed daily by the patient and are machine washable. They also provide excellent sock marks on the skin for determining the degree of pressure over the residual limb. They are cheaper and available at most department stores (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b><strong>A</strong></a>). We simply cut off the elastic tops and use them as nice fitting #2 size, 2 ply socks.</p> <p>Tube socks are cut in long and short lengths. Short tube socks are effective for localized compression with a bulbous limb so that progressively diminishing shrinkage can be achieved from the distal to proximal area.</p> <p>For the large residual limb, when the tube socks may not be long or wide enough, Soft-socks (Knit-Rite, Inc.) can be used.</p> <p><i>Plaster Cast</i></p> <p>The cast for a R.R.D. (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b><strong>B</strong></a>) is shorter than that of the IPSF. It extends only up to the knee level for easy removal. The casting procedure also differs slightly for pressure relief. In the IPSF, felt paddings are used to bridge the bony areas. In the R.R.D., cotton paddings, six layers at the center and tapered to the margins, are used as "spacers" over the bony prominences of the tibial tubercle, tibial crest, fibular head and any pressure sensitive areas. Once the cast is made, the spacers are discarded. An empty space between the cast and the skin is formed to provide a controlled pressure relief (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg"><strong>Figure 4. Cotton paddings are used as spacer for pressure relief.</strong></a><br /> <p>The trim line of the plaster cast is up to mid-patellar level anteriorly and lower posteriorly to allow knee flexion. It is wider proximally in order to ensure easy removal and reapplication of the cast. This is especially true with a bulbous limb where the concave side needs additional padding to avoid a cast that is too tight at the top (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg"><b>Fig. 5</b></a>). In case of a narrow proximal opening, a longitudinal cut on the back of the cast can be used to widen the proximal part and allow reapplication (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg"><strong>Figure 5. Adequate medial padding is needed to assure a wider proximal opening for easier cast re-application (a). A narrow opening makes cast reapplication impossible (b).</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg"><strong>Figure 6. If cast opening is too narrow, a longitudinal cut on the back of cast allows widening of the cast proximally while still maintaining distal compression.</strong></a><br /> <p><i>Suspension Stockinette</i></p> <p>The suspension stockinette, made of 4-inch casting stockinette with one end tied, secures the cast to the suspension cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b><strong>C</strong></a>).</p> <p><i>Supracondylar Suspension Cuff</i></p> <p>The suspension cuff is made of thermoplastic material. It has a Velcro® closure to keep the cuff in place and a strip of Velcro® hook along the upper edge to secure the suspension stockinette (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3D</b></a>). For the obese patient who has very limited purchase over the femoral condyles because of tissue bulk, a fork strap with a waist belt can be used.</p> <h3>Application Of The Removable Rigid Dressing</h3> <p>After the surgical wound is properly dressed, the proper number of tube socks are applied layer by layer to avoid possible wrinkles. Then the plaster cast is applied and followed by the suspension stockinette and the supracondylar cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg"><b>Fig. 7</b> (a, b, c)</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg"><b>Fig. 7</b> (d, e, f)</a>). To make the application easier, a semi-circular mark is made on the cast and another on the supracondylar cuff so that the patient can match both marks to form a circle over the patella.</p> <h3>When To Apply The R.R.D.</h3> <p>The R.R.D. can be applied at the completion of surgery or when the first thigh-high rigid dressing is removed for wound inspection. It can be used whenever there is a need for limb shrinkage in any new or old amputee.</p> <h3>Adding Socks</h3> <p>When possible, additional socks are applied to maintain a comfortable snug fit and to facilitate progressive shrinkage. Sometimes short socks distally are preferred to provide localized distal compression without building up the thickness proximally (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg"><strong>Figure 9. Short tube socks provide localized compression in bulbous stump.</strong></a><br /> <h3>Weight Bearing Exercise</h3> <p>It is not possible to say how many days after amputation one can start weight bearing. In general, initiation of weight bearing exercise is determined by the state of wound healing, usually seven to 14 days after surgery. Immediate postoperative weight bearing is likely to cause mechanical shearing from movement and delay wound healing during the first two weeks after amputation, as reported by Mooney.4 However, steady pressure without mechanical shearing on the residual limb using a wheelchair strap can be very beneficial (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg"><b>Fig. 8</b></a>). We have found this can be used even within the first week after surgery. While in the wheelchair, the patient is encouraged to push frequently with the R.R.D. against resistance of the strap.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg"><strong>Figure 8. A strap is attached to the arm rests for the patient to exert partial weight bearing exercise while in the wheelchair (left). A car jack mounted onto plywood becomes an inexpensive adjustable stool for weight bearing and balance exercise (right).</strong></a><br /> <p>Because it is removable, one can decide the time to start body weight bearing exercise based on the wound condition. The R.R.D. allows observation of the limb after each graded weight bearing exercise. By doing so, one can plan both the amount and duration of the next weight exercise.</p> <p>For unilateral amputees, the weight bearing exercise can be done by standing on a padded car jack (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg"><b>Fig. 8</b></a>).</p> <p>For bilateral amputees, the tilt-table is used for weight bearing. The degree of weight stress is controlled by the inclination of the tilt table and the duration of standing. This proceeds progressively to the upright position and is followed by ambulation with walking heels attached to the casts (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg"><b>Fig. 10</b></a>). Walking with Rigid Dressings helps bilateral amputees develop balance and sometimes is preferred by the obese and cardiac patients at home (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg"><b>Fig. 10</b></a>). Walking with the R.R.D. also assists the evaluation of questionable candidates for prosthetic fitting. Ambulatory use of the R.R.D. produces simulation of prosthetic stress, allowing the amputee to quickly adapt to the actual prosthesis, an impossible step when using the conventional elastic bandaging method.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg"><strong>Figure 10. A) For bilateral amputees, weight bearing exercise is done on the tilt table. B) The stump is examined to modify the amount of weight bearing, i.e. the degree of inclination and duration of weight bearing. C) Weight bearing continues to the upright position in the parallel bars, and D) eventually to ambulation with walking heels attached to the casts or with a preparatory prosthetic fitting.</strong></a><br /> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg"><b>Fig. 11</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg"><b>Fig. 12</b></a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg"><strong>Figure 11. A stump with bony prominence and scars cannot tolerate the elastic bandage, but has no difficulty with Removable Rigid Dressing.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg"><strong>Figure 12. A one handed patient, either due to hemiplegia or upper limb amputation, can use the system easily.</strong></a><br /> <h3>Making A New Cast</h3> <p>The below-knee cast is changed whenever the residual limb has shrunk to the point at which too many tube socks are being used, usually about 10-14 ply of socks. The total number of casts needed depends on the speed of progressive shrinkage. Frequently three or four casts are required before the patient is ready to be fitted for a preparatory prosthesis.</p> <h3>R.R.D. Compared To IPSF</h3> <p>Both the R.R.D. and the thigh high rigid dressing provide immobilization of soft tissue, prevention of trauma, and prevention of edema. However, being removable, the R.R.D. allows frequent limb observation without a need for cast-cutting and cast-reapplication as needed in a thigh high rigid dressing. More importantly, it permits frequent addition of tube socks for fast shrinkage.</p> <p>Because space is provided between bony prominences and the plaster, adding tube socks will produce compression force to soft tissues, but will not cause pressure sores (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg"><b>Fig. 4</b></a>). If there is excessive pressure over an area, the cast can be softened from outside with a hammer, then pushed from inside for relief.</p> <p>Being removable, the R.R.D. has been very useful in monitoring the limb's response to weight bearing exercise. This facilitates progressive weight bearing within the safe tolerance range. Both undesirable skin breakdown from excessive weight bearing activity and hesitation in application of early graded weight bearing stress are minimized.</p> <h3>R.R.D. Compared To The Shrinker</h3> <p>The residual limb shrinker is an effective method for shrinkage, except for the danger of excessive pressure over bony areas or thin grafted skin. It does not protect the limb from unexpected falling, nor does it allow weight bearing exercise. The compression force can be adjusted by sewing the shrinker periodically rather than by adding socks as with the R.R.D.</p> <h3>R.R.D. Compared To The Elastic Bandage</h3> <p>The elastic bandage is not only difficult to apply for the staff and the elderly below-knee amputees,<a></a> but also is so unreliable that it frequently causes skin breakdown and distal edema (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg"><b>Fig. 2</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b></a>). It cannot protect the limb from trauma due to accidental falling. With the R.R.D., it is much easier for the patient to don and doff as well as adjust the compression, accommodate progressive shrinkage,<a></a> and perform weight bearing exercise.</p> <p>Since the adoption of the R.R.D. at this medical center, the problems of skin breakdown and distal edema, commonly seen in the past from elastic bandaging, have been completely eliminated (<b>Fig. 13</b>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-14.jpg"><strong>Figure 13. One of the first patients achieved 15-ply shrinkage in 7 days and spontaneous healing of the right pretibial sore caused by an elastic bandage.</strong></a><br /> <h3>R.R.D. For Delayed Wound Healing</h3> <p>Delayed wound healing is not a contraindication for using the R.R.D. or a preparatory prosthesis. The R.R.D. is a useful means to facilitate wound healing, because the system reduces edema and tissue tension. The size of the open wound can be reduced and the edges of the wound can be brought closer together. With frequent debridement of the necrotic tissue and adding socks for shrinkage, often a big open wound can be healed without surgery (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg"><b>Fig. 14</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg">Figure 14. Removable Rigid Dressing facilitated shrinkage of the limb (upper left) and the open wound. By frequent debridement and prosthetic fitting (upper right), the wound completely healed without skin graft (lower left).</a><br /></strong><br /> <h3>Scotchcast™ Preparatory Prosthesis</h3> <p>When the patient is able to tolerate full weight bearing in the R.R.D. and the residual limb is no longer bulbous, a Scotchcast™ preparatory prosthesis can be fit for early gait training and further shrinkage.<a></a> The advantages of the Scotchcast™ preparatory prosthesis are its moderately light weight, comfortable fitting, rare need for realignment, and reduction of fabricating time. This is achieved by, 1) direct formation of the socket on the residual limb with special pressure relief techniques, 2) use of a wool sock lining as the soft interface, and 3) precise semi-dynamic alignment of the prosthesis. Since the Scotchcast™ prosthesis can be fabricated within 1 1/2 hours during the patient's initial visit, the delivery of this prosthetic service is very efficient and cost effective.</p> <h3>Conclusion</h3> <p>The Removable Rigid Dressing has proved to be a very reliable means of preprosthetic management of the below knee amputee at this institution and others for the past nine years. It has proven to shorten the time from amputation to the initial preparatory prosthesis; is shown to be equal to or superior to all other means of preprosthetic stump management; features easy application; simple donning and doffing by the patient; progressive stump shrinkage by adding socks under the cast; gives protection through its rigidity for the not yet healed stump; ease in wound inspection; and allows early weight or pressure bearing to be started, thus conditioning the soft tissues for the first prosthesis. The R.R.D. has no contraindications other than application to a residual limb with a deep wound infection that requires surgical intervention.</p> <h3>Acknowledgments</h3> <p>The authors wish to express their appreciation to Henry B. Betts, M.D., Robert Keagy, M.D., Nasim Rana, M.D. and Dudley Childress, Ph.D., for their support in the development and demonstration of this technique.</p> <p><b>References:</b></p> <ol> <li>Burgess, E.M. and Romano, R.L., "The Management of Lower Extremity Amputees Using Immediate Postsurgical Prostheses," <i>Clin. Orthop.</i>, 57, 1968, pp. 137-146.</li> <li>Burgess, E.M., Romano, R.L., and Zettl, J.H., "The Management of Lower Extremity Amputations," <i>Technical Report TR10-6</i>, Prosthetic and Sensory Aids Service, Departments of Medicine and Surgery, Veterans Administration, Washington, D.C., 1969.</li> <li>Kay, H.W. and Newman, J.D., "Relative Incidence of New Amputations: Statistical Comparisons of 6,000 New Amputations," <i>Orthotics and Prosthetics</i>, Vol. 29, No. 3, 1975.</li> <li>Mooney, V., Harvey, J.P., Jr., Mcbride, E., and Snelson, R., "Comparison of Postoperative Stump Management: Plaster vs. Soft Dressings," <i>Journal of Bone and Joint Surgery</i>, 53-A, March, 1971, pp. 241-249.</li> <li>Mueller, M.J., "Comparison of Removable Rigid Dressing and Elastic Bandages in Preprosthetic Management of Patients with Below-knee Amputations," <i>Physical Therapy</i>, 62, 1982, pp. 1438-1441.</li> <li>Wu, Y. and Flanigan, D.P., "Rehabilitation of the Lower-Extremity Amputee with Emphasis on a Removable Below-Knee Rigid Dressing," pp. 435-453, and "Gangrene and Severe Ischemia of the Lower Extremities," edited by John J. Bergan, M.D. and S.T. James Yao, M.D., Grune and Stratton, New York, 1978.</li> <li>Wu, Y., Keagy, R.D., Krick, H.J., Stratigos, J.S., and Betts, H.B., "An Innovative Removable Rigid Dressing Technique for Below-the knee Amputation," <i>Journal of Bone Joint Surgery</i>, 61A, 1979, pp. 724-729.</li> <li>Wu, Y., Brncick, M.D., Krick, H.J., Putnam, T.D., and Stratigos, J.S., "Scotchcast™ P.V.C. Interim Prosthesis for Below-knee Amputees," <i>Bulletin of Prosthetics Research</i>, BPR 10-36, Fall, 1981.</li> <li>Parhad, A., Gervis, B., and Wu, Y., "From The Clinic: The Rigid Dressing; Pre-prosthetic Ambulation for the Below-knee Amputee, A<i>mer. Corr. Ther. J.</i>, 37, 1983, pp. 66-89.</li> <li>Gervis, B., Parhad, A., and Wu, Y., "From The Clinic: Fabrication of the Removable Rigid Dressing and Supracondylar Cuff for the Below-knee Amputee," <i>Amer. Corr. Ther. J.</i>, 35, 1982, pp. 126-133.</li> <li>Wu, Y., Krick, H.J., and Sankey, J.A., "Postoperative and Prosthetic Management of Below-knee Amputee with Removable Rigid Dressing and Scotchcast™ Preparatory Prosthesis." <i>Proceedings of 8th annual Conference of Rehabilitation Engineering Society of North America</i>, 1985, pp. 370-372.</li> </ol> <b>Harold Krick, CP. </b> Rehabilitation Institute of Chicago, 345 E. Superior Avenue, Chicago, Illinois 60611.<br /><br /><b>Yeongchi Wu, M.D. </b> Rehabilitation Institute of Chicago, 345 E. Superior Avenue, Chicago, Illinois 60611.<br /> <div style="width: 400px;"></div> Page Number(s) 33 - 44 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg Figure 7 FIGURE 7 (a,b,c) http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg FIGURE 7 (d,e,f) http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource Removable Rigid Dressing for Below-knee Amputees Creator An entity primarily responsible for making the resource Yeongchi Wu, M.D. * Harold Krick, CP. * https://staging.drfop.org/files/original/f19a203dc83608d15f834f83cded733e.pdf 6d2e37d1ab4e9eb40057c0b1eda9787a https://staging.drfop.org/files/original/626bec40f3c1712a163754c6407d8b7f.jpg 0889da54c981b532c0f7f9fca7ab7393 https://staging.drfop.org/files/original/4d23e4efd15dbd56d0d3c0d64d42a12c.jpg 235bf482c5bbd2d6df9a57a8e062d9f8 https://staging.drfop.org/files/original/84c1981f28fb0bd2b78a57f08cd3370e.jpg 29185ddb7cfae11354a16dd183354883 https://staging.drfop.org/files/original/be68f5014bf3e41306651775bb6aaa72.jpg 8728c5cf6a697fb1e11581b23e406435 https://staging.drfop.org/files/original/d47a2e29fc5ef0a8ed843d1a7dda7878.jpg db1eff3b83d2b60637bad4ef7307fada https://staging.drfop.org/files/original/5acc660a9991a044a33f6cdb80803607.jpg 3728771041c94d3d1d9b937fd099d600 https://staging.drfop.org/files/original/1f702da7b89a464c498010a1abcc516c.jpg 3dfc6a240ebdc1b4f044c9d2a70f29fc https://staging.drfop.org/files/original/350e92414c3f250e585c0c410483f05f.jpg e5cc9412d004ff923fa9cfe0116c8d67 https://staging.drfop.org/files/original/e0c8a2a383af1b8f73d88ad5a6e19878.jpg d135ed31bad70f44ed05da85fa80e938 https://staging.drfop.org/files/original/3d5ad29d6d20a80babbcb352572dc9c3.jpg 3dd7c369b1d5402e8bec9a1a13200601 https://staging.drfop.org/files/original/23e38cbe718dfe3bb7d85f6ed388efd9.jpg cfcb75970fefc5d722cd18ebb13f14af https://staging.drfop.org/files/original/83d73db1e1c4c310e0f458551ea5dbe8.jpg 41dc790f623b91b39085ce3145a0c1c4 https://staging.drfop.org/files/original/cbdfe4b7b4f81d816508d5add65aa3ed.jpg 6bd1b183c2bb185fdd17b2df9045e440 https://staging.drfop.org/files/original/0f06eae8e85a93d7810db6e5d53ec00d.jpg c2853522e2b04d169b43a87fb15b85e2 https://staging.drfop.org/files/original/a974bfac3181ff32c7452e179378f236.jpg 75455b1a6dc267f36a971693a75beeba Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_081.pdf Text Any textual data included in the document <h2>Report From: International Workshop on Above-Knee Fitting and Alignment Techniques</h2> <h5>C. Michael Schuch, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>An "International Workshop on Above-Knee Fitting and Alignment Techniques" was held in Miami, Florida, May 15-19, 1987. Conceived and organized by A. Bennett Wilson, Jr. and Melvin L. Stills, CO., the workshop was supported and sponsored jointly by the International Society for Prosthetics and Orthotics and the Rehabilitation Research and Development Service of the Veteran's Administration. Hosting the workshop was the Prosthetics and Orthotics Education Program of the School of Health Sciences, Florida International University, and more specifically, Dr. Reba Anderson, Dean of Health Sciences and Ron Spiers, Director of Prosthetic Orthotic Education. Approximately 50 invited professionals attended the workshop, representing the United States, England, Scotland, Denmark, Sweden, Israel, the Netherlands, and Germany. Invited professionals included physicians, engineers, educators, and researchers, as well as prosthetic practitioners, all known to be active in the field of prosthetics.</p> <p>The intent of the workshop was an organized sharing and discussion of information and experiences relative to the management of above-knee amputees. Above-knee socket design variables, specifically the accepted and established quadrilateral design and the newer ischial-con-tainment designs known by various acronyms (CAT-CAM, NSNA, Narrow M-L), were discussed in great detail. Goals were to determine differences/similarities, advantages/disadvan-tages, indications/contraindications, as well as to develop recommendations for future action with respect to the various socket designs. While many prosthetists and/or clinics may have considerable experience with the newer above-knee socket designs within the United States, it is true that there are still many questions and concerns on the part of consumers, prescribing physicians, third party paying agencies, and educators in the U.S., as well as a great curiosity on the part of our international colleagues abroad.</p> <p>After introductory remarks from Dr. Anderson, Dean of Health Sciences at Florida International University, Mr. John Hughes, President of ISPO, and Dr. Margaret Gianninni, Director of the Rehabilitation Research and Development Service of the Veteran's Administration, the program began with a presentation by A. Bennett Wilson entitled, "Recent Brief History of AK Fitting and Alignment Techniques." This paper began with the advent of the suction socket in the U.S. shortly after World War II and proceeded with the development of the total contact quadrilateral socket in the early 1960's. The audience was reminded that the total-contact quadrilateral socket, with or without suction suspension, was the socket design of choice from 1964 until very recently, when ischial-containment socket designs emerged. It was noted that, at present, the three senior prosthetic education programs in the U.S. (UCLA, Northwestern University, and New York University), in addition to teaching the application of the standard total contact quadrilateral socket, are offering special courses in what at first glance appear to be radical departures from the quadrilateral design. The technique at UCLA is known as CAT-CAM (Contoured Adducted Trochanteric-Con-trolled Alignment Method), based on work by John Sabolich, C.P.O., and inspired by Ivan A. Long, CP. The technique being presented at Northwestern University is said to be based more directly on the Ivan Long technique and is known as NSNA (Normal Shape-Normal Alignment). The technique taught at New York University is usually referred to as the narrow ML socket design based on a special tool designed by Daniel Shamp to facilitate casting. Mr. Wilson concluded his remarks by saying "unfortunately, none of these techniques has been subjected to an evaluation program independent of the development group, and a great deal of confusion exists among clinicians responsible for amputee care. I hope that this workshop can be helpful in clearing away some of the confusion, and point the way for action that will bring order to the present day practice of above-knee prosthetics."</p> <p>The next speaker on the agenda was Charles Radcliffe, Professor of Mechanical Engineering at the University of California, Berkeley. Professor Radcliff's presentation was entitled, "Review of UCB Quadrilateral Socket and Alignment Theory." Having been a member of the Prosthetic Devices Research Project of UC Berkeley in the 50's and 60's, Professor Rad-cliff is still a strong proponent of the quadrilateral socket. He presented a detailed review of the history and development of the quadrilateral socket and summarized this section of his presentation with the following comments. "The net result of all of this work in the 1950-1963 period was a better understanding of the complex interrelationships between the functional capability of the amputee, the rehabilitation goals, the prosthetic components required in the prescription, the gait of the amputee, the biomechanical forces generated, the socket shape, and the alignment. The socket was no longer described as a cross-section shape at the ischial level, but rather a three-dimensional receptacle for the stump with contours at every level which could be justified on a sound biomechanical basis. ... It should be emphasized again that the quadrilateral type of fitting is not just a socket, it is a complete system which includes the amputee as a most important component. The socket is the interface between stump and prosthesis, and its primary functions are to provide for weight-bearing in the stance phase, allow the use of the stump and hip musculature to control motion and posture of the upper body in the stance phase (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg"><b>Fig. 1</b></a>), and to provide for control of the prosthesis in the swing phase of walking."</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg"><strong>Figure 1. Biomechanical forces diagram, Above-knee amputee weight-bearing in the stance phase.</strong></a><br /> <p>The next section of Professor Radcliffe's presentation focused on biomechanical and alignment principles of a prosthesis with a quadrilateral socket. Here he related his feelings that many of the biomechanically related claims made by proponents of the newer non-quadrilateral socket designs are equally attainable in the quadrilateral socket if the original biomechanical principles are followed. "Regardless of the fitting method employed, the socket for any patient must provide the same overall functional characteristics, including comfortable weight-bearing, a narrow base gait, and as normal a swing phase as possible consistent with the residual function available to the amputee after amputation. It is possible to provide this with a quadrilateral socket and it is being done routinely in many facilities." Professor Radcliffe went on to say, "In most of the recent articles that I have read, statements have been made which indicate clearly that the author is comparing very poorly fitted quadrilateral sockets to the results obtained using the new technique. They show diagrams of typical fittings and gait deviations which can only be described as a complete list of horror stories describing what not to do in fitting a quadrilateral socket. Any prosthesis with the problems listed in these articles should never have been delivered. If the average pros-thetist in the United States is having the problems described by Long, Shamp, and Sabolich, then I must suggest that something is wrong with the methods being taught and used in daily practice. I am aware that the schools have made significant changes in the way that the principles are taught, with each school emphasizing different aspects of the problem. I suspect that there may have been a shift away from the fundamentals of teaching of overall objectives, including the interrelationships of amputee evaluation, components prescribed, biomechanics, and why sockets are fitted with particular contours."</p> <p>Following Professor Radcliffe was Tim Staats, Director of the UCLA Prosthetics Education Program. Mr. Staats' presentation was on the "UCLA CAT-CAM." UCLA began teaching CAT-CAM above-knee prosthetics with a pilot course in March 1985, which included both John Sabolich and Tom Guth as course instructors. Mr. Staats made it clear that the UCLA CAT-CAM philosophy of 1987 has departed from that of Sabolich, Guth, et al. and that the UCLA philosophy has now evolved to the point where a third edition of a teaching manual was published in March, 1987. To quote Mr. Staats as he spoke about this new manual, "the third edition of the UCLA CAT-CAM Above-Knee Prosthesis teaching manual integrates much additional material, covering the anatomy/socket relationship and how this is best achieved—material not yet fully understood and synthesized at the time of preparation of the previous edition. The UCLA CAT-CAM above-knee socket is a variation of the CAT-CAM design developed by John Sabolich, C.P.O., and Tom Guth, CP., and the NSNA AK prosthesis of Ivan Long, CP. Through countless hours of literature search, discussion, and intensive training given in this and nine foreign countries, and through the results of over 200 students who have fabricated and fit over 1,000 sockets under the guidance of our staff, a new insight has been developed. Our staff has refined the techniques of measurement, casting, and model modification to the point where it is a clearly teachable and viable above-knee fitting method. It is with great respect that we continue to recognize the published contributions of John Sabolich, C.P.O., Tom Guth, CP., and Ivan Long, CP., to the development and evolution of the UCLA technique. We would hope that this manual captures, blends, and enhances their philosophies. We recognize that our technique and CAT-CAM evolved from NSNA and we hope that these professionals can appreciate our efforts to refine and further evolve their clinical approach into a methodical step-by-step teaching manual."</p> <p>At this point I will briefly review the highlights of the UCLA CAT-CAM sequence, beginning with patient evaluation and measurement and proceeding through model modification and bench alignment. For the details, I suggest referencing the third edition of the UCLA manual.</p> <p>The recommended evaluation/measurement protocol is very complete and detailed, covering many of the procedures with which we should all be familiar. Adduction and flexion analysis of the residual limb are emphasized. Some new measurements and/or evaluations are introduced and illustrated:</p> <ul> <li> <p>Skeletal ML dimension, actually measured on patient (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg"><b>Fig. 2</b></a>)</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg"><strong>Figure 2. UCLA CAT-CAM medial-lateral diameter measurements.</strong></a></li> <li> <p>Soft tissue ML dimension, taken from Ivan Long's chart of circumferences and related ML values (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg"><b>Fig. 2</b></a>)</p> </li> <li> <p>Ilio-femoral angle, actually measured on the patient (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg"><b>Fig. 3</b></a>)</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg"><strong>Figure 3. Ilio-femoral angle, as measured for UCLA CAT-CAM.</strong></a></li> <li> <p>Public arch angle, evaluated by palpation and captured in the wrap cast (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg"><b>Fig. 4</b></a>)</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg"><strong>Figure 4. The pubic arch angle, as evaluated for UCLA CAT-CAM.</strong></a></li> <li> <p>Ischial inclination, evaluated by palpation and captured in the wrap cast (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg"><b>Fig. 5</b></a>)</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg"><strong>Figure 5. The ischial inclination angle, as evaluated for UCLA CAT-CAM.</strong></a></li> </ul> <p>The wrap cast is taken with the patient in a standing position, and all shaping of the cast is accomplished by hand molding. The goal is good definition and containment of the medial and posterior aspects of the ischial tuberosity and ischial ramus within the wrap cast and subsequent socket, as well as allowance for the pubic ramus to exit the socket near the midline of the medial wall (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg"><strong>Figure 6. Medial view of pelvis-socket relationship, UCLA CAT-CAM.</strong></a><br /> <p>The initial trimlines for the resultant socket are as follows:</p> <ol> <li> <p>Anteriorly, just proximal to the inguinal crease. The anterolateral brim must clear the superior iliac spine when the patient is sitting.</p> </li> <li> <p>Laterally, the brim extends approximately 3" above the trochanter. The final height of this wall will be determined during fitting.</p> </li> <li> <p>Posteriorly, the trim line should begin at least 1" above the level of the inferior border of the ischial tuberosity. The curve that defines the posterior to lateral trim line normally begins at a point between the lateral third and the midline of the socket ML dimension at ischial level.</p> </li> <li> <p>The medial proximal brim will be "V" shaped, with the vortex of the "V" located at the point where the pubic ramus crosses the medial wall. This trim line projects upward from the vortex, posteriorly to encapsulate the medial aspect of the ischial ramus and tuberosity. (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg"><b>Fig. 6</b></a>) A circumference reduction chart is used to attain suction suspension. The values used in this chart are slightly less than those normally used in quadrilateral suction sockets.</p> </li> </ol> <p>For bench alignment, the following references are used:</p> <ol> <li> <p>Posteriorly, bisect the socket at the level of the soft tissue ML, this reference line should fall as a plumb line to the center of the heel.</p> </li> <li> <p>Laterally, bisect the socket AP dimension at ischial level, this reference line should fall as a plumb line between 0" and 1" anterior to the foot bolt.</p> </li> <li> <p>Socket is set in measured adduction, and measured flexion plus 5°.</p> </li> <li> <p>The distal aspect of the medial wall should be on the line of progression.</p> </li> <li> <p>The knee bolt is externally rotated 5°.</p> </li> <li> <p>The top of the foot, as well as the prosthetic shank should lean medially 4°, or alternatively, the socket is hyper-ad-ducted 4° beyond measured adduction with the foot parallel to the floor and the shank perpendicular to the floor.</p> </li> </ol> <p>The UCLA CAT-CAM can be fabricated using rigid socket or flexible socket techniques. If a flexible socket or brim system is desired, the proximal medial trimline in the ischial area must be more aggressive during casting to allow for the linear shrinkage factor known in most thermoplastics.</p> <p>A final comment: the manual reflects the accumulated experience of the UCLA staff and includes a section on problem solving the difficulties that might be experienced in the CAT-CAM socket.</p> <p>Next to speak was Gunther Gehl, CP., Director of Prosthetic Education at Northwestern University in Chicago. Northwestern has been teaching the NSNA AK techniques of Ivan Long for several years now, and it was Mr. Gehl's task to report to the workshop on NSNA and Long's Line. He said that he and his staff taught NSNA as presented by Ivan Long with no changes. Ivan has been fitting Long's Line, now known as NSNA, for more than 12 years, and his approach has been consistent, with few changes. Perhaps changing the name from Long's Line to NSNA in July, 1985 is the most significant change. Mr. Long has published three technical papers describing his technique: "Allowing Normal Adduction of the Femur in Above Knee Amputees," (<i>Orthotics and Prosthetics</i>, December, 1975); "Fabricating the Long's Line Above Knee Prosthesis," (1981); and as a reprint of the Long's Line article with new title, "Normal Shape-Normal Alignment (NSNA) Above Knee Prosthesis," (<i>Clinical Prosthetics and Orthotics</i>, Fall, 1985). These articles were the basis for Gunther Gehl's presentation to the International Workshop.</p> <p>I will attempt to review and highlight the NSNA philosophy as I did the UCLA CAT-CAM. Again, within the limitations of this report, this will only be an overview. With the widespread availability of Ivan's publications, it does not seem necessary to go into details.</p> <p>NSNA is less detailed regarding evaluation and measurements, placing great emphasis on the wrap cast, subsequent model modification, and alignment, all based on Long's Line, which is defined as a straight line, starting approximately at the center of a narrow socket, passing through the distal femur, and on down to the center of the heel (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-07.jpg"><b>Fig. 7</b></a>). Long's Line is not always vertical because it shifts constantly when the amputee goes from a standing position to a walking position.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-07.jpg"><strong>Figure 7. Long's Line.</strong></a><br /> <p>The wrap cast is taken with the patient in a standing position. The important points about the wrap cast procedure are identification of the ischium and proper alignment. The hand will be held to indicate the medial and posterior surface of the ischium, but not forward of the ischium. The amputee then adducts as tightly as possible and extends his thigh to tighten the hamstrings. At this point a lateral reference line is established.</p> <p>The resultant cast model is oversized and will require considerable modification. Practically all modification will take place on the lateral wall. Following is a brief description of modification goals and resultant trimlines, taken from Mr. Gehl's presentation and from Mr. Long's publications.</p> <ol> <li> <p>The lateral wall is to be shaped to give support over a wide area, and particularly the lateral-posterior aspect of the socket.</p> </li> <li> <p>The medial wall will be lower than seat level, and the wrap cast will be the guideline as to how low.</p> </li> <li> <p>Depth of the socket will be the same as the measured length of the thigh.</p> </li> <li> <p>The seat will be at a right angle to Long's Line.</p> </li> <li> <p>Long's Line is drawn from the center of the seat level ML to the center of the distal femur. The distal femur will be very close to the lateral surface, probably only covered by skin.</p> </li> <li> <p>The top 1" of the medial wall will flare outward at 45°.</p> </li> <li> <p>The lateral wall extends above the trochanter.</p> </li> <li> <p>The ischium will bear on the flare of the socket, both medially and posteriorly.</p> </li> <li> <p>The cast is taken down in the ML as though the trochanter does not exist. In order to achieve the desired ML, many casts will be reduced 2" or more. The desired ML dimension is taken from Ivan's chart of ML values related to the thigh circumference just below the ischium (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-08.jpg"><b>Fig. 8</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-08.jpg"><strong>Figure 8. Table of M-L values determined from circumference just below ischium, used in NSNA.</strong></a></li> </ol> <p>Circumference reductions for suction suspension begin at 1" of tension proximally, reducing to 3/4", then 1/2", with the remaining tensions at 1/4".</p> <p>Mr. Long does not advocate use of an alignment device. Bench alignment is critical and is based on Long's Line. The center of the lateral wall is marked at seat level for TKA and the vertical reference line established during casting should parallel the TKA line. Long's Line is marked on the posterior of the socket. For the male, the socket is mounted with the inner aspect of the medial wall (which follows the pubic ramus angle) in 30° internal rotation to the line of progression (the outer edge of the medial trimline is on the line of progression), and with the knee bolt axis 4° higher on the lateral side. This is the same as adding 4° additional adduction to Long's Line. For the female, the socket is mounted with the inner aspect of the medial wall in 40-45° internal rotation to the line of progression (again, the outer edge of the medial trimline is on the line of progression), and with the knee bolt axis 7° higher on the lateral side (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-09.jpg"><b>Fig. 9</b></a>). Mr. Long emphasizes that it is not necessary to change the alignment. When the amputee is allowed time to adjust to the new prosthesis, then alignment changes will not be necessary.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-09.jpg"><strong>Figure 9. NSNA socket shape and alignment diagram, male and female.</strong></a><br /> <p>Following Gunther Gehl was Daniel Shamp, C.P.O., presenting, "The Shamp Brim, For the Narrow ML Above-Knee Prosthetic Socket." Mr. Shamp's system of brim casting and evaluation is currently the content of a special short course offered by New York University's Prosthetic and Orthotic Education Program.</p> <p>Long and Sabolich, as well as UCLA, advocate that the hand casting technique is the most successful in their experience with the narrow ML, wide AP, or ischial-containment socket for above-knee amputees. In response, Mr. Shamp stated, "Experience with the Shamp Brim system has proven to make the procedure more uniformly successful and more easily learned and applied by the practitioner who has spent years working with the brim method for quadrilateral socket casting and modification." Mr. Shamp went on to present detailed biomechanical rationale for the narrow ML socket. Biomechanical descriptions such as bony lock on the ischium, ischial containment within the socket, retention of normal adduction, etc., are consistently relevant to Mr. Shamp's socket system, as well as all of the latest ischial-containment socket designs. Two noticeably different aspects of Mr. Shamp's technique are (1) the brim forming system itself, which allows for evaluation of brim design under weight bearing conditions before proceeding with the wrap cast, and (2) what Mr. Shamp refers to as centralization of the femur. To accomplish centralization of the femur, during the casting procedure, the prosthetist pulls the distal medial tissue in a lateral direction while stabilizing the femur with the other hand by means of a 45° force against the lateral shaft of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-10.jpg"><b>Fig. 10</b></a>). Mr. Shamp stated that this centralization procedure is essential to prevent a large medial-distal bulge with resultant cosmetic problems when the femur is maintained in a position of maximum adduction in the AK prosthesis.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-10.jpg"><strong>Figure 10. Centralization of the femur, as proposed by Dan Shamp for Narrow ML Socket.</strong></a><br /> <p>Again, I will present an overview of the Shamp Narrow ML technique, summarizing from Mr. Shamp's presentation and from the "Manual for use of The Shamp Brim," which was provided for the workshop attendees. This manual was produced by Prosthetic Consultants, Incorporated of Akron, Ohio in cooperation with the Department of Prosthetics and Orthotics, New York University Post-Graduate Medical School, and is published by the Ohio Willow Wood Company.</p> <p>The measurement and evaluation procedure includes a careful observation and recording of the characteristics, lengths, and circumferences requested on the Narrow ML AK Information Chart. Review of this information chart will show the practitioner who is familiar with the technique for the quadrilateral socket that only a small number of measurements are different for the Narrow ML socket. It is important to note that three ML measurements must be taken precisely as follows:</p> <ol> <li> <p>Distal Ischial Tuberosity (DIT): firm ML measurement of the anatomy taken 1" to 2" distal to the ischial tuberosity (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-11.jpg"><b>Fig. 11</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-11.jpg">Figure 11. Distal Ischial Tuberosity (DIT), medial-lateral diameter measurement for Narrow ML Socket</a>.</strong></li> <li> <p>Oblique ML (OB): firm ML measurement taken from the medial side of the ramus of the tuberosity to a point just superior to the greater trochanter of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-12.jpg"><b>Fig. 12</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-12.jpg"><strong>Figure 12. Oblique ML (OB), medial-lateral diameter measurement for Narrow ML Socket.</strong></a></li> <li> <p>Ischial Tuberosity ML (IT): firm ML measurement taken from the medial border of the ramus of the ischial tuberosity to the subtrochanteric area of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-13.jpg"><b>Fig. 13</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-13.jpg"><strong>Figure 13. Ischial Tuberosity ML (IT), medial-lateral diameter measurement for Narrow ML Socket.</strong></a></li> </ol> <p>The Shamp Brim, which is compatible with the Berkley brim stand, is now set up and adjusted to the patient's measurements. As stated earlier, the brim allows for weight-bearing evaluation of the patient with regard to socket design before the actual wrap cast is taken.</p> <p>As with all of the ischial-containment socket designs discussed at the Workshop, the location of the ischial tuberosity in the socket is essential to both a comfortable fit and a stable femur in maximum adduction. For the Shamp technique, the ideal location is 1/2" inside the medial-proximal wall of the prosthesis and indicates the area referred to as the IT ML measurement. The medial wall has a 45° angle that assists the wedge effect in stabilizing the femur and so the location of the tuberosity on this slope is important. The trimlines are similar to both NSNA and the UCLA CAT-CAM, including the low anterior wall with clearance for the ASIS, the relatively horizontal posterior wall, and the high lateral wall, which extends generously above the trochanter. Although, not as exaggerated as the UCLA CAT-CAM, the medial wall is lowered as it approaches the anterior wall, allowing for the pubic ramus to pass from within the socket.</p> <p>Alignment follows generally accepted quadrilateral alignment principles for TKA and knee bolt external rotation. For alignment in the frontal plane (posterior view, ML plane), Mr. Shamp advocates the principles of Long's Line.</p> <p>Dr. Hans Lehneis, C.P.O., of the Rusk Institute of Rehabilitation Medicine was the next speaker and his presentation covered work done at the Rusk Institute and the New York Veterans Administration. Dr. Lehneis and associates are investigating anatomical, physiological, and biomechanical characteristics of geriatric above-knee amputees in an attempt to develop a set of design criteria for geriatric above-knee sockets. As this project is still in the developmental stages, I will not elaborate on this subject.</p> <p>Following Dr. Lehneis was Ossür Kris-tinsson of Iceland. As the developer of the flexible socket-rigid frame system, he was the first to speak on flexible sockets. Mr. Kris-tinsson reported that he was continuing development of flexible sockets, including walls and brims. He is conducting an extensive materials search in hopes of finding the materials that will make possible the ultimate flexible socket design.</p> <p>Mr. Kristinsson went on to say that we need some simple definition of flexible socket characteristics. "To label a socket as flexible, I would say that you should be able to deform it by your hands, and the material should not be elastic enough to stretch under the loads it will be subjected to." Concerning flexible socket design, Mr. Kristinsson stated, "When designing a flexible socket system, the most critical aspect for the comfort of the wearer is how the frame is designed. It has to be capable of supporting the flexible socket, preventing permanent deformation, and the socket-frame combination has to be structurally strong and stable enough to counteract the reaction forces." Mr. Kristinsson made a final, important point: "There may be doubt among professionals and users about the value of the flexible wall. I am, however, totally convinced that the flexible socket is here to stay. If anything, I think it will get more flexible as we gain access to more suitable materials than we are using today, and some obstacles on the way to proper understanding of the socket-stump interaction are overcome."</p> <p>Continuing the flexible socket presentations was Norman Berger of New York University's Prosthetic Orthotic Program. Mr. Berger's presentation was the ISNY (Icelandic-Swedish-New York) flexible socket design as taught by NYU. Mr. Berger described the socket and frame fabrication technique used in the ISNY. Three interesting points are worthy of mention:</p> <ol> <li> <p>The flexible socket is fabricated with polyethylene, which has a known shrinkage factor.</p> </li> <li> <p>The desired wall thickness of the flexible socket is 60/1000".</p> </li> <li> <p>Lateral distal support for the femur is not provided for by the frame.</p> </li> </ol> <p>The final presentor on the topic of flexible sockets was Charles Pritham, C.P.O. of Durr Fillauer Medical Company. A co-author and co-developer of Durr-Fillauer's flexible socket technique, Mr. Pritham described the biomechanical function of the flexible walled ischial-gluteal bearing quadrilateral socket as follows:</p> <ol> <li> <p>Ischial/gluteal weight bearing;</p> </li> <li> <p>Stabilization of the distal femur laterally;</p> </li> <li> <p>Total contact; and</p> </li> <li> <p>Flexible walls.</p> </li> </ol> <p>Note the mention of stabilization of the distal femur laterally; this is provided for by the frame design of the Scandinavian Flexible Socket. Mr. Pritham went on to say, "It will be appreciated that the design is actually not fundamentally different, flexible walls aside, from a similarly designed socket in the rigid walls. Indeed one of the factors that undoubtedly hastened its acceptance was the fact that previously learned methods of casting and fitting quadrilateral sockets were fully acceptable when fitting a flexible walled socket. While the advantages cited are formulated with the quadrilateral socket in mind, there is no reason to suspect that they are significantly different from non-quadrilateral above-knee sockets. Indeed, flexibility is often considered by the designers of one another of the various designs as an integral factor in their success."</p> <p>Mr. Pritham listed advantages of flexible walled sockets as:</p> <ol> <li> <p>Flexible walls;</p> </li> <li> <p>Improved proprioception;</p> </li> <li> <p>Conventional fitting techniques;</p> </li> <li> <p>Minor volume changes readily accommodated;</p> </li> <li> <p>Temperature reduction; and</p> </li> <li> <p>Enhanced suspension.</p> </li> </ol> <p>Indications for use of the flexible wall socket are:</p> <ol> <li> <p>Mature stumps (where frequent socket changes are not anticipated);</p> </li> <li> <p>Medium to long stump (where a significant portion of the wall will be left exposed and flexible); and</p> </li> <li> <p>Suspension is not a factor.</p> </li> </ol> <p>While the use of flexible wall sockets has been well accepted, Mr. Pritham pointed out that questions have arisen in at least three areas.</p> <p><i>Material</i></p> <p>Both Surlyn® and low density polyethylene (in a variety of types and name brands) have been used successfully and each has its advocates. Mr. Pritham and colleagues at Durr Fillauer prefer Surlyn® for three reasons: clarity, no shrinkage, and ease of rolling the edge.</p> <p><i>Thickness</i></p> <p>Originally socket walls of 30/1000" thickness were specified, however, this proved to lack durability. Subsequently, thickness in the neighborhood of 80-90/1000" were specified and are preferred. (Note: NYU prefers 60/1000".)</p> <p><i>Frame configuration</i></p> <p>At least three different configurations have been described for quadrilateral sockets. The differences center on the lateral wall and the amount of support considered necessary for the femur.</p> <p>A variety of designs have been put forth in order to achieve specific features in non-quadrilateral sockets, including the well known total flexible brim.</p> <p>Mr. Pritham concluded his presentation by saying, "the crucial point would seem to be that flexibility is independent of socket shape and can be modified to provide specific design features in a socket-frame system. The specific configuration depends upon the prosthetist's experience and fitting philosophy and the needs of the individual patient."</p> <p>Rounding out the first day of presentations was Dr. Robin Redhead, Senior Medical Officer at the Roehampton Limb Fitting Centre in London. Dr. Redhead's paper was entitled "Experience With Total Surface Bearing Sockets." This presentation centered more on weight-bearing distribution and biomechanics than on socket design or shapes. Dr. Redhead and associates maintain that regardless of socket shape or design, well distributed weight-bearing can eliminate the need for single point, bony weight bearing (such as ischial weight-bearing). This system of well distributed weight-bearing was referred to as a total-surface-bearing socket. It infers a hydrostatic type of socket fit utilizing the incom-pressibility of the fluids in an above-knee residual limb.</p> <p>This presentation brought a reaction from of Professor Radcliffe, who doesn't agree with the hydrostatic concept of weight-bearing in prosthetics. He stated that "you need a closed system for hydrostatics and the AK residual limb is not a closed fluid system. With an open fluid system, the fluids are pushed out."</p> <p>There was considerable discussion on this topic, both pro and con, and it was never resolved.</p> <p>Beginning the morning of the second day, John Sabolich, C.P.O., from Oklahoma City, and Glenn Hutnick, CP., from New York, presented another view of CAT-CAM. As stated earlier, Tim Staats, C.P.O. reported that the UCLA CAT-CAM is evolving independently of the CAT-CAM technique of the original developers.</p> <p>Sabolich and Hutnick report that the original CAT-CAM is continuing to evolve and develop. Sabolich stated that, "it took five to six years to develop the current medial wall design, which has become increasingly more aggressive in enclosing and capturing the ischial ramus." They advocate use of the total flexible brim. "The key is the flexible brim system—it is totally flexible in the proximal area, where most patients complain." Aside from 100% use of the total flexible brim, the Sabolich/Guth CAT-CAM differs from NSNA and the UCLA CAT-CAM by not advocating the 4° to 7° medial lean of the foot, pylon, and knee bolt in bench alignment as proposed by Long and UCLA. John Sabolich went on to say "this additional adduction or tilting of the knee bolt is a cover-up for lost stability due to inadequate ischial containment." Mr. Long's response was that this was incorrect. Probably the most noticeable aspect of design that separates the Sabolich/Guth CAT-CAM apart from the other recent ischial-containment designs is the earlier mentioned aggressive capture of the ischial tuberosity and ramus. Sabolich claimed that they are enclosing more and more of the ischial ramus, as much as possible and still allow pubic ramus comfort. This ramus enclosure provides two biomechanical functions: (1) a medial bony stop for ML stability, and (2) rotational control, especially on soft fleshy residual limbs. Other than these departures, the Sabolich/Guth CAT-CAM differs very little from the UCLA CAT-CAM, especially in terms of brim shape, trimlines, and biomechanics. Sabolich, unlike Long, does advocate the use of dynamic alignment devices.</p> <p>At this point in the Workshop, Professor Radcliffe returned to the podium in an attempt to present and clarify the comparative biomechanical principles of both quadrilateral and ischial-containment sockets. The following biomechanical analyses are taken from Professor Radcliffe's discussion and from the paper he later submitted reviewing his presentations.</p> <p>"It has been demonstrated that pressure against the medial aspect of the pubic ramus can be used to supplement the weight-bearing on the tuberosity of the ischium and contribute to medial stabilization in the upper one-third of the above-knee socket. In taking advantage of the weight-bearing potential on the medial aspect of the ramus, the prosthetist is creating a situation much like weight-bearing on the seat of a racing bicycle. To prevent the ramus from sliding laterally and downward into the socket, the prosthetist must exaggerate the counterpres-sure from the lateral side. This has been done by a reduction in the M-L dimension particularly in the area just distal to the head of the trochanter. The soft tissue must be accommodated. Therefore, the A-P dimension is correspondingly increased as compared to the quadrilateral socket. As compared to the quadrilateral fitting, the height of the anterior brim is typically lowered and flared and the gluteal area is filled in and fitted higher as a result of the ischium being encased deeper into the socket."</p> <p>"The medial brim of the socket must slope forward and downward to the point where the pubic ramus crosses the medial brim and emerges from the socket. The ischial ramus clearly is capable of providing medial counter-pressure which supplements the medial pressure on the adductor musculature. Since the socket slopes downward and inward along the entire medial brim, this contour is flared into the medial wall of the socket, which gives the impression of exaggeration of the medial coun-terpressure in the upper one-third of the socket."</p> <p>"The adduction of the socket and the use of lateral stabilization should not differ from that achieved by a properly fitted quadrilateral socket. There is an apparent exaggeration of the modification of the lateral wall, but this is primarily limited to the area just below the trochanter where the M-L dimension has been reduced to insure that the encased pubic ramus and ischium are maintained in the desired position on the medial brim. The exaggeration of the medial flare and reduction of the M-L dimension in the upper third of the socket leads to the impression of a greater angle of femur adduction, but the actual angle of the femur should be similar in both types of fittings if the quadrilateral socket is properly fitted and aligned."</p> <p>"Long's Line as proposed by Ivan Long is the anatomical axis of the lower extremity as described in anatomy textbooks. Placing the fe-mural stump in an advantageous position for normal use of the hip musculature by adduction and flexion of the socket has been a part of good prosthetic practice for at least 40 years in the United States and perhaps longer in certain European centers. Mr. Long's Line appears to be most useful in the cast taking procedure and subsequent modifications of the model rather than have any fundamental bearing on the alignment of the prosthesis. It appears to offer no new concepts useful in the bench or dynamic alignment of the prosthesis."</p> <p>Professor Radcliffe told the Workshop attendees that the use of "catchy names" should be avoided, and he therefore proposed the terminology of Ischial-Ramal weight-bearing socket, as well as Ischial-Gluteal weight-bearing socket.</p> <p>Professor Radcliffe continued his biomechanical analysis by saying "The biomechanics of the ischial-ramal weight-bearing socket are similar to the ischial-gluteal weight-bearing quadrilateral socket. The major differences are in the manner in which the ischium is maintained in position within or on the brim of the socket. In each case, there must be vertical support with a combination of lateral and anterior counterpressure to maintain the ischium in position" . . . "Some of the socket shape diagrams I have seen published are so crude and inaccurate as to be almost meaningless. The level of the cross section shown is often not indicated and a section at ischial level is sometimes compared to a section which is obviously higher or lower." Professor Radcliffe then sketched on the blackboard what he believed to be a more accurate comparison with emphasis on the three-dimensional shape both above and below the level of the tuberosity of the ischium. In each case, he showed a cross section of the socket at, (1) ischial level with the medial wall projected upward to this level; and (2) the outline of the highest points on the brim (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-14.jpg"><b>Fig. 14</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-15.jpg"><b>Fig. 15</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-14.jpg"><strong>Figure 14. Socket contours for an Ischial-Gluteal weight-bearing socket using the UC Berkeley Brims.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-15.jpg"><strong>Figure 15. Socket contours for an Ischial-Ramal weight-bearing socket of the NSNA type provided by Ivan Long.</strong></a><br /> <p>This concluded all presentations of current fitting techniques. The remaining presentations were concerned with evaluation techniques. Bo Klasson of Een-Holmgren Company in Sweden presented on "Socket Fit With Reference to Soft Tissue Force Transmission." Briefly, Mr. Klasson's theory is that we should attempt to design sockets with physical characteristics that match the physical characteristics of the residual limb. In other words, where the tissues of the residual limb are firm, so should the matching area of the socket material be; where the tissues are soft and flexible, so should the socket be. Mr. Klasson refers to this as "surface matching."</p> <p>The next speaker was Professor George Murdoch of Dundee, Scotland, presenting "A Method for the Description of the Amputation Stump." Professor Murdoch's paper was based on his premise that there is a need for an international classification system for residual limbs to be developed in order to compare one publication with another, one patient with another, one fitting technique with another.</p> <p>The final presentation was made by A. Bennett Wilson on "Physiological Monitoring Equipment in Evaluation of Lower Limb Prosthetic Components and Techniques." He reported on a system of physiological monitoring originally developed by MacGregor of the University of Strathclyde in the 1970's. Recently modified for use by the University of Virginia Division of Prosthetics and Orthotics, this system consists of a compact tape recording component worn on a waist belt that records electronically, step count, walking velocity, standing versus sitting, and heart rate, plotted against time up to 24 hours. The tapes are then analyzed by a special micro-computer program, which subsequently prints the information in digital and graphic format.</p> <p>Under some circumstances the heart rate data can be useful in providing an energy index, but probably more importantly, the step count, standing versus sitting, and velocity data provide specific information about the activity of the subject. Mr. Wilson and colleagues have recently developed a solid state device which is less costly and more reliable. The new system has 17 information gathering channels. Mr. Wilson concluded by saying, "At this point, we do not have sufficient experience to know how many subjects have to be monitored and how much data is needed to show significant differences, but it certainly appears that at last we have a breakthrough in instrumentation for evaluation of prosthetic devices and other treatments involving the function of the musculoskeletal system.</p> <p>With all presentations complete, the plenary group was divided into six panels of six to nine members with the following charges:</p> <ol> <li> <p>Determine similarities</p> </li> <li> <p>Determine differences</p> </li> <li> <p>What is the role of flexible walls?</p> </li> <li> <p>Indications and contraindications</p> </li> <li> <p>Recommendations for future action</p> <ol> <li> <p>Evaluation</p> </li> <li> <p>Education</p> </li> <li> <p>Application</p> </li> </ol> </li> </ol> <p>This first group of panels reported back on Sunday morning. The reports were quite consistent among the different panels. A synopsis of these reports will be presented in concluding this report.</p> <p>On Monday, new panels were formed to re-study the rationale for and possibly develop protocol for evaluation. The reports from this second group of panels was heard in plenary session on Tuesday morning.</p> <p>The meeting was adjourned Tuesday, May 19, 1987 at noon.</p> <p>What follows here is a synopsis of the conclusions and recommendations of the panel reports.</p> <ol> <li> <p><b>Similarities &amp; Differences</b></p> <ol> <li> <p>Biomechanics</p> <ol> <li> <p>Ischial Containment:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>all ischial containment sockets advocate and utilize varying degrees of ischial containment</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quads do not utilize ischial containment</p> </li> <li> <p>ischial containment sockets, amount of ischial containment</p> </li> </ul> </li> </ol> </li> <li> <p>Weight Bearing Distribution:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>ischial containment sockets, combination of ischial tuberosity and ramus, and peripheral (soft tissue)</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quads, ischial-gluteal weight bearing</p> </li> </ul> </li> </ol> </li> <li> <p>ML Stability—maintenance of adduction</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>goal of all AK socket systems</p> </li> <li> <p>greater success and maintenance in ischial containment sockets due to ischium acting as bony stop or lock</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quad, soft tissue lock only, no bony lock</p> </li> <li> <p>less successful maintenance of adduction, thus less ML stability</p> </li> </ul> </li> </ol> </li> <li> <p>Socket Shape—ischial level cross section</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>ischial containment sockets, narrow ML, wider AP, concave post-trochanteric shape</p> </li> </ul> </li> <li> <p>differences</p> <ul> <li> <p>quad, wider ML, narrower AP</p> </li> </ul> </li> </ol> </li> <li> <p>Trimlines:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>ischial containment sockets, generally; especially anterior, posterior, and lateral wall trimlines</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quads, especially higher anterior, lower posterior and lateral wall trimlines</p> </li> <li> <p>medial wall of CAT-CAM</p> </li> </ul> </li> </ol> </li> <li> <p>Suspension:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>all compatible with suction</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>ischial containment sockets, unclear about auxiliary suspension</p> </li> </ul> </li> </ol> </li> <li> <p>Alignment:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>all but NSNA utilize alignment devices</p> </li> <li> <p>ischial containment sockets, medial wall not on line of progression</p> </li> <li> <p>NSNA &amp; UCLA CAT-CAM, tilting of knee bolt in bench alignment</p> </li> <li> <p>Shamp Narrow ML &amp; NSNA, use of Long's Line</p> </li> <li> <p>ischial containment sockets,TKA bench alignment, socket midline</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>NSNA does not use dynamic alignment device</p> </li> <li> <p>quad medial wall on LOP</p> </li> <li> <p>not all tilt knee bolt</p> </li> <li> <p>NSNA, varying degrees of knee bolt tilt, 7°, female, 4°, male</p> </li> <li> <p>quad, bench alignment, more stable TKA, T reference point is located at posterior l? of socket</p> </li> </ul> </li> </ol> </li> <li> <p>Rotational Control:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>ischial containment sockets, bony lock of Ischium and post-trochanteric concavity</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quad, muscular-soft tissue cross-section</p> </li> </ul> </li> </ol> </li> </ol> </li> <li> <p><i>Method of Obtaining Cast</i></p> <ol> <li> <p>similarities:</p> <ul> <li> <p>quad and Shamp Narrow ML utilize a casting brim</p> </li> <li> <p>UCLA CAT-CAM &amp; Sabolich/Guth CAT-CAM, hand molding technique</p> </li> <li> <p>NSNA &amp; UCLA CAT-CAM, standing</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>CAT-CAM &amp; NSNA, hand molding technique</p> </li> <li> <p>Sabolich/Guth CAT-CAM, sometimes cast lying down</p> </li> </ul> </li> </ol> </li> <li> <p><i>Anatomical Considerations</i></p> <ol> <li> <p>UCLA CAT-CAM detail about pelvic differences:</p> <ul> <li> <p>ischial inclination</p> </li> <li> <p>pubic arch angle</p> </li> <li> <p>ilio-femoral angle</p> </li> </ul> </li> <li> <p>NSNA male, female alignment differences:</p> <ul> <li> <p>bolt tilt</p> </li> </ul> </li> </ol> </li> </ol> </li> <li> <p><b>Role of Flexible Walls</b></p> <ul> <li> <p>not linked to any one philosophy of designing an AK socket</p> </li> <li> <p>vital to the success of the Sabolich/Guth CAT-CAM</p> </li> <li> <p>improved sitting comfort</p> </li> <li> <p>improved proprioception</p> </li> <li> <p>better heat dissipation</p> </li> <li> <p>improved muscle activity</p> </li> <li> <p>reduced weight</p> </li> <li> <p>ease of socket change within frame, no loss of alignment</p> </li> <li> <p>enhanced suspension, if suction suspension</p> </li> </ul> <p>All participants agreed there is great need for improved flexible materials.</p> </li> <li> <p><b>Indications and Contraindications</b></p> <ul> <li> <p>there were no specific contraindications noted for any socket design</p> </li> <li> <p>some advocated not changing successful quad wearers</p> </li> <li> <p>quads are most successful on long, firm residual limbs with firm adductor musculature</p> </li> <li> <p>ischial containment sockets are more successful than quads on short, fleshy residual limbs</p> </li> <li> <p>ischial containment sockets are the better recommendation for high activity/sports participation/running</p> </li> <li> <p>lack of agreement on best recommendation for bilateral above-knee</p> </li> </ul> </li> <li> <p><b>Recommendations</b></p> <p>The panels' conclusions and recommendations were remarkably consistent. Most consistent was the recommendation for improved terminology, lumping what I have referred to as ischial containment into a single, workable term. Suggestions ranged from "Narrow ML" to Ischial/ Ramus Containment (IRC) and Non-Ischial Containment (Non-IRC). Due to time constraints, arguments about this recommendation were never resolved. It is hoped that all recommendations can be addressed in a future workshop or through some other form of action.</p> <ol> <li> <p><i>Evaluation</i></p> <p>There was unanimous agreement for formal evaluation of the newer above-knee techniques (NSNA, CAT-CAM, Shamp Narrow ML) as well as evaluation of implications of the inferiority of the quadrilateral technique.</p> <ol> <li> <p>A program for scientific/laboratory evaluation should be set up at a center or multiple centers, depending upon resources. This study might include: cinematography, force plate, motion analysis, gait mat and other "gait lab" studies as well as radiographical data on alignment and containment, physiological data, residual limb/socket force analysis, and/or any other relevant laboratory studies.</p> </li> <li> <p>A program of clinical evaluation, based on previous fittings and continuing fittings in clinics already utilizing new fitting techniques. This would be a more subjective study, and would require a greater effort for coordination and pooling of data.</p> </li> <li> <p>Complete manuals should be developed for each individual technique, unless the developers can find it mutually agreeable to work together and blend the new techniques. The panels found the latter option to be most desirable.</p> </li> <li> <p>Evaluation should be independent of the developers.</p> </li> <li> <p>Any evaluation needs to be coordinated by an authoritative group. ISPO and/or the U.S. Veterans Administration were recommended. The American Academy of Ortho-tists and Prosthetists should also be involved.</p> </li> <li> <p>Possible funding sources within the states include the Veterans Administration and the National Institute on Disability and Rehabilitation Research (NIDRR).</p> </li> </ol> </li> <li> <p><i>Education</i></p> <p>The post-graduate, specialized courses for experienced practitioners appear to be most appropriate for teaching these newer techniques at this time. Incorporation into entry level education programs should follow as well written, experience based manuals are developed. Any teaching course should include "hands-on", patient contact, fitting, and management as part of the curriculum.</p> </li> <li> <p><i>Application</i></p> <p>The application of these new techniques, while certainly not as widespread and accepted as the quadrilateral technique, or even the flexible socket technique, is occurring at this time. Growing acceptance and application will most certainly follow. It is hoped that this workshop, as well as future workshops, will aid in safe and proper application of these and future advances and developments in prosthetics.</p> </li> </ol> </li> </ol> <p><b>References:</b></p> <ol> <li>UCLA AK Teaching Manual, 1977-1978.</li> <li><i>UCLA CAT-CAM Above Knee Prosthesis</i>, Teaching Manual, Third Edition, March 1987.</li> <li><i>Fabricating The Long's Line Above-Knee Prosthesis</i>, by Ivan long, 1981.</li> <li>Ivan Long's business card.</li> <li><i>Manual for use of THE SHAMP BRIM for the Narrow ML Above-Knee Prosthetic Socket</i>, The Ohio Willowwood Co., 1987.</li> <li>By Charles Radcliffe. Re-drawn by A. Bennett Wilson, Jr.</li> </ol> <em><b>*C. Michael Schuch, C.P.O. </b> C. Michael Schuch, C.P.O., is Assistant Professor of Orthopaedics and Rehabilitation and Associate Director of the Department of Prosthetics and Orthotics at the University of Virginia Medical Center, Box 467, Charlottesville, Virginia 22908.<br /><br /><br /></em> Page Number(s) 81 - 98 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Report From: International Workshop on Above-Knee Fitting and Alignment Techniques Creator An entity primarily responsible for making the resource C. Michael Schuch, C.P.O. * https://staging.drfop.org/files/original/1d0b1902a4d7fb7cc437f75ca2c997b1.pdf f5ec7dfc784092ec4c05b42b0a9ca722 https://staging.drfop.org/files/original/07c03e80401b5c87d8d82c363e054d8c.jpg 53dd0b9a9b94ba4619665e0dc21d6fd3 https://staging.drfop.org/files/original/ace09578c7da7ee48bdd67c240b778fe.jpg f52289221839e24d1976512808b88d40 https://staging.drfop.org/files/original/ad5dc9979c8c97cb0bd8047ec31bc02f.jpg 5bf470bdcf3132b882ae78d66b4fd38d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_122.pdf Text Any textual data included in the document <h2>Research and Development Considerations and Engineering Perspective</h2> <h5>Douglas A. Hobson, P. Eng.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Background And Introduction</h3> <p>Contrary to the impression given by a segment of current literature, the rapidly emerging field of specialized seating remains largely an art rather than a science. Established clinical principles, supported by a documented knowledge base are sparse, and clinical decision making remains largely subjective. That is, seating practice is not promulgated by an organized educational process.</p> <p>Specialized seating is still in the 1950's era. At that time, significant advances in prosthetics and orthotics were being made. Prosthetics advancements included below knee and above knee socket fitting, fabrication, and alignment principles. In the 1970's, orthotics introduced vacuum formable plastics to the field. Only in the last five years has specialized seating offered more than one or two commercial options for individuals requiring custom contoured body support.</p> <p>Specialized seating is still a comparatively young, but now a rapidly developing sub-specialty of rehabilitation technology.</p> <p>It is probably of value to attempt to define what is meant by the field of specialized seating. First, it is a clinical process which attempts to maximize function through the provision of appropriate "body support" for a nonambulatory person, usually in the seated posture, and usually in combination with a wheeled device, such as a wheelchair. The nature of the body support is dependent largely on the needs arising from the individual's disability. It can be thought of as providing seated body support in a manner that is usually less intimate and technically demanding than is required by conventional spinal orthotics (i.e., a body jacket).</p> <p>Specialized seating has been an exciting area for involvement and research and development, especially during the last ten years or so. Engineers first became clinically involved in specialized seating in the late 1960's in Canada. During the intervening years, other professionals such as prosthetists, orthotists, therapists, and technicians throughout North America and Europe have been actively involved in specialized seating developments. This article attempts to focus on the research and development process that has led to the emerging principles and products that are now becoming common place throughout the delivery system, especially for individuals with cerebral palsy.</p> <p>Perhaps of importance are the experiences that have shaped the views (and biases) of the author regarding the research and development process in the rehabilitation field. Firstly, early design experience in lower extremity modular prosthetics (Winnipeg, 1963-69), strongly reinforced the opinion that research and development should ideally take place in close proximity to an ongoing clinical commitment. Secondly, design and development must take place with a sense of reality towards the strengths and limitations of the manufacturing, marketing, and delivery system associated with the particular technology. This later view is the result of many frustrations, failures, and sometimes successes, in attempting to guide approximately a dozen "ideas" from conceptualization through clinical application over the past 15 years.</p> <p>The R&amp;D process for the field of rehabilitation engineering technology may be viewed as consisting of three interrelated phases of activity, a) research, b) design and development, and c) clinical utilization. The approach taken in this article will be to examine each of these activities as they relate to the development of principles and devices currently employed in the field of specialized seating. Emphasis will be given to applied clinical research versus basic research. The final section will address the current status of the field and suggest future needs for its continued growth. Along the way, developments familiar to the author will be used to illustrate key points. The flowchart (<a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg"><b>Fig. 1</b></a>) illustrates the process and suggests the primary outcomes from each step of the process.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg"><strong>Figure 1. The three steps in the seating product development process, suggesting the major outcome for each step.</strong></a><br /> <h3>Research Contributions</h3> <p>The engineer, especially when entering new clinical areas, can be overwhelmed by the apparent opportunities to employ engineering principles towards what appear to be readily resolvable problems. With the passing of time, the realization emerges that most problems are much more complex than they first appeared and the best solutions involve creativity, simplicity of design, patience and a good deal of perserverance. Applied research, as it applies to technology and rehabilitation, could be defined as "a logical process which attempts to reduce chaos in favor of logical problems solving, during which time a few significant principles and related devices can be developed." This definition may appear rather non-scientific; however, most developments of significance to date have resulted from attempts to solve a morass of seating problems. From these attempts we see repeated positive results become positioning principles and related successful devices become commercial products.</p> <p>At this point the question could be asked, What, of significance, has been learned about meeting the needs of individuals requiring specialized seating over the past 15 years? First, every person has a unique set of needs, therefore one generalized solution does not work for all. Second, it has been possible to group needs, or residual abilities, which can greatly assist in clinical decision making regarding the choice and provision of technical options. Third, there are three disability related (intrinsic) factors that dictate both research and clinical activities in specialized seating. These are a) lack of postural control (i.e., resulting from spasticity); b) existing or potential deformity; and c) the degree of loss of tissue sensation. The schematic diagram (<a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg"><b>Fig. 2</b></a>) combines these intrinsic factors in a three dimensional array. As can be seen, postural control can be graded as good, fair, or poor; deformity as mild, moderate, and severe; and sensation as normal, impaired, or asensitive. The groupings that result (Groups 1, 2, 3) give an indication of the degree of body support that the seating system must provide to compensate for the patient's intrinsic deficiencies. For example, a child with cerebral palsy, with a mild deformity, good postural control, and essentially normal sensation falls into Group 1. Individuals with Group 1 needs usually do not require custom contoured body support and often only need a simple seat insert (standardized modular insert) that can provide midline orientation and improve the fit of the wheelchair. Whereas a teenager with Duchenne Muscular Dystrophy, who has poor postural control, severe deformity, but normal sensation, would be in Group 3. This individual would require extensive custom contoured support, including pressure relief throughout the seating surface to accommodate for the discomfort associated with prolonged stationary sitting. A person with a low level spinal cord lesion (paraplegic) with only moderate deformity and fair postural control would fall into Group 2. In this case, some contoured support may be necessary to compensate for deformity and loss of postural control. Also, a primary concern may be the loss of tissue sensation, so pressure redistribution over the seat surface would be necessary.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg"><strong>Figure 2. A three-dimensional representation of the key intrinsic factors (control, deformity, and sensation) that guide decision-making in specialized seating.</strong></a><br /> <p>Let us now go a step further and briefly look at a few disabilities in more depth. For example, individuals with cerebral palsy typically demonstrate a wide range of symptomatic intrinsic factors. It's usually obvious what group (i.e., Group 1, 2, or 3) they fall into for their general seating needs. However, what will be the short and long term postural needs for the child, how these needs can best be met through the seating system, and how the whole seating system must relate to the child's primary environments are all extrinsic factors that are best addressed by our therapy colleagues. That is, not only does one type of seating device not work for all, the manner in which it is configured for an individual, as well as how well it compliments the broader needs of the individual and the families are equally important. Experience has shown that specialized seating is best accomplished through a multidisci-plinary approach in which the technical and therapy contributions are orchestrated within a medical environment, with a physician assuming primary medical responsibility.</p> <p>In recent years, clinical research has begun to scientifically investigate the therapeutic principles related to positioning children with cerebral palsy. For example, Nwaobi<a></a> has shown that under certain conditions approximately 90° of hip flexion tends to minimize spasticity and optimize upper extremity function. More recent work by the same group<a></a> has also shown the importance of posturing in order to improve respiratory function in children with cerebral palsy. Present studies are looking at the potential contributions of posturing and seating support to reduce asymmetrical spinal muscle activity, which is thought to be a caustive factor in spinal deformity in the child with cerebral palsy.</p> <p>Earlier work in Rehabilitation Engineering at Rancho Los Amigos Hospital with the spinal cord injured<a></a> established safe pressure level thresholds for the tissue over the bony prominences, such as the ischial, coccyx, and the greater trochanters. These thresholds provide guidelines for clinicians when fitting cushions for individuals who require pressure relief in order to prevent development of pressure sores. This early work has paved the way to more recent work that is now modifying and refining these principles.<a></a> Clinical programs employing these techniques have significantly reduced the onset and development of pressure sores. For example, Ferguson-Pell<a></a> has developed a computer program which assists therapists and others in decision-making regarding the selection and fitting of wheelchair cushions. This system combines and integrates much of the existing knowledge in terms of pressure sore prevention and guides the clinician towards a logical solution in which the chances for error are minimized.</p> <p>Research in recent years has also developed other useful clinical tools. Again, for the spinal cord injured, there are now at least three commercially available devices (Scimedics TIPE, Oxford Pressure Monitor) that will measure and record the pressure that exists between the seated person and his support surface.<a></a> Other seating approaches use what is termed a "simulator approach" to assist in evaluation and fabrication of seating devices. For example, the MPI system<a></a> for cerebral palsy in children uses a multiadjustable frame and quickly detachable seat and back modules to allow the therapist to rapidly simulate the definitive seating arrangement. Tools of this type help in terms of therapy decision making and the subsequent communication with the technical staff responsible for the fabrication and fit of the device. Another research effort<a></a> is concerned with the collection of anthropometric data derived from taking measurements of a patient positioned in a subjectively good posture. This information will eventually be useful in the design of standardized componentry that will better match the dimensions and shapes of the individual.</p> <p>Another outcome of research activities has been the classification of seating devices into five generic groups based on their methods of fabrication. Space does not permit detailed discussion of this classification scheme, especially since it has been published elsewhere.<a></a> The following table is a synopsis of the classification scheme as it applies primarily to individuals with cerebral palsy. The table also incorporates the needs groupings discussed previously. This overall scheme has proven useful in helping inexperienced clinicians to better understand the key issues involved to match a client's needs with available commercial options.</p> <p>In addition, the above classification scheme provides a framework through which a student in the field of specialized seating can begin to appreciate the differences that exist between the various technical options; and more importantly, what general needs each system is designed to meet. Further study involves learning the fabrication steps involved in the various systems, the positive and negative features associated each approach, and how features from various types can be combined to produce hybrid devices for meeting very specialized user needs.</p> <p>Probably the most significant advancement is that both research and clinical experiences are now being brought together in the form of educational manuals<a></a> and instructional courses. This development is a major step towards establishing the body of knowledge that is so crucial if specialized seating is to progress from an "art" to a recognized field of professional endeavor.</p> <h3>Design And Development</h3> <p>One of the obvious benefits of a research team working in close proximity to clinical activities is the potential for identification of "real" needs requiring technological intervention. Once these needs are identified, they then form the basis of design specifications which become the goals for the initial phase of the design and development process. Of all the endeavors involving rehabilitation engineering technology over the past twenty years, this step of defining what needs to be done has probably been the most poorly managed. There is probably no greater waste of technological resources than to solve problems for which there is either already an existing solution, or for which a solution cannot be sufficiently generalized to meet the needs of a commercially viable segment of the population.</p> <p>Assuming a "green light" is still on after the "real" needs are identified, the next step is to develop a prototype solution, which in this context could be a technique, a clinical tool, or a seating device. The development is usually very "fragile" at this time, and the sooner it can be subjected to clinical trials and critique in a positive environment the better. Invariably, modifications and design refinements are required until a solution is developed that is acceptable to both the clinicians and their test subjects. Ideally, the development should then be exposed to wider critique within environments different from those in which the development took place. Also, manufacturing, marketing, and costing analysis should take place in preparation for the preproduction phase. Assuming all these steps yield positive outcomes, an initial preproduction run is made so controlled evaluations can be done in selected external environments. The results of the external evaluations should be carefully monitored, documented and made available to the production design team. Over the past six years, four such developments from the University of Tennessee Rehabilitation Engineering Program have gone through this process, some more rigorously than others. These developments, the Modular Plastic Insert, the Spherical Thoracic Support, the Foam-In-Place, and the Bead Seat System, are now all commercial products being marketed by three different commercial firms.</p> <p>The final stages of the design and development process can vary depending on development and the resources of the commercial firm involved. In general, the market volume for seating devices is still relatively low. Therefore, it is important that the "front end" cost to the commercial firm be minimized. This can be accomplished in several ways by the development team. First, it is crucial that the design be "elegantly simple" so that it can be reproduced in relatively low volumes inexpensively. Secondly, design refinements and problems solving support should be provided well into the commercialization phase. Royalty arrangements and other "front end" type payments to the developer should be minimized and based on product sales. And finally, support in terms of providing educational materials, publications, and instructional seminars all assist in creating a receptive market place.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-3.jpg"><b>Table</b></a></p> <h3>Clinical Utilization</h3> <p>This final phase of the R&amp;D process is most often neglected, since it is usually not very exciting to the development team. From the R&amp;D perspective, this design activity addresses those features of the development that will make it an attractive alternative to existing methods or devices being used. Again, development of instructional materials, provision of evaluation prototypes to "trend setters" and conducting instructional courses have already been mentioned. However, these supporting activities in themselves are usually not the key influencing factor. The development team must address the question, Why would a service provider working within a particular service delivery system choose the new development over another technical option? The answer usually is that the service provider can provide a higher quality service at equal or lower cost. Therefore, the new development must provide improved function to the user, and possibly increased status for the clinic/provider, at costs that can be paid for by the payment structure in which the service is provided. Failure by the design and development team to recognize the realities of the delivery system in which the development must be marketed is probably a primary reason why so many developments fail to make the transition from laboratory to widespread clinical application.</p> <h3>Current Trends In Specialized Seating</h3> <p>A 1985 survey of 26 facilities in 17 states<a></a> provides considerable insight into the state of maturity of the field of specialized seating. Of the 26 respondents, 12 were hospital based, six were state funded programs or institutions, and 8 were from private industry. The majority reported the use of plywood and foam technology (61 percent) or custom produced molded plastic parts (17 percent). The payment was received primarily from Medicaid, State Crippled Chil-drens Services, or private insurance carriers. The average number of clients fitted with new devices per year/facility was 185, with a total number fitted of 3,293.</p> <p>The importance of this survey, in the context of design and development, is that the majority of the facilities reported the use of basic "bench" fabricated technology (78 percent). This is not surprising since the majority of the new developments have only been available commercially for less than three years, and related educational programs are just beginning to have a significant clinical impact. Continuing education programs supported by the American Academy of Orthotists and Prosthetists, the Rehabilitation Engineering Society of North America, and institutions like the University of Tennessee Rehabilitation Engineering Program, Newington Children's Hospital, and Elizabethtown Children's Hospital, and private firms, such as Pin Dot Products, and Mobility Plus have been the primary sources for training in the new concepts and seating systems. As these efforts are expanded to involve larger numbers of clinicians, the newer technology in seating will permeate into the service delivery system.</p> <p>Of importance to the prosthetic and orthotic professions is that many of the professional skills and shop resources required to deliver improved specialized seating services are already in place. Also, specialized seating is now becoming recognized by many of the major third party payment sources as a recognized clinical service. The new commercial systems have been designed to be less labor intensive and to permit the provision of a quality product at a reduced cost. The overall result is that it is now feasible to invest in the education and inventory required to enter the field and expect to realize a return on that investment over a 2 to 3 year period. That is, specialized seating now presents a viable growth area for the prosthetic and orthotic field.</p> <p>Projecting into the future, one may speculate as to what developments are likely to take place in the field. As far as design and development, it is likely that refinements to the newer commercial products will preoccupy the efforts and available development resources over the next two to three years. New and ongoing basic research will continue to develop or validate positioning principles for the cerebral palsy population. We should see refinement and expansion in the use of computerized expert systems, primarily by institutional settings that are doing larger volumes of evaluation and prescription of seating devices. Educational courses should become more available on a regional basis through several of the participating professional associations. Hopefully, the American Academy of Orthotists and Prosthetists will continue its continuing education efforts in this area.</p> <p>Probably the most urgent and difficult issue to be resolved is the further education of third party payment sources, so that seating services can be provided and reimbursed throughout the country. In this regard, initial efforts by the Rehabilitation Engineering Society of North America appear promising. Similar, and probably coordinated, efforts by other organizations such as the American Occupational Therapy Association, the American Orthotic and Prosthetic Association, and the American Academy of Orthotists and Prosthetists would be most timely.</p> <p>In summary, research and development has made significant contributions to the field of specialized seating. This statement is based in the fact that there are not less than six new seating developments that have become available to the practitioner over the past five years. Basic studies, published articles, and manuals are establishing the foundation for educational activities that are becoming more widely disseminated. Third party payment sources have been slow to respond, but diverse efforts throughout the country have been successful at receiving reimbursement for seating services. In conclusion, more remains to be accomplished, and research and development can be expected to continue its contribution. Specialized seating is being transformed from an "art" to a recognized field of professional endeavor.</p> <p><b>References:</b></p> <ol> <li>Nwaobi, O.M., Hobson, D.A., Trefler, E., "Hip Angle and Upper Extremity Movement Time in Children with Cerebral Palsy," <i>Proceedings of the Eight Annual Conference of the Rehabilitation Engineering Society of North America</i>, Memphis, Tennessee, June, 1985, pp. 39.</li> <li>Nwaobi, O.M., Smith, P.D., "Effect of Adaptive Seating on Pulmonary Function of Children with Cerebral Palsy," <i>Develop. Med. Child Neurol.</i>, 28, 1986, pp. 351-354.</li> <li>Rodgers, J.E., Rewsick, J., "Program for Prevention of Tissue Breakdown," <i>Annual Report</i>, Rancho Los Amigos Hospital-REC, 1974/75, pp. 24-31.</li> <li>Paterson, R., "Is Pressure the Most Important Parameter," <i>Proceedings, National Symposium on Care Treatment and Prevention of Decubitus Ulcers</i>, Paralyzed Veterans of America, Washington, D.C., November, 1984, pp. 73-74.</li> <li>Ferguson-Pell, M., "Research Relating to Pressure Sore Prevention," <i>Proceedings, National Symposium on Care Treatment and Prevention of Decubitus Ulcers</i>, Paralyzed Veterans of America, Washington, D.C., November, 1984, pp. 53-54.</li> <li>—Scimedics, 170 Vander St., Units A &amp; B, Corona, California 91720.&nbsp;<br />—TIPE-Tee Kay Applied Technology, 11915 Meadow Trail Lane, Stafford, Texas 77477.&nbsp;<br />—Oxford Pressure Monitor-International Medical Equipment Corporation, 11000 E. Rush Street, Suite 4, South El Monte, California 91733; (213) 350-1410.</li> <li>Modular Plastic Insert System marketed by Pin Dot Products, Inc., 2215 Belmont Street, Chicago, Illinois 60618.</li> <li>Reger, S., Hobson, D.A., "Seat Design Factors for Wheelchairs," <i>Annual Report</i>, University of Virginia- REC, 1985, pp. 25028. Charlottesville, Virginia.</li> <li>Hobson, D.A., Trefler, E., "Towards Matching Needs with Technical Approaches in Specialized Seating," <i>Proceedings of the Seventh Annual Conference of the Rehabilitation Engineering Society of North America</i>, June, 1984, Ottawa, Canada, pp. 486-488.</li> <li>Bergen, A., Colangelo, C, <i>Positioning the Client with CNS Deficits: The Wheelchair and Other Adapted Equipment</i>, Valhalla Rehabilitation Publications, Ltd., New York, 1982.</li> <li>Trefler, E. (Ed.), <i>Seating for Children with Cerebral Palsy: A Resource Manual</i>, University of Tennessee Center for the Health Sciences-Rehabilitation Engineering Program, Memphis, Tennessee, 1984.</li> <li>Ward, D., "Positioning the Handicapped Child for Function," <i>Pin Dot Products</i>, Chicago, Illinois, 1983.</li> <li>Holte, R., Shapcott, N., "A Survey of Wheelchair Seating Service Delivery Programs in the USA," <i>Proceedings of the Eighth Annual Conference of Rehabilitation Engineering Society of North America</i>, Memphis, Tennessee, June, 1985, pp. 157-159.</li> </ol> <b>*Douglas A. Hobson, P. Eng. </b> Douglas A. Hobson, P. Eng., is Technical Director at the Rehabilitation Engineering Center, for the University of Tennessee Health Science Center, 682 Court Avenue, Memphis, Tennessee 38163.<br /><br /> <div style="width: 400px;"></div> Page Number(s) 122 - 129 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg Figure 3 TABLE http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research and Development Considerations and Engineering Perspective Creator An entity primarily responsible for making the resource Douglas A. Hobson, P. Eng. * https://staging.drfop.org/files/original/a75bb5af32b91c1f69b33d56c8e8c13c.pdf 7038d74466afb3f6db7db53e207d99f1 https://staging.drfop.org/files/original/83201447bfbcd1b4e9c4e43420cb46c0.jpg bbea9d1c00254560b22e2b807b1c8d08 https://staging.drfop.org/files/original/7ea7735793548661de0e6720877337e8.jpg b400e6e9832514b4295b6404a02ba862 https://staging.drfop.org/files/original/0dd26f7dd4ed5f35fb0c91028a1a8e1d.jpg 366678f0b5ceb5eadc4f020eee144577 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_111.pdf Text Any textual data included in the document <h2>Restoration of Walking in Patients with Incomplete Spinal Cord Injuries by Use of Surface Electrical Stimulation: Preliminary Results</h2> <h5>T. Bajd&nbsp;<a style="text-decoration: none;">*</a><br />B.J. Andrews&nbsp;<a style="text-decoration: none;">*</a><br />A. Kralj&nbsp;<a style="text-decoration: none;">*</a><br />J. Katakis&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>This article was reprinted with permission from </i>Prosthetics and Orthotics International<i>, 9, 1985, pp. 109-111</i>. <i>Further information about Prosthetics and Orthotics International can be obtained from Joan E. Edelstein, Secretary-Treasurer, US Member Society ISPO, 317 East 34th Street, New York, N.Y. 10016.</i></p> <h3>Introduction</h3> <p>A group of patients who are good candidates for the application of Functional Electrical Stimulation (FES) to restore reciprocal walking is described. They have incomplete lesions of the spinal cord. Because of the degree of preserved voluntary control, proprioception and sensation, some of these patients can achieve crutch assisted walking by means of multichannel electrical stimulation. In a number of cases the patient has sufficient strength and voluntary control in the upper limbs and at least one leg to provide safe standing for short periods in forearm crutches. For these patients a two channel stimulator controlled by a hand-switch was applied to achive safe and practical crutch assisted walking in a relatively short period of time.</p> <h3>Background</h3> <p>A new group of patient which can benefit from the orthotic use of functional electrical stimulation (FES) has been identified. These are incomplete spinal cord injured patients.</p> <p>This group of patients is increasing in numbers mainly due to improvements in primary care.</p> <p>The clinically incomplete lesion of their spinal cord results in preservation of some voluntary movements of the lower extremities. Some of these patients are able to walk with the help of various short-leg or long-leg orthoses which fix the knee and ankle joints. Support of the foot is often provided by the addition of a toe spring. Locomotion of most other incomplete spinal cord injured (SCI) patients is performed with the help of a wheelchair. They can walk only for very short distances, usually in their homes. Some tetraplegic patients are totally confined to a wheelchair. The reason is often very strong spasticity or developed contractures. The upper extremities are also partially paralyzed. Nevertheless, the arms and hands are strong enough to provide support on crutches. Wrist and finger movements are often limited and the grip is rather weak. However, the patients are in most cases able to hold the handle of the crutch.</p> <p>It was found that a minimum of four channels of FES was required for synthesis of a simple reciprocal gait pattern in the complete thoracic patient (Bajd et al., 1983; Kralj et al., 1983). During the stance phase, knee extensor muscles are stimulated, while the swing phase is accomplished by eliciting a synergistic flexor response in hip, knee and ankle joints through electrical stimulation of an afferent nerve. It was observed in the present study that in most of the incomplete tetraplegic patients one leg was almost completely paralyzed while the other leg was under voluntary control and sufficiently strong to provide safe standing for short periods using only crutches. Unilateral stimulation of knee extensors and an afferent nerve was helpful in these patients. Less frequently it was found that the patients could stand but were unable to take a step with one or both legs. Unilateral or bilateral stimulation of afferent nerves proved helpful for them. There are also patients whose extension and flexion capabilities in both lower extremities are so poor that they need three or even four channels of stimulation.</p> <h3>The Fes Orthosis</h3> <p>From the point of view of control of the patient, the gait cycle was divided into stance and swing phase. The transition from one phase to another was achieved by pressing a hand switch mounted on the handle of the crutch. When the switch was not pressed, knee extensors were stimulated. When the switch was pressed, the afferent nerve was excited, resulting in the swing phase of walking. The duration of the swing phase was regulated by the time of pressing the switch. In the present investigation the peroneal nerve was stimulated near fossa poplitea. The stimulation of this mixed, sensory and motor, nerve provided direct dorsi-flexion and eversion of the foot and simultaneously also the reflex knee and hip flexion.</p> <p>The gait of most of the incomplete SCI patients can be restored by the two-channel stimulator only. Any stimulator can be used for the described application where the stimulation parameters can be adjusted close to the following values: 0.3 ms pulse duration, 20 Hz pulse repetition frequency, and an amplitude up to 120 volts (measured with a 1k Ω load. Surface electrical stimulation of the knee extensors was delivered to the muscles through large (6 x 4 cm) sheet metal electrodes covered with water soaked layers of gauze. When stimulating the common peroneal nerve, two small round electrodes (diameter 2.5 cm) made of sheet metal and covered by gauze saturated with water were used. The interconnection of the hand switch with the outputs of the stimulator to the electrodes can be readily accomplished. The hand switch was attached to the handle of the crutch by adhesive tape for trial purposes.</p> <h3>Patient Tests</h3> <p>Five patients with incomplete spinal cord lesions have so far been included in the program of FES assisted walking. Only a short strengthening program was required for disuse atrophy of their thigh muscles. The learning program of walking was extremely fast and simple. After the first few days the patients were able to go from mobile parallel bars to crutches (<a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg"><b>Fig. 1</b></a>). The difference between walking with and without FES was evident. The patients were not able to take a single step with their severely paralyzed extremity when the stimulator was switched off. After a few days of training they were able to rise from the sitting to the standing position independently with the help of the crutch support and knee extensor stimulation only. Soon they were able to walk on uneven ground (<a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg"><b>Fig. 3</b></a>) and go up and down steps (<a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg"><b>Fig. 2</b></a>). The subject shown in <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg"><b>Fig. 3</b></a> has an incomplete lesion at the level T6/7 (age 36 yrs., height 168 cm., mass 61 kg., 7 yrs. post injury). The subject shown in <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg"><b>Fig. 1</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg"><b>Fig. 2</b></a> has an incomplete lesion at the level C6 (age 21 yrs., height 188 cm., mass 70 kg., 3 yrs. post injury). In both cases one leg was paralysed while the other had sufficient voluntary control to maintain safe standing with crutches without stimulation.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg">Figure 1.</a> Paraplegic subject with incomplete lesions at T6/7 walking on a level surface.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg">Figure 2</a>. Tetraplegic subject with incomplete lesion at C6 negotiating uneven steps.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg">Figure 3</a>. Patient walking on uneven ground; end of swing phase for the paralyzed leg.<br /></strong><br /> <h3>Discussion</h3> <p>Such activities can only be achieved in a few completely paraplegic patients after many months in the training program. These differences between incomplete and complete spinal cord injured patients are due not only to the remaining voluntary movements of their lower extremities, but also to the preserved sensation and proprioception. The present FES orthotic systems provide active movements at the joints of the limbs, but no feedback is available in practical clinical systems. The patients feel safe and secure when unattended because in the event of a failure of the orthosis, they are able to support themselves. For these reasons the incomplete SCI patients appear to be the most appropriate candidates for FES. The FES assisted walking may require less energy from the SCI patients with incomplete lesions than walking with passive mechanical knee and ankle orthoses, because no hip hiking is necessary with active FES systems. Finally, FES assisted walking is much more aesthetic to the observer than orthoses assisted and is preferred by the patients. There may be a number of therapeutic benefits to be gained from the use of FES orthoses such as the prevention of pressure sores, contractures, muscle atrophy and bone demineralisation.</p> <h3>Acknowledgments</h3> <p>The authors wish to acknowledge the financial support of the Multiple Sclerosis Society and the A. Onasis, Public Benefit Foundation. The work was conducted at the Bioengineering Unit, University of Strathclyde, Head, Prof. J.P. Paul and in collaboration with Mr. P.A. Freeman F.R.C.S. and staff of the West of Scotland Spinal Injuries Unit at the Philipshill Hospital, Glasgow.</p> <p><b>References:</b></p> <ol> <li> <p>Bajd, T., Kralj, A., Turk, R., Benko, H., Sega, J., "The use of a four channel electrical stimulator as an ambulatory aid for paraplegic patients," <i>Phys. Ther.</i>, 63, pp. 1116-1120, 1983.</p> </li> <li> <p>Kralj, A., Bajd, T., Turk, R., Krajnik, J., Benko, H., "Gait restoration in paraplegic patients. A feasibility demonstration using multichannel surface electrodes FES," <i>J. Rehabil. Res. Dev.</i>, 20, pp. 3-20, 1983.</p> </li> </ol> <em><b>*J. Katakis </b> Member of the Bioengineering Unit at the University of Strathclyde in Glasgow.</em><br /><br /><em><b>*A. Kralj </b> Member of the faculty of Electrical Engineering at Edvarda Kardelja University in Ljublana.</em><br /><br /><em><b>*B.J. Andrews </b> Member of the Bioengineering Unit at the University of Strathclyde in Glasgow.</em><br /><br /><em><b>*T. Bajd </b> Member of the faculty of Electrical Engineering at Edvarda Kardelja University in Ljublana.<br /><br /><br /></em> Page Number(s) 111 - 114 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.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 Restoration of Walking in Patients with Incomplete Spinal Cord Injuries by Use of Surface Electrical Stimulation: Preliminary Results Creator An entity primarily responsible for making the resource T. Bajd * B.J. Andrews * A. Kralj * J. Katakis * https://staging.drfop.org/files/original/a962e11e32431a447a3ce708cbc2efbd.pdf e6d793879e49c2715fac7901c9ab48ab DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_034.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 34 - 43 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_034.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_034.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>Review of Visual Aids for Prosthetics and Orthotics</h2> <h5></h5> <h4>Prosthetics (General)</h4> <p><i><strong>"A Day in the Life of the Amputee," Hosmer-Dorrance, 1955, 26 min., color, silent, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents a bilateral upper-extremity amputee as he performs a number of activities related to self-care, work, and recreation. These include fishing, bowling, gardening, dressing, eating, playing pool, driving a car, and lighting a cigarette.</p> <p><i>Evaluation: </i>A technically well-executed film of a man who has acquired unusual skill in the use of the prostheses. It is recommended for upper-extremity amputees and for professional groups who wish to become familiar with the potential accomplishments of this type of amputee. Essentially, its purpose appears to be to encourage upper-extremity amputees to use prostheses and to develop maximal skill in their use.</p> <p><i>Distributor: </i>A. J. Hosmer Corporation, P. O. Box 37, Campbell, Calif. 95008.</p> <p><i><strong>"A Triple Amputee Steps Out," U.S. Veterans Administration, 1964, 25 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Shows the rehabilitation of a male adult with an above-knee amputation on one side, a below-knee amputation on the other, and a unilateral above-elbow amputation. The patient also suffers from heart and kidney complications that add to the difficulty of rehabilitation. Preprosthetic exercises and balancing activities are followed by ambulation with stubbies and, finally, with permanent prostheses and crutches.</p> <p><i>Evaluation: </i>The level of rehabilitation for this severely involved patient appears unrealistic; and, although he finally ambulates, the gait is labored and unsteady. Use of the upper-extremity prosthesis, which would seem a more useful activity for this patient, is not discussed. This film has little place in paramedical teaching and would be of interest only to note the accomplishments of this unusual and highly motivated amputee.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Diary of a Sergeant," U.S. War Department, 1945, 22 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>The story of a soldier (Harold Russell) who, having lost both arms during World War II, wages a determined and successful fight to achieve success in the use of artificial limbs and to establish himself as a useful member of society.</p> <p><i>Evaluation: </i>An excellent film for its era. It has lost much of its value, however, through the passage of time and today is primarily of historical interest. It deals with the emotional trauma involved in loss of arms and portrays the courage required by an amputee to achieve his rehabilitation goals. For these reasons, the film may still serve a purpose when used to motivate discouraged upper-extremity amputees or when shown to groups concerned with the emotional impact caused by crippling disease or injury.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Dynamic Exercises for Lower-Extremity Amputees," U.S. Veterans Administration, 1959, 10 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Reviews normal gait and the relationships of body segments during walking. Following the physician's examination of the above-knee stump, the amputee patient demonstrates a series of dynamic exercises to develop balance, coordination, and strength. These exercises are part of a physical-therapy program that prepares the amputee to meet daily functional demands. Several amputee gaits are demonstrated.</p> <p><i>Evaluation: </i>This is a large order for a ten-minute film, particularly since it goes beyond the scope of the title. The exercises <i>per se </i>are excellent, but the rate at which they are presented limits the use of the film as a teaching device. A patient-to-patient type of teaching contributes to some worthwhile scenes. The film is considered useful for those who are previously oriented in the techniques of dynamic exercises and who are experienced in working with amputees.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Gait Analysis," Northwestern University Medical School, 1961, 27 min., color, sound, 16 mm.</strong></i> <a style="text-decoration:none;">*</a></p> <p><i>Summary: </i>Demonstrates the most common gait defects that may be seen in an above-knee amputee, including circumduction, abduction, vaulting, medial and lateral whips, instability of the knee, long prosthetic step, and others. The defects are shown on a subject wearing an adjustable above-knee prosthesis and are described in detail, then discussed as to possible causes, considering the amputee, the stump, and the prosthesis. Demonstrates a normal gait so that comparison between normal and abnormal gait can be made. The narration is conducted by a physician, a prosthetist, and a physical therapist, all faculty members of the Prosthetic-Orthotic Education Program at Northwestern University Medical School. A pocket-size folder that summarizes the material presented has been prepared for use as a handout at showings.</p> <p><i>Evaluation: </i>This is a valuable teaching film. Ample time is allowed for the viewer to observe each gait deviation, making it possible for him to correlate the movie sequence with the material presented in the booklet that accompanies the film. Recommended for all medical groups concerned with the management of the lower-extremity amputee, including physicians, physical and occupational therapists, nurses, and prosthetists, at both the student and the graduate levels. The amputee patient would also benefit from seeing this film.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>$3.00.</p> <p><i><strong>"New Geriatric Prostheses Adaptable to Bilateral Amputees," Waterbury Hospital, Waterbury, Conn., 1964, 10 min., color, silent, 16 mm.</strong></i></p> <p><i>Summary: </i>Describes an above-knee prosthesis designed for use by the geriatric patient and points out the advantages of certain modifications over the more conventional "temporary" prosthesis. Demonstrates the use of these prostheses as fitted to a bilateral amputee, a 64-year-old woman.</p> <p><i>Evaluation: </i>This film would be of interest only to those who are dealing with the problems of prescribing, designing, or fabricating prostheses for the geriatric patient. The graphic description of the prosthesis is well presented.</p> <p><i>Distributor: </i>Dr. Sung J. Liao, Director, Department of Physical Medicine and Rehabilitation, Waterbury Hospital, Waterbury, Conn.</p> <p><i><strong>"New Legs," National Council for Care of Cripples, South Africa, 1960, 18 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents the case history of a young railway plate-layer who suffered an accident that ultimately resulted in a bilateral hip disarticulation. He is fitted with a pair of prostheses that incorporate double-action hip joints. Following a training program, he is shown walking with prostheses and crutches and participating in many physical activities with and without the prostheses.</p> <p><i>Evaluation: </i>The purpose of this film is to encourage people living in South Africa to support rehabilitation through the purchase of Easter Seal stamps. Perhaps this accounts for the optimistic tone of this technically excellent picture. The amputee is unusually cheerful, physically agile, and well motivated, and his well-planned rehabilitation program is highly successful. This film might be of interest to the patient and family. For paramedical groups it is of interest only to show the potential achievement of one amputee with a bilateral hip disarticulation.</p> <p><i>Distributor: </i>Film Library, International Society for Rehabilitation of the Disabled, 219 East 44th St., New York, N. Y. 10017.</p> <p><i>Rental Fee: </i>$10.00. (No rental fee for members in good standing with the International Society.)</p> <p><i><strong>"Normal Human Locomotion," University of California at Los Angeles, 1965, 3 hr., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>This seven-reel film reproduces a classroom lecture as presented by Cameron B. Hall, M.D., in the UCLA courses in lower-extremity prosthetics. In his presentation, Dr. Hall graphically describes the normal pattern of human locomotion and explains it in terms of pertinent basic principles, including determinants of gait and mechanical forces. The film is printed at a contrast level that permits it to be shown in a partially lighted room, thereby allowing viewers to write on the illustrated lesson sheets provided with the film.</p> <p><i>Evaluation: </i>The film is of special value. It encompasses a difficult subject on the basis of research from voluminous literature, and it is organized in a clear, concise, and understandable manner.</p> <p>No attempt is made to achieve a technically perfect film; it comes "as is" from the classroom. Dr. Hall's teaching methods, which include skillful execution of illustrations, a keen sense of timing, and--most important-a sequential, organized presentation of materials, combine to make this film an excellent teaching device for both students and instructors.</p> <p>The film is highly recommended for any professional person engaged in gait training or concerned with any aspect of human locomotion. Its use in undergraduate programs will vary according to the teaching talents of the faculty members and the curriculum content. If the length precludes showing it in one session, it can be shown in two or three sessions. It is recommended that instructors review the film in order to strengthen their own teaching methods and to determine in what way it can supplement or reinforce instruction in their own particular situation.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>$3.00. (The film may be retained by the borrower for a maximum time of two weeks. Requests for the film should indicate the number of lesson sheets desired.)</p> <p><i><strong>"One Step at a Time," Rehabilitation Institute of Montreal, 1963, 15 min., black and white. sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Portrays a unilateral above-knee amputee who is first seen walking with crutches but without an artificial limb. After considerable introspection, this young male decides to be prosthetically fitted. As the story unfolds, it depicts his reaction to the various steps in the rehabilitation program. The three key people responsible for the program-the physician, the physical therapist, and the prosthetist-are presented, and their roles are briefly explained. The prosthetist plays the major role in this film.</p> <p><i>Evaluation: </i>The close-ups, the music, and the general tone of this picture are designed to show the emotional impact on the amputee of the various situations that evolve during the rehabilitation process. The movie is photographically artistic and technically good. Its use to professional people is limited, however, because of the superficial manner in which the material is handled. It appears to be directed toward the layman and especially toward the unfitted amputee.</p> <p><i>Distributor: </i>National Film Board of Canada, 690 Fifth Ave., New York, N. Y. 10019.</p> <p><i>Purchase Cost: </i>$75.00. (Available for review if viewer is interested in purchasing the film.)</p> <p><i><strong>"Physical Therapy Management of a Bilateral Lower-Extremity Amputee," U.S. Army, (PMF 5382), 1964, 32 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Illustrates the progression of physical-therapy procedures in the management of the amputee, following the program from the day preprosthetic stump exercises are initiated until the time skillful use of the prostheses is achieved and the amputee-a military officer-is returned to duty as an instructor. The various procedures include bandaging of the above-knee and below-knee stump, joint measurement, stump exercises, stump hygiene, care of the suction socket, body-strengthening and balancing exercises, gait training and analysis, and advanced functional activities. Also, briefly presented are the principles involved in fitting two types of prostheses, the suction socket and the patellar-tendon-bearing socket.</p> <p><i>Evaluation: </i>The film is technically superior and professionally sound. Of particular interest and worthy of mention are the well-presented progression of exercises, the clear graphic descriptions, the inclusion of training with the patellar-tendon-bearing prosthesis, and the portrayal of the exacting self-discipline required by the patient.</p> <p>Although the rehabilitation team is acknowledged, the film is presented entirely from the physical therapist's point of view. Because of the extensive amount of material in this film, its primary value lies in an orientation to a good physical-therapy program rather than its use in teaching skills. It is recommended for viewing by physical therapists and students, and also by any of the allied medical professions who have an interest in the management of the amputee. New amputees would also appreciate this preview of the treatment program.</p> <p><i>Distributor: </i>Requests for Army Medical Service motion pictures should be directed to the Commanding General, Attn.: Audio-Visual Communication Center, of the Army Area in which the requesting individual or institution is located, as follows: First U.S. Army, Governors Island, N. Y. (includes Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Vermont); Second U.S. Army, Fort George Meade, Md. (includes Delaware, Kentucky, Maryland, Ohio, Pennsylvania, Virginia, and West Virginia); Third U.S. Army, Atlanta, Ga. (includes Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, and Tennessee); Fourth U.S. Army, Fort Sam Houston, Tex. (includes Arkansas, Louisiana, New Mexico, Oklahoma, and Texas); Fifth U.S. Army, 1660 East Hyde Park Blvd., Chicago, Ill. (includes Colorado, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, South Dakota, Wisconsin, and Wyoming); Sixth U.S. Army, Presidio of San Francisco, Calif. (includes Arizona, California, Idaho, Montana, Nevada, Oregon, Utah, and Washington).</p> <p><i><strong>"Some Biomechanical Methods for Evaluating Activities," VA Prosthetics Center, 1956, 18 min., color, magnetic sound {requires special projector), 16 mm.</strong></i></p> <p><i>Summary: </i>Shows some of the biomechanical methods used in the laboratory to measure the effectiveness with which both normal and handicapped people can perform various activities. Various photographic, mechanical, and electrical techniques are demonstrated.</p> <p><i>Evaluation: </i>This interesting film deals with research methodology and is, therefore, of interest primarily to individuals engaged or interested in research.</p> <p><i>Distributor: </i>Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</p> <p><i><strong>"Suction Socket Artificial Limb," U. S. Veterans Administration, 1951, 24 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Describes the suction-socket prosthesis in terms of the anatomical principles involved in its fabrication and fitting. Presents the indications and contraindications for its prescription, emphasizing the importance of the emotional maturity of the patient. Demonstrates briefly gait abnormalities and training. Also illustrates check-out procedures.</p> <p><i>Evaluation: </i>Although made in 1951, this excellent film is valuable in its presentation of a type of above-knee prosthesis that continues to be widely used. This film is of greatest value to physicians, prosthetists, and physical therapists, both staff and students. As background information, it could be useful for anyone concerned with the management of the above-knee amputee.</p> <p><i>Distributor: </i>Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</p> <p><i><strong>"The Urban Maes Amputation for Peripheral Vascular Disease," U. S. Veterans Administration, 1956, 14 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Demonstrates the Urban Maes operative technique of below-knee amputation in a patient with disease of compromised circulations. Shows the healed stump and joint range of motion some weeks later. Also presented are several other patients whose treatment management is similar. Several views of stumps are shown, and the patients are seen ambulating on a temporary pylon as well as on the permanent prosthesis.</p> <p><i>Evaluation: </i>Primarily of value to physicians. Because of its relative simplicity, however, the film would be a good selection to illustrate a well-defined surgical procedure to individuals who have not observed actual surgery.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Total Rehabilitation of a Bilateral High Upper-Extremity Amputee" U. S. Veterans Administration, 1959, 30 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Stresses the roles of all members of the rehabilitation team in the management of this amputee. Illustrates the team approach in establishment of the program-examination and supervision by the physician; preprosthetic preparation of the stump and an exercise program by the physical therapist; prosthetic training by the occupational therapist; and vocational guidance by the counselor. Most of the time in this film is devoted to occupational therapy, and the amputee is shown in several learning situations involving functional activities.</p> <p><i>Evaluation: </i>The scenes that show how the patient encounters difficulty in performing normally simple chores and how the patient and the therapist work together to find an efficient method of performance are well presented. Although the film does not attempt to present a step-by-step prosthetic training program, the omission of any reference to solving toilet problems, a real concern with this type of amputee, is unfortunate. The team approach is somewhat overemphasized in the film, particularly insofar as the meetings are concerned. This film has teaching value for occupational therapy students and for occupational therapists who have had limited experience in working with patients with upper-extremity amputations. It may also be useful as an orientation for any paramedical group whose members are concerned with the management of the high upper-extremity amputee.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D. C, 20420.</p> <p><i><strong>"Upper-Extremity Prosthetics," U. S. Veterans Administration, 1952, 23 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents two veterans, both of whom are upper-extremity amputees. One wears his prosthesis successfully; the other keeps his device in his desk. The film explains the dynamics leading to this difference. The successful patient is portrayed as the recipient of services offered in a well-planned amputee management program. The absence of such a program, together with other deterrent factors, is presented as the cause for the second patient's rejection of his original prosthesis. A program designed to correct his reluctance to wear the prosthesis is outlined.</p> <p><i>Evaluation: </i>This film succeeds in achieving its objectives, as it clearly demonstrates the importance of good technical and psychological management of the amputee patient. It is not recommended as a teaching film, for it is lacking in its portrayal of the ideal training program. It is recommended as a general type film for paramedical groups and for patients who might be resistant to the intensive effort needed to obtain maximal use of the prosthesis.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D. C. 20420.</p> <p><i><strong>"Upper-Extremity Prosthetic Principles," U. S. Veterans Administration, 1955, 29 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Demonstrates several interesting activities that were part of a research program aimed at improving upper-extremity prosthetic devices. Of special interest are the demonstration of normal movements of the human hand in a variety of grasping and gripping activities, an analysis of lost movements at various levels of upper-extremity amputation, and the types of upper-extremity prostheses appropriate for specific levels of amputation.</p> <p><i>Evaluation: </i>As far as paramedical groups are concerned, this film is of interest to those who would like to be better informed about the development of prosthetic devices. It could be used to illustrate components of prostheses when these are not available, although it should be remembered that only those prosthetic devices in use prior to 1955 are included.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D. C. 20420.</p> <h3>Child Prosthetics</h3> <p><i><strong>"Adaptation of Children to Prosthetic Limbs," Michigan Crippled Children Commission, 1960, 20 min., color, optical and magnetic sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents five children, including upper- and lower-extremity amputees, each of whom demonstrates a wide range of physical activities while wearing his prosthesis. The disability of the child and the indicated prosthetic fitting are also presented.</p> <p><i>Evaluation: </i>This film demonstrates well how the artificial limb becomes an integral part of the body image at an early age. The remarkable skill and agility with which these children perform various physical activities are impressive. Some scenes are unnecessarily prolonged and repetitious. The technical quality of the film is not good, and prosthetically it is primarily of historical interest. Of possible interest to parents in demonstrating potential achievement.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <p><i><strong>"Child Upper-Extremity Amputee," University of Michigan Medical Center, 1964, 19 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents ten child amputees and portrays their accomplishments in use of an upper-extremity prosthesis at specified ages, covering a span of several years in some instances. The x-rays of the involved extremities are shown, and a pictorial description of the amputation or limb deficiency is given. In cases of congenital amputees, diagnoses are given in terms of roentgenographical appearance. The type of prosthesis prescribed for each child and the changes necessitated by his growth and development are shown.</p> <p><i>Evaluation: </i>A well-presented, informative film that graphically portrays the accomplishments that may be expected of the child amputee who has the advantage of an early treatment program. It points out clearly the disadvantage to the child when prosthetic fitting is delayed. An orientation film of a specialized nature, it should be of interest to any professional person involved in the care of the child amputee. Parents of child amputees could also benefit by seeing this film. It is recommended for public health nurses who are in a position to refer the young amputee to the amputee clinic.</p> <p><i>Distributor: </i>Audio-Visual Education Center, University of Michigan, Frieze Building, 720 East Huron St., Ann Arbor, Mich. 48104.</p> <p><i><strong>"Child Prosthetics Project: A Report," University of California at Los A ngeles, 1958, 22 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Explains the role of each member of a large prosthetics team, which includes the family physician, pediatrician, orthopaedic surgeon, social worker, psychologist, engineer, prosthetist, physical therapist, occupational therapist, and project administrator. Portrays proceedings of a prosthetics conference, during which the patient and parent are presented. The contributions of the social worker, the psychologist, and the engineer are emphasized. At the conclusion of the film, it is explained that one of the principal purposes of the team is to collect research data with a view toward improving training and prosthetic devices and procedures.</p> <p><i>Evaluation: </i>At the time the film was made, it undoubtedly served the purpose of showing the UCLA program as well as presenting the concepts of the prosthetics team and the early fitting of the child amputee. Although it might be of some value in demonstrating a research approach, its outdated quality relegates it, for the most part, to the category of "historical interest."</p> <p><i>Distributor: </i>Paul L. Brand and Son, 2153 K St., N.W., Washington, D. C. 20001.</p> <p><i>Rental Fee: </i>S7.60 plus shipping charges.</p> <p><i><strong>"Early Development of Ambulation-Unilateral Below-Knee Amputee," University of California at Los Angeles, 1965, 18 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Depicts the progress of the child amputee from the time he attempts to stand until he walks independently with the prosthesis, which has become an integral part of his body image. Shown are the changing patterns of rhythm, the gradual narrowing of the base of support, and the increasing stability as motor-kinesthetic development takes place and the child participates in increasingly complex skills and play activities.</p> <p><i>Evaluation: </i>Presents well the concept of early fitting, as the child is shown wearing and using the prothesis as effectively as a normal leg. The film should be shown in conjunction with <i>Infant to School-Age Child - Unilateral Below-Elbow Amputee.</i></p> <p><i>Distributors: </i>Child Amputee Prosthetics Project, UCLA Rehabilitation Center, 1000 Veteran Ave., Los Angeles, Calif. 90024. Also available for loan from the crippled children's services in all 50 states and in the District of Columbia, the Virgin Islands, Puerto Rico, and Guam through funds supplied by the Children's Bureau, Department of Health, Education, and Welfare.</p> <p><i><strong>"Infant to School-Age Child - Unilateral Below-Elbow Amputee," University of California at Los Angeles, 1964, 10 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents the various stages in the motor-kinesthetic development of the child and relates them to the specific times at which the child amputee is ready for initial prosthetic fitting as well as for increasingly complex devices. As skills and physical activities develop in response to demands of daily living, devices are provided that are appropriate to the level of function. The cooperation of the parents in the teaching process is stressed.</p> <p><i>Evaluation: </i>The concept of fitting the child amputee with the appropriate device at a specific time in his motor-kinesthetic development is well presented. The film has value, not only in demonstrating the progress of the child amputee, but also in teaching the basic principles of growth and development in the young child. Although the film is specialized in nature, it is recommended for undergraduate students in paramedical fields to present the principles of growth and development. It is highly recommended for professional groups working with child amputees. It should be shown in conjunction with the film <i>Early Development of Ambulation</i>-<i>Unilateral Below-Knee Amputee.</i></p> <p><i>Distributor: </i>Child Amputee Prosthetics Project, UCLA Rehabilitation Center, 1000</p> <p>Veteran Ave., Los Angeles, Calif. 90024. Also available for loan from the crippled children's services in all 50 states and in the District of Columbia, the Virgin Islands, Puerto Rico, and Guam through funds supplied by the Children's Bureau, Department of Health, Education, and Welfare.</p> <p><i><strong>"Juvenile Amputee with Congenital Skeletal Limb Deficiencies," Tulane University School of Medicine, 1964, 20 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents ten patients treated at a child-amputee clinic. As each case is presented, the limb deficiency is described on the screen in the terminology of the recently developed roentgenographic classification. The deficiency is further described by x-ray plates and by pictures of the child before surgical procedures. Scenes filmed at a later date show the patient wearing and using a prosthesis fitted to the surgically revised limb. The history of the child is outlined rather fully and, in some instances, the history is pictorially depicted at intervals over a number of years.</p> <p><i>Evaluation: </i>This film would be helpful in reinforcing use of the classification of limb deficiencies as developed by O'Rahilly and Frantz. The results obtained in fitting severely involved children are impressive. The information presented is too extensive for the time allotted, making it difficult to stay with the narrator and detracting from the technical quality of the film. This film is recommended for professional groups interested in orientation to this particular type of patient and program. It could also benefit parents of the congenital child amputee.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>S3.00.</p> <p><i><strong>"Lower-Extremity Amputees - Toddlers," Michigan Crippled Children Commission, 1957, 22 min., color, magnetic sound {requires special projector), 16 mm.</strong></i></p> <p><i>Summary: </i>Presents briefly the motor development of the child as it relates to the upright position and ambulatory progress. Describes anomalies and stumps, both pictorially and roentgenographically. Discusses the prosthetic fitting and the child's ambulatory program. Changes in gait patterns over a number of years are demonstrated.</p> <p><i>Evaluation: </i>The development of the gait pattern over the years is especially interesting. Because of advances in design, fabrication, and the fitting of prostheses since the film was made, it has outlived its period of optimal value.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <p><i><strong>"Prosthetic Training of the Very Young Child Amputee - Upper Extremity,'" Michigan Crippled Children Commission, 1959, 20 min., color, optical and magnetic sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Demonstrates the training technique used in teaching three upper-extremity child amputees to use their prostheses. It shows a child-sized APRL hand that was in the experimental stage at that time.</p> <p><i>Evaluation: </i>This film shows good beginning training technique, outlining three different areas of training-basic body-control motions, development of prosthetic control, and functional prosthetic use. The training situations shift abruptly, causing the film to lose continuity. Technically, it is not a high-quality film. Occupational therapists might find this film of value because some of the techniques of training are still acceptable, although the prostheses are outdated.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <p><i><strong>"Upper-Extremity Amputees - Toddlers," Michigan Crippled Children Commission, 1956, 22 min., color, magnetic sound (requires special projector), 16 mm.</strong></i></p> <p><i>Summary: </i>Presents type, diagnosis, and prosthetic fitting of several upper-extremity child amputees. Demonstrates the performance of skills and activities while wearing the prosthesis.</p> <p><i>Evaluation: </i>This film, made at the Mary Free Bed Guild Children's Hospital in Grand</p> <p>Rapids during the earlier years of the child-amputee program, serves to demonstrate how readily children adapt to early prosthetic fitting. Advancements in the prosthetic field, however, cause the film to be outdated. It should be noted that the sound, which is magnetic, is cut off for about the last ten minutes.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <h3>Orthotics</h3> <p><i><strong>"Assistive Devices for the Physically Handicapped," National Foundation for Infantile Paralysis, 1951, 12 min., sound, color, 16 mm.</strong></i></p> <p><i>Summary: </i>Illustrates many assistive devices and their use by postpoliomyelitis patients. The devices include mouth sticks, overhead slings, feeders of various types, automatic page turners, hydraulic lifts, and several others.</p> <p><i>Evaluation: </i>This very comprehensive film is useful to show the kinds of devices used to increase the functional capacity of the post-poliomyelitis patient with severe residual paralysis. Credit is due those whose ingenuity resulted in the improvised equipment demonstrated here. While the film is photographically excellent, its content in terms of emphasis on certain devices, such as the mouth stick, is questionable. The film, made prior to the poliomyelitis vaccines, is necessarily outdated in some aspects, but the devices shown would still be of interest to personnel working with the severely disabled.</p> <p><i>Distributor: </i>Film Library, International Society for Rehabilitation of the Disabled, 219 East 44th St., New York, N. Y. 10017.</p> <p><i>Rental Fee: </i>$10.00. (No rental fee for members in good standing with the International Society.)</p> <p><i><strong>"Kinetics and Orthotics for Function," Institute of Physical Medicine and Rehabilitation, New York University Medical Center, 1963, 25 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents the basic principles in the selection and the use of orthotic devices to achieve as normal function as possible in the presence of upper-extremity weaknesses. The basic normal motions of the upper extremity in the performance of several everyday activities are carefully depicted. The subject, a quadriplegic patient, is introduced as he is undergoing a manual muscle test. The test, which reveals severe weakness in the musculature of the upper extremities, also serves as a basis for determining the degree and nature of the mechanical assistance required to supplement the existing strength. Periodic evaluations are made; and, as strength increases, the appliances are adjusted or replaced. Finally, the amount of assistance is reduced to the minimum required by the patient, who is shown performing a number of activities. Before discharge from the hospital, the patient is equipped with a flexor-hinge hand and is planning to return to his former occupation.</p> <p><i>Evaluation: </i>An excellent analytical presentation of the prescription and use of orthotic devices for severely involved upper-extremity patients. Outstanding in this picture is its adherence to the practice of sound teaching principles. As each new step is presented, the principle underlying the selection of orthotic devices is applied and illustrated. The analysis of normal motion serves as a basic approach to the problem. The film gives a feeling for the long time involved and is realistically hopeful in terms of patient accomplishment. This film is highly recommended for all paramedical groups; for occupational therapists it is of value in teaching specific techniques of training.</p> <p><i>Distributor: </i>Film Library, New York University Medical Center, 342 East 26th St., New York, N. Y. 10016.</p> <p><i>Rental Fee: </i>$5.00.</p> <p><i><strong>"Spinal Cord Injury" Rancho Los Amigos Hospital, 1961, 25 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Depicts eight levels of spinal-cord injury and demonstrates the degree of independence that the average patient can attain after injury. Independence is accomplished through a program of maximum strengthening of the remaining active muscles, combined with appropriate assistive devices, such as short leg braces, long leg braces, overhead slings, artificial muscles, special splints, crutches, hydraulic lifts, etc., and training.</p> <p><i>Evaluation: </i>This well-organized film discusses clearly and precisely each level of injury in terms of specific pertinent information, such as key muscle groups involved, functional loss, and orthotic devices. It points out that the prognosis of the patient is not constant with the level of injury, but is based on demonstrable muscle function. Limitations are carefully noted, and goals are realistic. The film is highly recommended for any professional person working with the paraplegic or quadriplegic patient and for inclusion in the undergraduate curriculum for therapists and nurses. Patient and family would benefit from seeing this film, provided they have accepted a realistic attitude toward rehabilitation.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>$3.00.</p> <p><i><strong>"The Heather Hand," U. S. Veterans Administration, 1960, 10 min., color, silent, 16 mm.</strong></i></p> <p><i>Summary: </i>Describes a light-weight, wrist-extension, hydraulic orthosis. Shows the patient putting it on himself and performing several activities.</p> <p><i>Evaluation: </i>Although this film illustrates the device very well and graphically demonstrates its function, it is of practically no value for paramedical groups because it is not accompanied by any explanation, either written or auditory.</p> <p><i>Distributor: </i>Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</p> <h3>Amputation Surgery and Fabrication of Prostheses</h3> <p>The compilers of this review did not consider themselves qualified to evaluate films on amputation surgery or the fabrication of prostheses.</p> <p>Titles of films on surgery may be found in the <i>Film Reference Guide for Medicine and Allied Sciences, </i>U. S. Department of Health, Education, and Welfare, Public Health Service, Communicable Disease Center, Atlanta, Ga. 30333.</p> <p>For those interested, the following films on the fabrication of prostheses are listed.</p> <p>Available from the Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001: <i>Above-Knee Prosthetics</i>-<i>Stump Casting with the Use of a Casting Stand; Below-Knee Prosthetics</i>-<i>Stump Casting with the Use of a Casting Stand; Fabrication Technique for Medial Opening, Polyester Nylon, Syme Prosthesis; Plastic Finishing of an Above-Knee Socket; The Total-Contact, Soft-End, Plastic Laminate Above-Knee Socket.</i></p> <p>Available from Hydra-Cadence, Inc., 623 South Central Ave., P. O. Box 110, Glendale, Calif.: <i>Hydra-Cadence, Reel 1; Hydra-Cadence, Reel 2.</i></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">Enhancing the value of this film and intended to be used in conjunction with it are 16 loop films, each of which depicts one gait deviation. These loops are 7 ft. in length and can be rerun an indefinite number of times on standard projectors. The set may be purchased for $25.00. When the film is ordered, a check in this amount should be made payable to the distributor: Ideal Picture Co., 417 North State St., Chicago, Ill. 60610.</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 Review of Visual Aids for Prosthetics and Orthotics https://staging.drfop.org/files/original/465b011652d5a340194157a65a7ec6cc.pdf 058afa0a050515ba9cadcbbbe5bbdcbc https://staging.drfop.org/files/original/1117b4f8d56a347cb37a8fec48fb1ba1.jpg fb35416caeea9a249029aa892a41fa14 https://staging.drfop.org/files/original/f48d51f3218c758f4338e50f0b689234.jpg fabaf7cea0b1796ff8316615aabb3e95 https://staging.drfop.org/files/original/812c173d343ffad067c6c208af011518.jpg e1dad0e0174b7d66a96d04ede66f5469 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/cpo/pdf/1984_04_024.pdf Text Any textual data included in the document <h2>Rochester Parapodium</h2> <h5>Edwin Kinnen, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Martha Gram, P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Kenneth V. Jackman, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Franklin V. Peale, M.D., P.C.&nbsp;<a style="text-decoration: none;">*</a><br />P.W. Haake, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Gerald A. Tindali, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />James A. Brown, O.P.A.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The Biomechanics Team at the University of Rochester Medical Center has been developing and testing design modifications to the Toronto parapodium since 1975. Early in 1983, these design modifications had stabilized, and prototypes of the new design were offered to medical centers and orthopedic laboratories in the United States and Canada. The Rochester parapodium has now been fitted to over 80 young children of ages 17 months to 14 years. Most of these children have flaccid paralysis due to spina bifida or spinal injury from L5 to T12.</p> <p>The Rochester parapodium differs from the Toronto design in the hip and knee hinge and locking mechanisms. The hip joints unlock together with a single lever release and lock automatically on extension. The hip joints unlock with a forward motion and have no lateral projections, which allows ease in releasing hip lock in a confined space such as a wheelchair. The knee joints also unlock independent of the hip joints with a second single lever release and lock automatically on extension with the aid of an extension assist bar.</p> <p><b><a href="/files/original/1117b4f8d56a347cb37a8fec48fb1ba1.jpg">Figure 1</a>: The hip joints unlock independent of the knee joints.</b></p> <p>Without lateral projections, rolling is easier for the child who applies the orthosis sitting or in the supine position on floor, then rolls to prone position in order to elevate to a standing posture. This separated locking and unlocking action has simplified many everyday activities for the paraplegic child.</p> <p>With increased control, the child can become independent in sitting and standing from a chair with arms. He can also bend over to pick up objects from the floor with hips flexed and knees locked. These are important functions for a preschooler exploring his or her surroundings and participating in peer group activities.</p> <p><b><a href="/files/original/f48d51f3218c758f4338e50f0b689234.jpg">Figure 2</a>: Both joints unlock with a pull of a lanyard.</b></p> <p>Previously, children wearing the parapodium had to get up from a prone position on the floor by pulling to standing with fully extended knee and hip joints. Now a child can use jackknife-like movements to stand. These movements appear to require much less energy and open the activity to children with higher levels of paralysis.</p> <p>The lateral supports have also been redesigned for the Rochester parapodium, using bar stock instead of tubular sections. These flat lateral supports facilitate rolling, a very important movement for a child who is independent in dressing and changing positions. The new side bar design, a more rigid construction, also improves the child's momentum during swivel walking. With polypropylene added to the bottom of the base, many children can learn to swivel-walk at functional speeds, with hands free.</p> <p><b><a href="/files/original/812c173d343ffad067c6c208af011518.jpg">Figure 3</a>: A child can bend over to pick up objects with hips flexed and knees locked.</b></p> <p>The activities now possible with the new design allow the paraplegic child to function at home and in school with relatively little need for adult supervision or assistance.</p> <p><i>Partial support for this work has been provided by the J.M. McDonald Foundation, Cortland, New York.</i></p> <em><b>James A. Brown, O.P.A. </b> Rochester Orthopedic Laboratories, Inc., 1654 Monroe Avenue, Rochester, New York 14618.</em><br /> <div style="width: 400px;"><em><b><br />Gerald A. Tindali, C.P.O. </b> Rochester Orthopedic Laboratories, Inc., 1654 Monroe Avenue, Rochester, New York 14618.</em></div> <div style="width: 400px;"></div> <div style="width: 400px;"><em><br /><b>P.W. Haake, M.D. </b> 220 Alexander Street, Rochester, New York 14610</em></div> <div style="width: 400px;"><em><b><br />Franklin V. Peale, M.D., P.C. </b> 220 Alexander Street, Rochester, New York 14610.</em></div> <div style="width: 400px;"><br /><em><b>Kenneth V. Jackman, Ph.D. </b> Associate Professor of Pediatric Orthopedics, University of Rochester, Rochester, New York 14642.</em><br /><br /></div> <div style="width: 400px;"><em><b>Martha Gram, P.T. </b> Dept. of Pediatrics, University of Rochester, Rochester, New York 14627.</em></div> <div style="width: 400px;"><br /><em><b>Edwin Kinnen, Ph.D. </b> Dept. of Electrical Engn, University of Rochester, Rochester, New York 14627.<br /><br /><br /></em></div> Page Number(s) 24 - 25 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_024/1984_04_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_024/1984_04_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_04_024/1984_04_024-3.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 Rochester Parapodium Creator An entity primarily responsible for making the resource Edwin Kinnen, Ph.D. * Martha Gram, P.T. * Kenneth V. Jackman, Ph.D. * Franklin V. Peale, M.D., P.C. * P.W. Haake, M.D. * Gerald A. Tindali, C.P.O. * James A. Brown, O.P.A. * 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. Contact Name/Title Nainu Singh - Director Address C2-2199 Vasantkunj City New Delhi State/Province Delhi Countries Served India Regions: AsiaCountries: IndiaSpecific cities, regions, or groups of people: NCR, New Delhi,Luknow, Chandigarh, Lakhimpur, BOMBAY etc. Regions: NationalCapital Region, UP, Bihar, Maharashtra. Poor groups.Age Group: Adults, ChildrenFees Charged: No Postal Code 110070 Phone 9213374588 Fax 91-11-26893172 Email rews100@yahoo.co.in Organization Type Including ID and tax status Non-profit Tax ID NGO Not-for-profit Type FCRA Services Provided Prosthetic Fitting, Orthotic Fitting, Medical Equipment / Supplies, Education, Medical / Surgical Care, Rehabilitation / TrainingThere is a facility/physical building for patient care at the specified location. Need I Financial Assistance Need II Materials, Components, and Equipment Need III Materials, Components, and Equipment: New, Disassembled, Equipment, Used, Medical Supplies, Other: Equipments as required. Additional Info & Comments Our organisation, founded in 1990, has been holding awareness camps for prevention of AIDS, Hepititis, Child and maternity care. We have inoculated more than 20000 individuals for hepetitis,polio, T.B ets. Regular seminars and camps have been held to provide artificial limbs, cruthes, tricycles, and other such equipment to the needy patients. Expert physicians and Orthotic & Prosthetic experts have examined and prescribed treatment and equipment as per needs of the patients. 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 Rural Education and Welfare Society https://staging.drfop.org/files/original/d387177f1743b2d3eb2e5fd8a7efd4c6.pdf 5152d646cade58bf58af3b450a7b5ac2 https://staging.drfop.org/files/original/cf533beb527fcd368a66e40b0251877b.jpeg 746bfce96a05847c161f7f8919e43c51 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/1983_04_001.pdf Text Any textual data included in the document <h2>S-N-S Knees and the Bilateral A/K Amputee</h2> <h5>Gustav Rubin, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>We have under our care at VAREC eleven adult male bilateral A/K <i>ambulators</i>. Ten of these use Swing and Stance (S-N-S) knees and one, a missionary to a remote area in Africa, was fitted with single axis knees because of the obvious need for simplicity in his special circumstances. Eight of our S-N-S users are active individuals, but two are household and limited community ambulators. As would be anticipated, all of our above-knee amputee ambulators are in good physical condition and strongly motivated. These were important aspects in prescribing prostheses. The S-N-S knees provided the amputees with the smooth gait characteristic of hydraulics, greater security, improved ease in reaching the sitting position, improved opportunity to recover from sudden stops or potential stumbles, better control when descending stairs, and the ability to lock one or both knees for negotiation of stairs. We have also found the S-N-S to be the sturdiest of the hydraulic units.</p> <p><b><a href="/files/original/cf533beb527fcd368a66e40b0251877b.jpeg">Image</a>: </b>A.H., an active bilateral A/K ambulator.<br /><br />No one of our amputee veterans demonstrates the potential of S-N-S knees better than A.H., injured in Vietnam at 21 years of age. A. H. was initially evaluated by the VAREC Clinic Team over one year later on Sept. 24,1970.</p> <p>A.H. sustained bilateral A/K amputations. The right A/K stump was eight inches in length and multiply scarred. The left A/K stump, partially covered by healed split thickness skin grafts, was seven and one-half inches in length. A.H. also sustained partial amputations of the fingers of both hands. The index and middle fingers of the left hand were amputated; on the right hand, the proximal phalanges of the fourth and fifth fingers and the first metacarpal of the thumb were retained. A.H. demonstrated that he was capable of grasping crutches with both residual hands. On the right he could come within an inch of opposing the first metacarpal to the fourth and fifth proximal phalangeal stumps. Opposition could be achieved on the left.</p> <p>A.H. was in excellent physical condition, very well motivated, without hip contractures, and with good muscle power of the trunk and residual extremities. He had been working out in his garage, which he had converted to a gym. When seen, he weighed 160 lbs. and indicated that his pre-amputation height was 6 feet, 1-1/2 inches (a height that was subsequently successfully reachieved at his request).</p> <p>The VAREC Clinic Team decided to prescribe bilateral A/K partial suction quad sockets with waist belt, rigid uprights and band, multiplex knees (to allow trial of several knee units "in the rough"), and, finally, a trial with first SACH feet, and then single axis feet. The S-N-S knee units and single axis feet were selected on the basis of A.H.'s performance with them.</p> <p>On May 13, 1971 A.H. walked to VAREC without a cane or crutches. After a subsequent trial with total suction and silesian belts he had to be returned to his original prescription, due to stump scarring.</p> <p>A.H. had been an accomplished skier prior to amputation and, on January 25, 1974, requested prostheses with which he could ski again. The clinic team notes of that date follows.</p> <p>"He has been informed that skiing will be dangerous. Nevertheless, he is anxious to try it, and, because of the morale factor and the intensity with which this patient wishes to ski, plus the fact that he was a skier prior to his leg amputations, the prostheses have been ordered." Outrigger ski poles with special adjustments for the hand grips were also prescribed.</p> <p>The first prescription was determined after another bilateral A/K skier was invited to visit the clinic team with his prostheses. That concept was copied and prostheses were supplied to A.H. with solid knees fixed at 45 degrees and correspondingly dorsiflexed feet. They were rejected shortly thereafter by A.H. since they allowed him to slide down only low slopes.</p> <p>The prostheses with S-N-S knees and single axis feet however, did allow him to actively ski. It is noteworthy that the most efficient position of his stumps, since he required strong abductor power for skiing, was found to be in sockets set up in almost twenty degees of abduction. Since the neutral position of the feet was more efficient for skiing the feet were not out-toed.</p> <p>A.H. proved his proficiency on skis (<a href="/files/original/cf533beb527fcd368a66e40b0251877b.jpeg">see photo</a>) by winning the handicapped Olympics in Norway in 1982. He has competed in numerous events in the U.S. and overseas and he reports that he can negotiate 40 slalom gates in 60 seconds.</p> <p>He has not been trouble free, however. The most serious of his problems occurred when a spur was removed from his left stump and overlying soft tissue breakdown occurred. Although this healed secondarily, the clinic team advised that the area be covered by adequate soft tissue. This was done and the amputee had no further difficulty. A.H. continues to be active and, in addition to skiing, sails his own boat.</p> <p>Not all amputees, however, follow the same road to successful ambulation. At one time, the clinic team believed they had two patients who had the potential and motivation to ambulate. The team provided prostheses but the patients became obese and gave up the effort. The rehabilitation of one, a triple amputee (BE on one side) was, unfortuntately, a notable failure.</p> <p><em><b><b>*Gustav Rubin, M.D. </b></b>FACS Chief, VAREC Special Clinic Team</em></p> <p><em>&nbsp;</em></p> Page Number(s) 1 - 2 Year 1983 Volume 7 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1983_04_001/1983_04_001-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource S-N-S Knees and the Bilateral A/K Amputee Creator An entity primarily responsible for making the resource Gustav Rubin, M.D. * https://staging.drfop.org/files/original/c14dfe270bafb90a2b20c29025446a0e.pdf ea4783b10f5c3a4d12c12442901d6cfc https://staging.drfop.org/files/original/e1c5e0817e16709456d081f6f415e65f.jpeg 25f2e057c93d0e69803ff76ac02699cb https://staging.drfop.org/files/original/b41bc35c2793e59d83d08621281b2157.jpg d5bfa6e4244d4b75c3af3ee1a2a68fca https://staging.drfop.org/files/original/38a21614eba81d206bc337aeb5d6e7fd.jpg b15d554896978844d9a1ee39e912bc50 https://staging.drfop.org/files/original/ab1b7ad80230fb3c67ffc6ab3131818b.jpg 382f8f76e28b2dde663fe0ef853f6e34 https://staging.drfop.org/files/original/4b05615aa03be409c03076b58f01516d.jpg d8571f4ee65ef85e91ebdfa64c11a806 https://staging.drfop.org/files/original/d44602f704718bd80028a10a39ab8557.jpg e1ed3363899743fe273d87b37d17f806 https://staging.drfop.org/files/original/aaeef9fb5c5bb12a4dd59e22be53a3c9.jpg 0f490c5304c88163f508047e5ba454cb https://staging.drfop.org/files/original/e0754e5e8e0d5cf1482166067833d458.jpg a89802e08f0b5c0fc15a0c44adff5e94 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_001.pdf Text Any textual data included in the document <h2>Scoliosis: Orthotic Management Concepts</h2> <h5>Edward P. Van Hanswyk, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The orthotic management of idiopathic scoliosis (<a href="/files/original/e1c5e0817e16709456d081f6f415e65f.jpeg"><b>Fig. 1</b></a>) over the years has employed a number of different orthotic systems. Included among them have been the Milwaukee and modified cervico-thoracolumbosacral orthoses (C.T.L.S.O.) as well as various prefabricated, modular, and custom fabricated thoracolumbosacral orthoses (T.L.S.O.).</p> <p>The prescription of any of the systems is dependent upon a number of variables, including the level and degree of curvature, the degree of rotation, the age and physical condition of the patient, and the degree of patient cooperation expected.</p> <p>No matter which system is selected, and no matter which set or combination of variables is present, there exists a number of orthotic management principles for consideration. The purpose of this paper is to outline these principles and theories, the similarities and differences presented by scoliosis, and orthotic management systems employed.</p> <p>In order to present these relationships, a number of somewhat original, and perhaps not so original, orthotic management concepts and theories are discussed. The theories include: 1. the reasons for reducing lumbar lordosis; 2. the idea and employment of a "righting reflex," both sagittal and coronal; 3. the concept of "costal distraction"; 4. the importance of axial alignment; and 5. a theory concerning the deviations of scoliosis, the creation of forces, and the force systems necessary for their control and correction.</p> <h3>Lumbar Lordosis</h3> <p>Historically, there has been an emphasis over the years on the reduction of lumbar lordosis (<a href="/files/original/b41bc35c2793e59d83d08621281b2157.jpg"><b>Fig. 2</b></a>) in the orthotic management of the spine, especially in the orthotic management of scoliosis with the C.T.L.S.O. and the T.L.S.O., for a number of reasons.</p> <ol> <li> <p>In the orthotic management of a lumbar or thoraco-lumbar scoliosis, flexion of the lumbar spine has a positive effect on scoliosis. The distraction that occurs between the thoracic spine and sacrum reduces lumbar scoliosis. The reasons presented for this "correction" include the release of the hip flexors and resultant pelvic tilt, and the stretch of the posterior longitudinal ligaments; the net result being an improvement of the lumbar scoliosis.</p> </li> <li> <p>When managing a lumbar curve in an orthosis with a corrective force from the posterior lateral direction in an attempt to reduce scoliosis and vertebral rotation by compressing of muscle bulge, it is necessary to provide an anterior counter-force to prevent an increase in lordosis.</p> </li> <li> <p>Recognizing that the thoracic and lumbar spine are interrelated, efforts to control lordosis with encasement and stabilization of the pelvis produce an opportunity for leverage and corrective forces, both inductive and direct, to be applied to the thoracic spine.</p> </li> </ol> <h3>"Righting Reflex"</h3> <p>The "righting reflex" (<a href="/files/original/38a21614eba81d206bc337aeb5d6e7fd.jpg"><b>Fig. 3</b></a>) is an example of an inductive force. When producing flexion of the lumbar spine, the kyphotic posture of the thoracic spine accentuates a forward flexion of the shoulder and head. The body's natural tendency to right itself over the center of gravity produces an extension or reduction in thoracic kyphosis. This sagittal plane reflex can be utilized in the orthotic management of Scheurmann's kyphosis and idiopathic scoliosis.</p> <p>Another "righting reflex" force developed is in the coronal plane. In double curves, thoracic and thoracolumbar, when the lumbar curve is reduced, causing a lateral shift of the head and shoulders, the body's natural tendency to right itself results in a reduction in thoracic scoliosis as well.</p> <p>In the orthotic management of scoliosis in a C.T.L.S.O., the "righting reflexes" can be planned as an adjunct to the direct counter-lateral and anti-rotational forces of the thoracic pad.</p> <p>In a T.L.S.O., this inductive extension is aided by a fulcrum created by the superior trim line of the orthosis. In theory, even though the length of the lever arm superior to the apex of the thoracic curve does not appear adequate for a significant force to be applied, the planned instigation of "righting reflex" forces is used to augment a lesser, direct force.</p> <h3>Axial Alignment</h3> <p>The encasement and stabilization of the pelvis provides the counter-force and leverage for direct force application to the thorax as well.</p> <p>Because of the rotational component present in scoliosis, axial alignment of the body, rib cage and pelvis is necessary. The direct force created by symmetric alignment of the pelvic and thoracic surfaces of the orthosis results in a direct anti-rotational corrective force. This is particularly applicable in the orthotic management of a thoracic curve in a T.L.S.O. Since the rotational component present in scoliosis is one variable that may preclude the use of a T.L.S.O., management of rotation in this system can be viewed as critical.</p> <h3>"Costal Distraction"</h3> <p>Another direct force advantage created by the encasement of the pelvis is "distraction." Stabilization of the pelvis and the "total contact" encasement of the lower rib cage in a T.L.S.O. produces an opportunity to maximize the distance between the pelvis and the rib cage, resulting in a distraction of the lumbar spine. The flattened abdominal surface induces lumbar flexion and also increases the intra-abdominal pressures, augmenting this force. The resultant costal-pelvis distraction is another planned, direct force in the orthotic management of lumbar scoliosis in a T.L.S.O.</p> <h3>Orthotic Management Goals</h3> <p>The concepts and theories presented might now be viewed in relation to orthotic management goals relative to scoliosis, specifically the evaluation of the various scoliosis deviations and the corrective forces available in the orthotic management system employed.</p> <p>In the normal spine, the muscles act antagonistically on either side to maintain a straight, neutral spine. The spine, rib cage, and pelvis are symmetrically related and supported by the musculature.</p> <p>In the scoliotic spine, as the vertebrae rotate and move laterally, the muscles lose their lever-arm advantage, and the spine, rib cage, and pelvis lose their symmetry. The orthotic management goals then become:</p> <ol> <li> <p>repositioning of the vertebrae, not only by direct forces, but also by inductive reflex forces.</p> </li> <li> <p>re-establishment of muscle levers and re-establishment of symmetry of the rib cage and between the rib cage and pelvis.</p> </li> </ol> <h3>Thoracic Scoliosis (Two Deviations)</h3> <p>In identifying the orthotic system to be used, the differences in scoliosis deviations should be recognized.</p> <p>Thoracic scoliosis (<a href="/files/original/ab1b7ad80230fb3c67ffc6ab3131818b.jpg"><b>Fig. 4a</b></a>) is seen as a two-deviational deformity, 1. a lateral deviation, the curve, 2. a rotational deviation, the rib prominence. Theoretically a three-directional force system is necessary for management of these deviations. The choice of C.T.L.S.O. or T.L.S.O. force systems depends, of course, on the variables outlined previously.</p> <p>In the three-directional force system C.T.L.S.O. (<a href="/files/original/4b05615aa03be409c03076b58f01516d.jpg"><b>Fig. 4b</b></a>), the forces include, 1. the counter-lateral force of the thoracic pad, 2. the anti-rotational force of the thoracic pad, and 3. the distractive force of the pelvic base opposed by the occipital portion of the neck ring.</p> <p>Certain thoracic curves can be managed also in a T.L.S.O. system: The two-deviational deformity of thoracic scoliosis managed with the lateral and anti-rotational force of the axially aligned surfaces of the orthosis, augmented by the righting reflex inductive forces, coronal and sagittal.</p> <h3>Lumbar Scoliosis (Three Deviations)</h3> <p>Thoraco-lumbar and lumbar curves (<a href="/files/original/d44602f704718bd80028a10a39ab8557.jpg"><b>Fig. 5</b></a>) are seen as a three-deviational deformity (<a href="/files/original/aaeef9fb5c5bb12a4dd59e22be53a3c9.jpg"><b>Fig. 6</b></a>). In addition to the lateral and rotational deviations there is usually a tendency toward lordosis. The asymmetry and loss of muscle levers and the shape of the lumbar vertebrae allow hyper-extension which contributes to a third deviation. It becomes necessary to incorporate a four-vector force system to manage this three-deviational deformity.</p> <p>The four-vector force system T.L.S.O. (<a href="/files/original/e0754e5e8e0d5cf1482166067833d458.jpg"><b>Fig. 7</b></a>) contains: 1. anti-lordotic, 2. lateral, 3. anti-rotational, and 4. costal distraction forces, all described earlier.</p> <p>In summary, understanding of the concepts and theories presented is necessary to provide the orthotic management system reflecting the re-positioning and forces required for appropriate correction.</p> <p><b>References:</b></p> <ol> <li>Van Hanswyk, Edward P., Hansen, Yuan, and Eckhardt, Wayne, A., "Orthotic Management of Thoraco-Lumbar Spine Fractures with a 'Total-Contact' TLSO," <i>Orthotics and Prosthetics Journal</i>, Vol. 33, No. 3, pp 10-19, September, 1979.</li> <li>Van Hanswyk , Edward P. and Bunnell, William P., "The Orthotic Management of Lumbar Lordosis and the Relationship to the Treatment of Thoraco-Lumbar Scoliosis and Juvenile Kyphosis," <i>Orthotics and Prosthetics Journal</i>, Vol. 32, No. 2, pp 27-34, June, 1978.</li> </ol> <div style="width: 400px;"><em><b>*Edward P. Van Hanswyk, CO. </b> Instructor, Department of Orthopedic Surgery, University Medical Center, SUNY, Syracuse, New York.</em></div> Page Number(s) 1 - 4 Year 1981 Volume 5 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-8.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 Scoliosis: Orthotic Management Concepts Creator An entity primarily responsible for making the resource Edward P. Van Hanswyk, CO. *