15 20 371 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/15815c49a6adce1760436c8f5ae00753.pdf ccf779f3680911a29673df7262a2d03a 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_215.pdf Text Any textual data included in the document <h2>Mobility and Mobility Devices for the Spinal Cord Injured Person</h2> <h5>Samuel R. McFarland, MSME&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>In the dictionary, the preferred definition of mobility is "the quality of being movable."<a></a> A second definition, more sociological in scope, defines mobility as "the movement of people in a population, from place to place, or job to job, or social position to social position." The second concept captures the significance of mobility as it relates to the life of a spinal cord injured individual. Spinal cord injury is a condition that most commonly affects young, physically active adults who have already established a social pattern in their lives. Certainly, spinal cord injury (SCI) causes impairment of movement, but more importantly, it may constrain a person's capacity for self-di-rected, purposeful movements, which are important to almost all activities. Much of the medical rehabilitation of a SCI patient involves therapeutic interventions aimed at increasing the range, strength, and coordination of body movements that have been impaired by an insult to the central nervous system. To fully appreciate the scope of mobility impairments encountered by SCI patients, we must examine the entire spectrum of activities that can be affected by limitations of movements. Independence, social and personal interactions, career development, and access to public facilities are some of the freedoms that can be adversely affected by mobility impairment.<a></a></p> <p>A thorough discussion of the methodology for reestablishment of mobility for SCI patients must include topics such as therapeutic interventions, orthotic appliances for stabilizing and enhancing the performance of musculoskeletal components, devices for extending the range or speed of movements, and substitutions for lost or severely limited functions. This article will not dwell on therapy, which is more appropriate for other authors, nor on orthotic appliances, since that subject is covered well in the accompanying articles on spinal stabilization and upper limb orthotics. Rather, it will attempt to represent some of the mobility considerations that are common to SCI and to discuss the application of products and techniques associated with ameliorating movement limitations. For the sake of simplifying the myriad array of details that can be covered under the general heading of mobility, this article will survey a sequence of activities that start with static support of the body and proceed to increasingly more complex movements in terms of range, speed, and energy demand.</p> <p>The author admits to a bias toward devices and technologies, which will be reflected in the discussions that follow, but he wishes to emphasize his belief that the only successful technical solution to a mobility problem is the one that integrates well with other rehabilitation interventions and withstands the test of time and use by the patient. Simplicity, cosmetic design, and reliability are essential to the immediate and long-range acceptance of adaptive technology by the user.<a></a></p> <h3>Background</h3> <p>Spinal cord injury commonly results in permanent paralysis of some of the large and powerful skeletal muscles of the body. The location of the injury along the spine correlates roughly to the cumulative amount of paralysis that results. The closer the injury site is to the head, the greater the involvement. Trauma incurred at the spinal column can affect the transmission of the nerve signals to all parts of the body served by the injury site and beyond. However, functional deficits incurred by SCI are almost always incomplete, meaning seldom is there complete loss of function or bilateral symmetry of effects below the site of the injury (lesion). For the sake of this paper, however, it will suffice to consider only two general types of functional paralysis: paraplegia and quadriplegia.</p> <p>Impaired voluntary control of skeletal muscles is not the only significant impediment resulting from SCI. Other organ functions can be affected as well. Bowel elimination, bladder voiding, sexual function, sweating, bone strength, and peripheral vascular circulation can all be altered in response to spinal cord insult. A common and troublesome side-effect is involuntary contraction of a muscle, spasm. Not only is the motor function of a nerve network affected, but also the sensory aspect. The combination of loss of sensation and reduced tissue blood circulation resulting from everyday bumps and pressures incur a high risk of undetected soft tissue damage. In insensate tissues, such seemingly minor injuries can easily progress into massive tissue death in the form of a decubitus ulcur. "Decubiti" are immensely threatening to a spinal injured person, not only because of the irreversible tissue damage, but also due to the extensive time loss and expense incurred in the treatment. All of these conditions must be kept in the forefront of planning for mobility and will be mentioned from time to time in the text that follows.</p> <h3>Transfer</h3> <p>The initial and simplest tasks of SCI mobility begin with rising from a reclining position, from which seated tasks, ambulation, or wheeled mobility can proceed. If starting from a bed, the person must first be able to sit up. A paraplegic or quadriplegic with good shoulder strength, may be able to sit up without assistance. Some may prefer to use an overhead handle, often called a trapeze, or a looped strap, to pull up into a sitting position. Sometimes a hospital type bed, with a powered drive to the articulated back section, can raise the person to a sitting position from which he can turn and let his legs off the bed in preparation for standing. A standing transfer, even with an attendant assisting is desirable because the weight is borne on the legs, but not by the attendant or a transfer device. If the legs are capable of supporting body weight, with or without bracing, the person may develop greater independence.</p> <p>When the quadriplegic or high paraplegic is not able to stand without braces, the transfer from a sitting position to another seat is somewhat more complicated because of the physical strength required to lift the body, change levels between sitting surfaces, and traverse the distance. Transfer aids foster independence and supplement the work of an attendant. For wheelchair transfers, it may be helpful to use a sliding board (also called a "transfer board"), a short length of wood or rigid artificial material that bridges the gap between two sitting surfaces, such as the bed and wheelchair. A paraplegic, and some low level quadriplegics, can momentarily life his weight and move in short, sideways increments from one surface to another. A strong and active paraplegic will probably vault by pushing downward with his hands or swing from an overhead handle, in lieu of being burdened with a transfer board. Even a person who cannot transfer himself can be aided by sitting on a piece of sturdy fabric which may be pulled sideways across the sliding board by an attendant.</p> <p>If a sliding transfer is not possible, a person can be lifted while sitting in a fabric hammock by a mechanical patient lift that incorporates an electrical motor or hydraulic jack mechanism to provide the lifting force. The hammock is attached overhead to the lifting device which is usually operated by an attendant. Some can be self-operated if appropriate fail-safe or emergency mechanisms are built in to compensate for equipment failure. Elaborate custom installations of overhead tracks can allow a person to be transported from bedroom to bathroom and beyond. Overhead lifts are also available for transferring from a wheelchair into a car, but with the advent of van adaptations, they are losing acceptance among users.</p> <p>The lifting and sliding principles used in transfer aids are applied in many products used in home and institutional settings, especially in the bedroom and bathroom. A common application of the sliding-lifting principle is the bathtub transfer aid, a device used to help a person transfer safely into the bathtub and lower himself into the tub for bathing. Some products are completely passive, incorporating a sliding pathway for the user to traverse across the tub rim. Some are powered seats, often driven by faucet water pressure, that raise and lower the seated occupant relative to the tub bottom.</p> <p>A more expensive form of lifting aid for the home is the vertical shaft home elevator that is used to give mobility between vertically separated living areas. Installation usually requires alterations to the structure of the building. A somewhat less expensive approach, where applicable, is the stairway elevator, which can be added to an existing staircase. Available as a chair for ambulatory persons and a platform for wheelchair riders, it typically follows the path and incline of the stairs and usurps a portion of the walking path. The least expensive adaptation for moving between levels, especially from outside, is the ramp. Ramps have been well defined in standards produced by the American National Standards Institute.<a></a> Outdoor elevators that are added on, rather than built into a building, usually called porch lifts, are made primarily for wheelchair users where ramp construction is impractical and a landing platform can be placed next to an outer door. Home elevators of all forms are usually sold and custom-installed by specialty vendors that are associated with vendors of other mobility aids.</p> <h3>Standing Aids</h3> <p>Paraplegics and quadriplegics, although unable to stand unassisted, can derive both physiological and psychological benefits from standing.<a></a> Being able to stand allows a wheelchair user to reach work surfaces and interact with standing people at their level. There are static devices, called standing frames, that hold a person in a standing position by binding him to an upright, rigid structure. The user must pull himself up from a seated position into the device and secure the binding straps or close and latch a supporting gate. The manipulations involved may require the assistance of another person.</p> <p>A more complicated device that allows more independent operation by the user is the mobile Stander that uses a power source to raise the person to a standing position and support him there. This principle has been incorporated into two forms of wheeled mobility. In the one form, the person may move slowly around for short distances on smooth surfaces after he rises to the standing position by controlling an electrically powered drive mechanism. In the other form, the assistive force standup mechanism has been added to a wheelchair. When the occupant is standing, the device is immobile. When the occupant is seated, it functions as a regular wheelchair.</p> <p>Another standing device, but one that provides a modicum of mobility is the swivel walker, or "parapodium," that is used by a very few paraplegic adults.</p> <h3>Ambulation</h3> <p>Walking is the most common form of mobility for humans and the mode most desired by people who have limitations that diminish or eliminate their ambulation abilities. Where there is any possibility of a mechanism to regain the ability to walk or move about in a standing posture, even if it is slow and requires great expenditure of energy, a person often prefers to ambulate rather than use wheeled mobility. Even temporary standing, without walking, can be used to enable a person to get through narrow entry ways, such as toilet compartments, bathrooms, and closets. The desire to remain upright has sustained the development and application of torso and leg braces, standing aids, and even artificial stimulation of paralyzed muscles by externally supplied electrical signals. At a lesion level around high thoracic, the instability of the torso suggests that ambulation may be less secure and more demanding of energy than wheeled mobility.</p> <h3>Stability</h3> <p>One of the more important considerations in assuring the fullest functional mobility of the SCI patient is stabilizing the proximal parts of the body in order to facilitate the most controlled movements of the distal portions. The person fitted with the finest of upper limb orthoses or supplied with the most elaborate vehicle control system will be substantially incapable of adequate performance if the body is not appropriately stabilized. Securing the proximal portions of the body is a critical consideration and can easily be both underestimated and overdone. It is quite common that a patient will be trained to substitute certain spared muscle functions for those that have been impaired. If a substitute muscle is occupied with stabilizing the torso, it will be effectively unavailable for its substitute function. Similarly, if the proximal base of distal limb segments has been too severely confined, the distal functions will be limited. In general, the SCI patient will be concerned with use of the upper body for control and work tasks, so the primary concern should be focused on providing a secure base for the torso, while retaining a sufficient range of upper body motion to allow the arms and hands to perform functional tasks. These principles will be restated more specifically in the sections that follow.</p> <h3>Wheeled Mobility</h3> <p>When walking is not an option, or when the upper limits of speed and range of ambulation are too low for the mobility needs of the person or the occasion, the indicated mobility aid is the wheelchair or any one of a variety of wheeled devices. The basic, most familiar form of the wheelchair is a shiny, tubular metal, open-framed structure that has four wheels, two small casters in front and two large drive wheels in the rear. Details of implementation vary slightly, but the design remains essentially the same from brand to brand. They are intended to fit an average sized person, withstand heavy use with minimal maintenance, and be propelled primarily by an attendant. A wheelchair produced for these purposes is known in the industry as a commodity wheelchair and is intended for temporary use by any one person but repeated use by many people. This is the type of wheelchair that insurance companies and government-based reimbursement programs provide for nursing home and convalescent use.</p> <p>Chronic users of wheelchairs should not use a commodity chair, but should be guided toward the use of a prescription wheelchair, which looks similar to the commodity chair, but is available in a variety of dimensions that can be more carefully sized to the user and embodies some optional features that better suit the demands of everyday, independent usage. Prescription wheelchairs tend to be lighter in weight, more durable, and offer less resistance to rolling than the commodity type because of the use of more specifically suitable materials and components and more exacting tolerances in their manufacture. Available options include variations in wheel and tire size and type, variable seating dimensions and configurations, removeable armrests and footrests, and selection of frame and upholstery material and color.<a></a> The diameter of the wheel and type of tire affect the maneuverability, rolling resistance, and riding comfort. Hard rubber or polymeric tires offer less rolling resistance than pneumatic tires, but transmit more of the shock of pathway irregularities to the rider than the softer, pneumatic tires. Similarly, small diameter wheels offer less inertial resistance to rolling than larger diameters, but the greater curvature imparts higher impact forces to the rider and inhibits movement over rough surfaces.</p> <p>For a chronic user, a wheelchair should be very carefully sized and the components and accessories selected to assure efficiency of operation, postural support, and prevention of medical complications of disability. In general, a wheelchair should be as narrow as possible without pressing against the hips, thereby allowing the greatest freedom of access through narrow passageways and the maximum of mechanical advantage for propulsion and control. The back height should provide good postural support, but minimize interference with the arms during a propulsion stroke. Low level, active paraplegics may prefer a very low back to maximize freedom of arm and upper body movements. The height of the seat bottom is governed by three dependent variables; arm access to the pushrims, footplate clearance above the ground, and even distribution of the sitting load along the underside of the thighs and buttocks (taking the compressed thickness of any cushion into consideration).<a></a></p> <p>The wheelchair seat cushion is a crucially important accessory component for a person who does not have sensation in the lower body and legs.<a></a> A cushion is intended to help distribute the gravitational loading forces of the occupant over the broadest possible area of the sitting surface and minimize the point pressure that occurs near the bony prominences of the pelvis and hips. There are many types of cushions that utilize a broad variety of materials and configurations, such as polyethylene foam, air and fluid-filled pillows, and semirigid and custom contoured devices. Each design has proponents who claim it is the best universal solution to the problem of pressure sores (decubitus ulcers), a major health problem for paralyzed persons with diminished or absent sensation. Since the formation of de-cubiti is related to many factors, such as pressure distribution and duration, temperature, moisture, diet, activity level and seating geometry,<a></a> it follows that no cushion can serve as a universal preventative measure. However, it is generally accepted by clinicians and users that there is a type of cushion best suited to each individual and careful selection for each person is important.</p> <p>It has also become increasingly more common for wheelchair seating experts to recommend that the hammock-style seat be replaced with a rigid member to provide a solid support structure for the type of cushioning material that is chosen. Hammock seats tend to wrap around the buttocks, creating a squeezing and shearing force pattern that tends to restrict tissue circulation. Also, the hammock is inherently unstable as a support for a high center of mass.</p> <p>The prescription wheelchair has recently undergone a rapid evolution in materials and design, resulting in lighter weight, smoother operation, greater durability and a change of image for the user. Wheelchairs are now offered in a mosaic of materials, colors, frame styles, and applications.<a></a> Largely because of the demand and innovations arising from the wheelchair sports movement, a new breed of daily use wheelchair has been developed and the market has accepted it with enthusiasm and buyer support. The new breed of wheelchair, now being labelled the "ultralight," embodies higher performance materials and design innovations including radial, rather than crossed (bicycle style) spoke patterns, aluminum alloy rims and hubs, die cast metal or injection molded polymeric wheels, adjustable position (fore/aft and up/down) and angle of axles, rigid (non-folding) and take-apart frames, and designer colors in anodized and polymeric finishes. The new product is less medical in appearance, more energy efficient to use, and more reliable and durable to the user. Although most of these changes have been directed at the manually propelled wheelchair for active adult paraplegics, some of the same innovations are beginning to be applied to powered chairs as well.</p> <p>The addition of mechanisms that propel the vehicle using electric motor power has provided a means of independent mobility for previously dependent users with quadriplegia. The most commonly used powered wheelchairs are supplied from the manufacturer as an integrated product that combines conventional frame and seating design with motorized propulsion. The power drive wheelchair (also called "electric" and "battery powered") was originally the result of relatively minor design improvements to the basic tubular metal wheelchair.</p> <p>Beginning in the early 1970s, the concept of a wheeled device, especially for severely disabled users, was reexamined by designers in North America and Europe. The result of that scrutiny was a proliferation of design ideas and clinical studies, some of which have resulted in commercially viable products. Out of that innovation revolution, stimulated in part by government supported research programs and workshops,<a></a> have come significant changes in propulsion and control of the electrically powered vehicle, an understanding of the health and performance benefits of carefully seating and positioning the occupant, and two new distinctly different types of powered vehicles.</p> <p>The first thrust of innovation dealt with obtaining new control modes for the user who could not operate the conventional joystick controller. One of the most common modifications of the powered wheelchair, and most important to the independence of the user, is the relocation or other alteration of the operator control device (typically an electromechanical joystick). It is now possible, with the purchase of options from the wheelchair manufacturer, or modifications developed by separate suppliers, for a severely impaired person to drive a powered wheelchair using any available physical movement on the body, including the head, chin, eyes and feet. It is also possible now to control a powered wheelchair with oral modulation of the breath and pneumatically powered electronic switching (the "sip and puff" control).</p> <p>The second most noteworthy trend in the redesign of the basic vehicle has been the separation of the seating function from the vehicular function. Conventional wheelchairs had been designed so that the chassis of the vehicle and the frame supporting the seat were the same. Therefore, changing the seat meant changing the total unit. The current focus on separating the functions has freed the vehicle designers and body positioning designers to pursue independent courses of study, resulting in both improved vehicle performance and enhanced comfort and health for the user. Scientific knowledge of the biomechanics and physiology of the wheelchair occupant is now being more appropriately applied to the development of specialized seating systems that position the body statically, and periodically reposition it, to promote improved vascular circulation and breathing, pressure relief and posture, leading to greater comfort, health, and prolonged periods of functional independence for the user.<a></a></p> <p>An entirely different form of vehicle, the powered cart, has also been developed during the past decade, primarily for people who are ambulatory, but limited in speed and range of ambulation. The cart does not look like the basic wheelchair, rather a scaled-down, one person version of the familiar golf cart. Intended primarily for public use by less severely disabled people, the cart is available in a variety of three and four-wheel versions with either tiller or joystick control. People who might otherwise use ambulatory aids or manually-propelled wheelchairs may choose a cart to gain greater speed, range, and (in some models) rough terrain travelling capabilities. Use of the cart should be confined, however, to areas where motor vehicles are not likely to travel. On the road travel for wheelchair users should be limited to persons riding in specially adapted automobiles, trucks, and buses.</p> <h3>Adapted Motor Vehicles</h3> <p>As a passenger or as an operator, a spinal cord injured person can greatly extend his range of travel by using a motor vehicle. The motor vehicle, whether a passenger car, a truck, or a mass transit vehicle, presents some significant impediments to use by an SCI person and typically must be modified to accommodate him. The impediments can be roughly grouped into three categories: access, securement, and control. In order to safely and comfortably use a motor vehicle, a person must be able to get into (and out of) the vehicle, be seated comfortably and secured against any hazards that are presented by vehicle motion, and, if feasible, he must be able to exercise guidance or accessory control over the vehicle.</p> <p>Access to the vehicle is the pivotal concern, for if the individual cannot enter the vehicle, securement and control functions are moot. Entry into a vehicle is affected by the size and shape of the doorway, the height and slope of the ground just outside the vehicle, and the amount of time consumed in the boarding process; these parameters can be effectively controlled with an adapted personal vehicle.</p> <p>Mass transit vehicles, which are designed to quickly transport large numbers of people, present a great challenge to people who use ambulation aids and wheelchairs because transit systems typically operate on hurried schedules and boarding occurs in tight spaces. Access to busses, trains, and airplanes is a problem if the person cannot enter the vehicle where it is normally available for boarding without displacing other passengers or delaying the route schedule. Despite these conflicts, many of the modern mass transportation systems have incorporated accommodations for mobility limited people and their mobility devices.<a></a> Older systems are typically not accessible and not feasible for retrofit. Personal vehicles and small busses for groups of mobility impaired people, however, can be selected and effectively adapted with structural modifications and add-on products.</p> <p>Personal vehicles are more adaptable. Many people prefer to use a passenger sedan, rather than a van or bus, simply because it is smaller and less costly to own and operate. Paralyzed people, except for those who ride power drive wheelchairs, can get into a sedan without using special access equipment, but may need a little more time than able-bodied people. They must learn to be selective about the place on the sidewalk, at the curb, or in the garage where they board, because the height and slope of the ground often affect the ease of boarding. Generally desirable features in a car include a tall, wide door opening, a door that swings open to a large angle, and a seat at chair height with firm padding and low friction upholstery. A broad driprail or handle located overhead near the door opening can give a person something to hold or pull against during the transfer process. Large interior leg space is important, especially to someone who wears a long leg brace.</p> <p>Seating is only part of the access problem, since once the person is seated, the mobility aid must be stowed. A crutch or cane can be stowed inside the car, but a walker may be too bulky unless it is the type that folds up for storage. A wheelchair creates a special problem which will be discussed later.</p> <p>The person who can enter a passenger car, even with difficulty, may find entry to a van or bus to be impossible because the height of the seat from the ground is typically too great to enable direct sitting from outside the van. The person must enter the van before sitting. Van seats more nearly resemble a chair in height and attitude, so they are more accommodating to a mobility impaired person than the seats of a passenger car, but the height of the entry step on a van is as much an impediment to an ambulatory SCI person as stairsteps in a building. Even if he can surmount the stepwell and get inside, he cannot stand upright either for sitting or moving about, unless the roof has been extended. On vans that have been modified for a raised roof, the side or rear cargo doorway is also modified to give more head clearance to people entering and leaving the passenger area.</p> <p>To accomplish the transition from ground level to the level of the van floor, both ambulatory people and wheelchair users can be aided by a ramp or a platform lift. The ramp is the least expensive access device and offers the most trouble free service, but another person is needed both to deploy it into operating position and to assist the user while he is traversing the bridge. The lift, though more expensive, is frequently preferred over the ramp. For attendant operation, a lift carries the load, thereby reducing the labor and risk of injury. Unlike a ramp, certain types of lifts can be self-operated by a passenger in a wheelchair. There are two general designs of platform lifts: the folding lift (also called flop-out) and the swinging lift (also called rotary). A lift of the folding type consists of a platform for supporting and carrying the passenger and an electromechanical or electrohydraulic power mechanism that provides the lifting force. Deployed for operation, it unfolds outward to a horizontal attitude ready for moving the passenger between the floor and ground levels. The folding lift is usually offered in semi or fully automatic operating modes. The semi-automatic version raises and lowers under power while an attendant provides the controlling function as well as the stowage operation (opening/closing doors and folding/ unfolding the platform). The more complicated, and more costly, fully automatic version is further equipped with switches and drive mechanisms that allow the user to control the entire process independently. Typically, the installation of a fully-automatic lift is accompanied by the installation of a powered door opener and an external lift access control panel to complete the total system of components that provide the user with a capability for independent access to the vehicle.</p> <p>The swinging lift is almost always provided in a fully-automatic configuration. The platform travels vertically outside the opened cargo door between ground and vehicle floor levels. At the floor level, the platform swings (rotates) about a vertical axis into the vehicle and remains there for its stowed position, thereby limiting the available floor space inside the vehicle. This type of lift is somewhat less expensive to purchase and is lighter in weight than the folding type, but typically will not accommodate a full-sized powered wheelchair or cart.</p> <p>Many users of wheelchairs can transfer to the automobile or van seat without assistance. Often the transfer is aided by the sliding across a transfer board and sometimes by pulling up on an overhead handle or wriststrap. Each person must develop his own transfer technique based on the spatial geometry of the opened doorway, the location of the seat and vehicle interior appointments, and the nature of his physical ability. The transfer process will also vary with the vehicle being used and nature of the trip. Use of a taxicab, rental car, or a friend's car presents a greater challenge because of the variability of vehicle type, many of which are not suitable to the individual wheelchair user. After transferring themselves into the car, passengers (or drivers) of sedan-type vehicles must load the wheelchair into the car or park it at the debarkation point before they can close the door. If an attendant (or cab driver) is present, the chair can be placed in the trunk, in the back seat, or on a special rack attached to the back bumper. The independent wheelchair user must either stow the wheelchair (folded or dismantled) inside the car behind the front seat or on the roof outside. Strong and agile paraplegics can usually fold the chair and pull it inside. Those who are less able sometimes use a rooftop carrier to stow the chair. A passenger who transfers to a seat inside a van (a desirable practice from the standpoint of safety) can usually tether the empty wheelchair next to him inside the van, making it readily accessible for re-transfer and exiting the vehicle.</p> <p>Access to the vehicle seat does not complete the process of safely preparing for travel. The passenger should be secured. With many SCI people, safety securement is more than a crash protection mechanism, because they may have insufficient upper body strength to withstand common vehicle accelerations. A seatbelt or over-the-shoulder harness can be very important for both purposes. When an ambulatory person is seated in a vehicle, he can almost always use the conventional safety restraint belt for passenger security. So can a wheelchair user who is able to transfer from the wheelchair to the vehicle seat. When a wheelchair user cannot transfer, he should use some form of restraining device. As a general rule, both the wheelchair and its occupant should be restrained (separately) by a vehicle structural member. Many designs of restraining devices have been tried and tested by researchers and manufacturers. To date, only two relatively satisfactory approaches have been produced. In one, the wheelchair is permanently fitted with an additional structural subassembly which serves to reinforce the structural integrity of the wheelchair and engage a mating assembly that is securely anchored to the frame of the van. Though demonstrated to be an impact resistant combination,<a></a> this approach has the disadvantage of restricting a passenger to the use of a van that carries the mating structure and of imposing additional weight on the routine mobility of the wheelchair, demanding additional propulsive energy from either the arms of the occupant or the batteries of the power system. A second approach separately tethers the wheelchair and the wheelchair occupant to the vehicle structure, using belts. The tethering operation is virtually impossible for a wheelchair user to perform independently and is time-consuming even for an attendant. Some of the restraint devices that are provided for wheelchairs, however adequate to the task for wheelchairs of the basic design, will not engage certain forms of wheeled mobility aids at all. Passengers using such non-standard aids must often travel unrestrained.</p> <p>Many SCI people can be adapted to driving.<a></a> Although they may lack the leg and arm function required to operate the pedals and steering wheel, they may employ specialized products called automotive adaptive controls (also called hand controls and foot controls). Such devices transfer the locus of driving control from its conventional position in the vehicle to a location and configuration that can be operated effectively by parts of the body that are functionally able to handle the task. If the feet are not able to operate the throttle or brake pedals, a mechanical linkage can be added to transfer the input to a hand-operated lever. For most products, the throttle and brake are combined into a single lever.</p> <p>Since the hand-control completely occupies one hand with starting and stopping, the other hand must do all the steering. If that hand is limited in strength, common to quadriplegics, a steering wheel spinner may be needed to assure constant hand contact with the wheel throughout its rotational circuit. Spinners are available in a variety of configurations, depending on the nature of the hand disability. Other adaptive devices take the form of extensions of vehicle control levers, shafts, and pedals (such as turn signal, gear selector, steering column, throttle, brake, and emergency brake) that improve the mechanical advantage, extend the locus of activation, or transfer the operation to the opposite side. Hand controls typically do not prevent another person, who is not disabled in driving function, to drive the car since the conventional controls remain intact, having been added-to rather than replaced.</p> <p>Just extending and relocating the application of forces is sometimes inadequate to enable a quadriplegic to drive. Where conventional power assisted steering and braking requires more force than the driver can exert, it is possible to further reduce the force or range of movement required to operate the controls by performing a more extensive modification of the vehicle control components. Reduced effort steering, throttle, and brake conversions diminish the force the driver must supply. Since the driver who needs force amplification is unable to operate the vehicle without the modification, the complete reduced-effort system should be supplied with backup power that will sustain hydraulic and vacuum reserves, even if the engine (the primary source) fails. With the use of a reduced-effort system, the mechanical advantage of a large diameter steering wheel and extended lever arms is no longer needed, so the range of movement of the input controls can be reduced to accommodate limitations in upper extremity movement. A small diameter steering wheel, even one that is repositioned through universal joints and angular drives (so-called "horizontal steering"), extends the possibility of driving to people with even greater limitations of limb movement.</p> <p>As with all mobility aids, professional help with selection and training is very important to the ultimate successful application of automotive adaptive aids. Specialized assessment and training facilities have been established in conjunction with major rehabilitation centers worldwide. The staff of these centers typically includes a therapist, a driver trainer, and an equipment specialist who combine their expertise to provide the disabled driver candidate with comprehensive assessment, equipment selection, vehicle modification, and driver training.<a></a> In some areas, the vendor of vehicle adaptive equipment and modifications is responsible for the recommendation of products and services, but the more comprehensive clinical team approach seems to be more objective.</p> <h3>Conclusion</h3> <p>Helping to attain mobility for the spinal cord injured individual is a multiparameter equation. Mobility is key and essential to almost all aspects of the process of rehabilitation and return to active life postinjury. Many products and technologies are available to help extend the residual capabilities of the patient. A team approach to mobility assessment, prescription, and training will greatly encourage the development of a system approach that can lead to a well integrated plan for the user.</p> <p><b>References:</b></p> <ol> <li>Axelson, Peter W., Dennis Gurski, and Ann Lasko-Harvill, "Standing and Its Importance in Spinal Cord Injury Management," <i>Proceedings of the Tenth Annual Conference on Rehabilitation Technology</i>, San Jose, California, June, 1987, pp. 477-479.</li> <li>Bolton, Michael, "The Ann Arbor Transportation Authority's Experience," Proceedings of the National Workshop on Bus-Wheelchair Accessibility, Seattle, Washington, May 7-9, 1986, U.S. Urban Mass Transportation Administration, DOT-1-87-11, pp. 2-16-2-21.</li> <li>Brubaker, Clifford, Ph.D., "Fitting a Person with a Chair," Clinical Supplement No. 2, "Choosing a Wheelchair System," <i>Journal of Rehabilitation Research and Development</i>, Veterans Administration Rehabilitation Research and Development Service, Baltimore, Maryland (in press).</li> <li>Crase, Nancy (editor), "Fourth Annual Survey of the Lightweights," <i>Sports 'N Spokes</i>, 11:6, March/April, 1986, pp. 19-30.</li> <li>Hobson, Douglas A. and Elaine B. Treffler, "Towards Matching Needs with Technical Approaches in Specialized Seating," Proceedings of the Seventh Annual Conference of the Rehabilitation Engineering Society of North America, June, 1984, Ottawa, Canada, pp. 486-488.</li> <li>Luce, Thomas P., <i>The Handicapped Driver's Mobility Guide</i>, American Automobile Association, Traffic Safety Department, Falls Church, Virginia, 1984.</li> <li>McFarland, Samuel R., "Personal Licensed Vehicles for Disabled Persons," <i>Paraplegia News</i>, 36(6), June, 1982, pp. 33-38.</li> <li>McFarland, Samuel R. and Lawrence A. Scadden, "Marketing Rehabilitation Engineering," <i>SOMA, Engineering for the Human Body</i>, 1:2, American Society of Mechanical Engineers, New York, July, 1986, pp. 19-23.</li> <li>Phillips, Lynn, Peter Axelson, Mark Ozer, M.D., and Howard Chizeck, <i>Spinal Cord Injury, A Guide for the Patient and Family,</i> Raven Press, New York, New York, 1987.</li> <li>Proceedings of the National Symposium on "Care, Treatment and Prevention of Decubitis Ulcers," Sponsored by the Paralyzed Veterans of America, Washington, D.C, November, 1984.</li> <li>Schneider, Lawrence W., Ph.D., "Sled Impact Tests of Wheelchair Tie-Down Systems for Handicapped Drivers," Project Report, University of Michigan Transportation Research Institute, Ann Arbor, 1985.</li> <li>"Specifications for Making Buildings and Facilities Accessible to and Usable by Handicapped People," ANSI Standard No. A117.1-1980, American National Standards Institute, New York, New York.</li> <li><i>The American College Dictionary</i>, Random House, New York, New York, 1967, p. 780.</li> <li>Wheelchair III, Report of a Workshop on "Specially Adapted Wheelchairs and Sports Wheelchairs," Sponsored by the Veterans Administration Rehabilitation Research and Development Service and the Rehabilitation Engineering Society of North America, LaJolla, California, September, 1982.</li> <li>Wilson, A. Bennett, Jr., <i>Wheelchairs, A Prescription Guide</i>, Rehabilitation Press, Charlottesville, Virginia, 1986.</li> <li>Zacharkov, Dennis, <i>Wheelchair Posture and Pressure Sores</i>, Charles C. Thomas, 1984.</li> </ol> <em><b>*Samuel R. McFarland, MSME </b> Samuel R. McFarland, MSME, is Director of Rehabilitation Engineering at the National Rehabilitation Hospital, 102 Irving Street, N.W., Washington, D.C. 20010.<br /><br /><br /></em> Page Number(s) 215 - 224 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 Mobility and Mobility Devices for the Spinal Cord Injured Person Creator An entity primarily responsible for making the resource Samuel R. McFarland, MSME * https://staging.drfop.org/files/original/527606029dde597c9241e01480a56072.pdf 4c755f2a1ca5cf1398a468e307fd2dea 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_087.pdf Text Any textual data included in the document <h2>Upper Extremity Cosmetic Gloves</h2> <h5>Sandra Bilotto, M.A., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> <p>Upper extremity rehabilitation includes the restoration of function and cosmesis to simulate the human hand.<a></a> Producing a replica of the hand which is functionally and psychologically beneficial to the amputee and quite importantly, acceptable to those with whom the amputee socially interacts,<a></a> is both challenging and of high priority.</p> <p>The technology for producing either custom made or mass produced cosmetic gloves has changed little in more than 20 years.<a></a> However, within the last several years, with the advent of new materials, there have been new developments. More specifically, there have been developments in a family of silicone elastomers the application of which offers solutions to problems associated with existing cosmetic glove technology.</p> <p>Briefly, cosmetic gloves have been made with latex, urethanes, and RTV silicones, but these materials were not successful because they had serious drawbacks. Latex skins were impermanent, coloration was unacceptable, tear strength was very low, absorption of clothing dyes was common,<a></a> and they did not last very long before deteriorating. Urethanes held promise, but the components to produce a plastic film are very difficult to control in small laboratories. They are too sensitive to moisture and extraneous contaminants, and require precise measuring. After limited use, they are weakened by ultraviolet light and thus their useful life as terminal device coverings is limited.<a></a> RTV or room temperature curing silicones, when first utilized in prosthetic restorations and glove-making, proved ineffective because the material required complicated molding procedures, was often manufactured pre-colored, had extremely low tear strength, and had very low elasticity and flexibility. In addition, one small tear would easily propagate, rendering the glove useless.</p> <h3>PVC Gloves</h3> <p>PVC, or polyvinyl chloride, has dominated glove making and still does to the present. Historically PVC is inexpensive and readily available. Gloves can be fabricated en masse in metal molds or custom made in flexible slush molds. In either technique, the plastisol cures against the wall of the mold, producing a thin skin of vinyl which can either be intrinsically and/or extrinsically colored.<a></a> Stabilizers and plasticizers are introduced to make the cosmetic glove flexible and resistant to degradation by ultraviolet light. Replication of the human hand has been adequate using PVC and thus these gloves have been widely available for most amputees. However, there are disadvantages associated with PVC as a material for use in prosthetic gloves.</p> <p>First and foremost is the inability of PVC to resist attack by most chemicals, soiling and staining agents, and newsprint. These substances are absorbed by the plasticizing agents and are impossible to remove. At temperatures close to freezing, the PVC stiffens and its flexibility is greatly reduced. This can inhibit the proper functioning of an electric or mechanical hand as the inability to open a finger or thumb can render a terminal device useless.<a></a> In warm temperatures, the plasticizers and stabilizers tend to bleed to the surface of the glove, causing peeling of the extrinsic coloring, as well as darkening and stiffening. PVC "feels" like plastic and not like human tissue, and for the most part, unless a PVC glove is custom made and tinted, the surface is rather opaque and cadaverous looking. Custom made PVC gloves present all of the above problems, but do match skin tone, hand shape, and surface characterization of the intact hand better. The time required to fabricate a custom glove is much longer because the technique is more elaborate, and as a result more expensive. Of course, the success of the glove is directly proportional to the ability of the prosthetist to make the cosmetic glove appear natural and reasonably well matched to the other hand.</p> <p>No matter what technique is utilized, the consensus is that PVC gloves are rather short lived: two weeks to eight months on average. Efforts to strengthen the glove with nylon fabric reinforcement or to retard discoloration by spraying clear solutions on the surface of the glove produce disappointing results.<a></a> Finally, there is a problem donning and doffing a PVC glove due to the inflexibility of the material proximal to the wrist. This gave rise to the practice of sewing zippers into gloves. Besides being bulky and unsightly, zipper installation is time consuming and the zipper may be easily jammed or broken. Thus, a better material which might resolve some of the above problems is needed.</p> <h3>Silicone Gloves</h3> <p>Silicone rubber offers excellent solutions to some of the aforementioned problems, and they now have properties which make them more readily processed in glove making.<a></a> In general, the new generation of silicones are tougher, more resilient, more durable, and more permanent than previously utilized materials. While not ideal, the silicone gloves presently being developed resist chemicals, dyes, soiling, and staining almost completely. The skins may be washed with mild detergents and water for cleaning. Unlike PVC, lower or higher temperatures have little effect on the strength, flexibility, or elasticity of the glove.<a></a> The result is better functioning of electro/mechanical hands, and in some cases, the elastic resistance of gloves can actually enhance functioning of the terminal device.</p> <p>Unlike PVC, silicone rubber may be modified to increase its elasticity where necessary without loss of tear strength. Cosmetic gloves of silicone elastomers may be intrinsically or extrinsically colored as with PVC. However, there is much greater adhesion of external pigments to silicone gloves and the resultant glove rarely sheds its external tinting. It is more color stable and is less affected by ultraviolet light than its PVC counterpart; Silicone neither darkens nor stiffens with the passage of time. Once fabricated, the glove is non-toxic as compared with PVC. This is an obvious advantage when fabricating gloves for babies and toddlers, as harmful agents do not leach out to the surface of the glove to enter the baby's mouth. Silicone can be formulated to reflect and absorb light in much the same way human skin does, producing a more natural and life like appearance. Likewise, silicone also simulates the "feel" of skin more closely as it relates to softness and texture.<a></a> Its higher coefficient of friction helps prevent glasses and other objects from falling out of the hand's grasp.</p> <h3>Discussion</h3> <p>There are some disadvantages in the production of silicone gloves which need to be addressed. The cost of manufacturing, the increase in fabrication time, and the slightly higher cost of silicone rubber<a></a> is retarding the availability of such gloves.</p> <p>However, if the technology to produce silicone gloves improves, and if they become more widely available, their cost and fabrication time should decrease. They have greater durability and esthetic appeal than PVC, and there can be no doubt that silicone offers possibilities heretofore unavailable with PVC.</p> <p>Silicone cosmetic coverings for the lower extremity are a future possibility. Swim and sport legs could be greatly inhanced by these tough, resilient and cosmetic coverings. Silicone compounds are presently used in maxillofacial prosthetics, breast prostheses, partial hands, partial feet, leg and arm buildups, and other body restorations.<a></a></p> <p>There is no doubt that a more natural, functional, esthetically and psychologically appealing cosmetic glove is needed by upper extremity amputees and that silicone gloves, despite some imperfections, will prove to be more promising and acceptable than PVC gloves.</p> <p><b>References:</b></p> <ol> <li>Arkles, B., "Look what you can make out of Silicones," <i>Chemteck</i>, Vol. 13, No. 9, pp. 542-555, September 1983.</li> <li><a href="al/1955_02_057.asp">Carnelli, W.A.; Defries, M.G.; and Leonard, F., "Color Realism in the Cosmetic Glove," <i>Artificial Limbs</i>, Vol. 2, pp. 57-65, May 1955.</a></li> <li>Davies, E.W.; Douglas, W.B.; and Small, A.D., "A Cosmetic Functional Hand Incorporating a Silicone Glove," <i>Journal of International Society of Prosthetics and Orthotics</i>, Vol. 1, No. 2, pp. 89-93, September 1977.</li> <li><a href="al/1955_02_047.asp">Dembo, T. and Tane-Baskin, E., "The Noticeability of the Cosmetic Glove," <i>Artificial Limbs</i>, Vol. 2 pp. 47-56, May 1955.</a></li> <li>Fillauer, C and Quigley, M., "Clinical Evaluation of an Acrylic Latex Material used as a Prosthetic Skin on Limb Prostheses," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 4, pp. 30-38, December 1979.</li> <li><a href="al/1955_02_078.asp">Fletcher, M. and Leonard, F., "Principles of Artificial Hand Design," <i>Artificial Limbs</i>, Vol. 2, pp. 78-94. May 1955.</a></li> <li>Lee, D. and Harlan, W., "Medical Sculpture: A Valuable Aid to Patient Rehabilitation," <i>American Family Physician</i>, Vol. 15, pp. 110-114, February 1977.</li> <li>Journal American Dental Assoc., "Maxillofacial Prosthetic Materials," <i>Council on Dental Materials and Devices</i>, Vol. 90, pp. 834-848, April 1975.</li> <li>Klasson, Bo, Personal communication, Een-Holmgren, Stockholm, Sweden.</li> </ol> <em><b>*Sandra Bilotto, M.A., C.P.O. </b> Sandra Bilotto, M.A., C.P.O., currently resides in Yonkers, N.Y. She received her education in prosthetics and orthotics at N.Y.U. Prior to that she received training in sculpture. Cosmetic restoration is a particular interest of hers.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 87 - 89 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 Upper Extremity Cosmetic Gloves Creator An entity primarily responsible for making the resource Sandra Bilotto, M.A., C.P.O. * https://staging.drfop.org/files/original/7cf119166ad87eb06c27bf19aa14601f.pdf 1c96a3b3328679e9ce5c00a407f461c9 https://staging.drfop.org/files/original/7a03de2fa3abd6434dbf35ea90f8a24f.jpg 9a3b91d6d25d0ea128bd129f72052d5c https://staging.drfop.org/files/original/41d2e99ef2712e6bf37fd90b99884729.jpg e365f90de9bf9d37b3e930728b987afe https://staging.drfop.org/files/original/45f9ecdd3583fca4a9b40e43d40b8fcb.jpg a3a4b242703db91a587f408c2738acdf https://staging.drfop.org/files/original/f25d2a79d7de53b2ee49b4c388895c22.jpg 792d3c81e1d5d48a515061f80fe3204a https://staging.drfop.org/files/original/c8ecb78314e07610c4b41af0358a23f4.jpg 68b404353e59f1a8fcdfd73e57d06d44 https://staging.drfop.org/files/original/e0db5f9e5fb35400f61e401dd85599b9.jpg e0b92835fd4de23f0c8bb8fb5d1635fa https://staging.drfop.org/files/original/7aa1f8cbe0e245431055b7fe9d6d2d6f.jpg 4bdf0fe2fee9272b3e8bb7c7a4fd1960 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_023.pdf Text Any textual data included in the document <h2>Evaluation of a Prosthetic Shank with Variable Inertial Properties</h2> <h5>Scott Tashman, M. Eng.&nbsp;<a style="text-decoration: none;">*</a><br />Ramona Hicks, R.P.T., M.A.&nbsp;<a style="text-decoration: none;">*</a><br />David J. Jendrzejczyk, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Above-knee amputees walk slower than the normal population. This has been documented in adults<a></a> and children.<a></a> It has been suggested that the prolonged swing phase of the prosthesis forces a slower cadence and, therefore, a slower walking speed.<a></a> Since children rely on a fast cadence to obtain an adequate walking speed,<a></a> a prolonged swing phase can be a major obstacle to comfortable, efficient normal-speed walking.</p> <p>To date, most efforts to reduce prosthetic swing phase time have been directed towards the prosthetic knee joint.<a></a> Various mechanisms have been designed to accelerate the extension of the prosthetic knee. Mechanical, hydraulic, and pneumatic systems have been developed in an effort to provide a more favorable gait.<a></a> Hydraulic knee units have been shown to provide a more normal cadence and walking speed for adults than simple constant friction knee units.<a></a></p> <p>Most of the prosthetic knee unit research has been directed towards the adult amputee population. Pediatric hydraulic knee units have been considered impractical because of size and weight limitations. Pediatric above-knee amputees are generally fitted with constant friction knee units because they are simple, light in weight, low in cost, easy to install and adjust, and require little maintenance.<a></a></p> <p>It has often been presumed that adjustments in the knee joint friction could be used to provide an optimum cadence for the amputee with a constant friction knee joint. A study was performed at the Newington Children's Hospital Kinesiology Laboratory to test this assumption.<a></a> When subjects were asked to walk at a comfortable speed, no significant changes were observed in cadence or actual prosthetic shank swing time as the knee joint friction was varied over a wide range. In all cases, the swing period of the prosthetic shank was close to the natural swing period of the shank measured off the patient. This indicates that the physical properties of the prosthetic shank play a significant role in determining the natural cadence of the above-knee amputee with a constant-friction knee joint. To force the shank to move at a frequency different from its natural frequency requires significant input of energy in the form of applied torque at the knee joint (from hip or pelvic muscle force). The test subjects, when asked to walk at a comfortable speed, did not supply the extra energy needed for a faster cadence; they instead aligned their cadence with the natural frequency of the shank.</p> <h3>Purpose</h3> <p>The above results led to the current project: the design and testing of a prosthetic shank with variable physical properties. The purpose of this study was to test the following hypotheses:</p> <ol> <li> <p>If the physical properties of the shank section of an above-knee prosthesis with a constant friction knee unit are changed in such a way as to alter the natural swing period, the swing period of the shank during gait will also be altered.</p> </li> <li> <p>Reducing the swing period of the shank will increase natural cadence and walking speed.</p> </li> </ol> <h3>Methods</h3> <p><i>Design</i></p> <p>The principal design goal for the shank was to reduce the natural swing period as much as possible. If the shank/foot is considered as a physical pendulum, it has a period T equal to:<br /><b>T = 2<i>pi</i>(I/Mgd)^(1/2)</b>, I is proportional to Md².</p> <p>Where:</p> <blockquote> <p>T = natural swing period of shank as a pendulum<br />I = rotational inertia of shank/foot above knee pivot<br />g = acceleration due to gravity<br />d = distance from knee pivot to center of mass<br />M = mass of shank/foot</p> </blockquote> <p>These equations indicate that changes in mass alone will not reduce the swing period of the shank; the center of mass must be shifted proximally (towards the knee joint) to significantly reduce the period.</p> <p>With reducing distal weight as the primary goal, an experimental shank was constructed for the test subject, a 13 year old male knee disarticulation patient with a "good" amputee gait pattern. Since the limb was to be used for laboratory testing purposes only, some strength was sacrificed in order to obtain the maximum possible reduction in distal weight while still using readily available materials. The shank was thin and hollow, with layers of polyester resin and one layer of carbon filter cloth laminated over a plaster mold. Excess material was ground away wherever possible. In addition, the prosthesis was set in correct alignment using a heel build-up on an ultra-light SACH foot to eliminate shoes and further reduce distal weight. To enable changes in the natural swing period, a lead mass which attached to a metal rod could be placed proximally or distally inside the shank. The additional mass was chosen so that the experimental shank/foot would weigh the same as the patient's standard prosthesis.</p> <p>The completed prosthesis is shown in <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg"><b>Fig. 1</b>.</a> With the moveable mass placed distally, the shank had a center of mass positioned similarly to the patient's original shank. Shifting the mass proximally caused the center of mass to move proximally by 13 centimeters. To determine the effect of changing the mass position, the pendulum swing period of the shank was measured by timing the swing of the shank, which was suspended by a metal rod through the knee joint axis. The light weight shank, with the mass placed distally, exhibited inertial properties very close to those of the patient's original shank. Shifting the mass to the proximal position reduced the pendulum swing period by 0.20 seconds or 15 percent (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-2.jpg"><b>Table 1</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg"><strong>Figure 1. Completed experimental prosthesis; shown during testing in the Kinesiology laboratory.</strong></a><br /> <p><i>Evaluation</i></p> <p>The Newington Children's Hospital Kinesiology Laboratory measured the effect on the gait of the changes made in the position of the center of mass of the experimental prosthesis. An automated video system was used to acquire three-dimensional kinematic data from 26 retro-reflective markers placed at designated positions on the body.<a></a> The kinematic data were used to determine the motions of all major body segments and calculate dynamic lower extremity joint angles in three planes. Linear movement and temporal measurements, such as stride length, single stance time, swing phase time, cadence, and walking speed were also determined. Swing time was determined by measuring the time from toe-off to heel strike. The shank pendulum time was determined by measuring the time required for the prosthesis to go from full extension into flexion and back to full extension; this is equivalent to one half of the period of the shank measured as a free-swinging pendulum.</p> <p>Kinematic data were acquired for two walks with the subject walking at:</p> <ol> <li> <p>normal speed, weight proximal</p> </li> <li> <p>fast speed, weight proximal</p> </li> <li> <p>normal speed, weight distal</p> </li> <li> <p>fast speed, weight distal</p> </li> </ol> <p>For the normal speed walks, the subject was asked to walk at a speed that was comfortable; no further prompting was given. For the faster speed walks, the subject was instructed to walk as fast as was comfortable; again, no further instructions were given. For each mass position, the knee joint friction was set to "clinically optimal" by matching the prosthetic side heel rise to the normal side heel rise at normal speed, and the patient was allowed to walk around for a while until he seemed reasonably comfortable with the altered characteristics of the limb.</p> <h3>Results</h3> <p><i>Stride Parameters</i></p> <p>Stride parameters measured during the four different conditions are shown in <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-3.jpg"><b>Table 2</b></a>. This data represents the first walk acquired for each condition; the variation between the first and second trials for all conditions was less than five percent. Cadence, stride length, and walking speed were all essentially the same at the "normal" walking speed with the mass placed proximally or distally. At the "fast" walking speed, the subject walked seven percent faster with the mass placed distally than with the mass placed proximally, due to both a faster cadence and a longer stride length.</p> <p><i>Shank Swing Dynamics</i></p> <p>At the normal walking speed, the shank pendulum time was reduced by eight percent with the weight placed proximally, resulting in an eight percent reduction in the swing phase time for the prosthetic limb (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-4.jpg"><b>Table 3</b></a>). Since the swing phase time for the normal side stayed the same, the swing asymmetry (prosthetic side vs. normal side) was reduced from 19.5 percent to 9.1 percent. A similar reduction in swing asymmetry was seen during the fast walk (from 32.4 percent to 19.6 percent). During fast walking with the proximal weight placement, the swing phase time was increased by five percent for the normal limb and reduced by eight percent for the prosthetic limb. The reduction in pendulum swing time was much greater (16 percent).</p> <p><a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-5.jpg"><b>Table 4</b></a></p> <p>The dynamic knee joint motion is shown for both weight positions (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg"><b>Figure 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg"><b>Fig. 3</b></a>). The peak knee flexion was reduced from 64 degrees to 54 degrees at the normal walking speed and from 84 degrees to 62 degrees at the fast walking speed with the weight placed proximally. The plots also indicate delayed initiation of knee flexion and faster motion of the limb with the proximal weight placement.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg"><strong>Figure 2. Knee flexion-extension angle vs. percent of gait cycle: normal walking speed, proximal and distal weight placement.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg">Figure 3. Knee flexion-extension angle vs. percent of gait cycle: fast walking speed, proximal and distal weight placement.</a><br /></strong><br /> <h3>Discussion</h3> <p>As expected, proximal weight placement in the shank produced a shorter shank swing time during gait. This subsequently resulted in a shorter swing phase (toe-off to heel-strike) for the prosthetic limb. At normal speed, the decrease in swing phase was equal in time to the decrease in shank swing time (eight percent). At a faster walking speed, the same eight percent decrease in swing phase was observed, but the shank swing period was reduced by a much greater amount.<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg"> <b>Fig. 3</b></a> illustrates the effect of this discrepancy: the limb reaches full extension well before heel strike. One explanation for this is that the subject did not have sufficient time to fully adjust to the new limb; further use should enable the subject to reduce swing phase as much as the shank swing period was reduced.</p> <p>A less expected outcome was the similarity in walking speed and cadence between the two different weight placements. The reduced swing phase did not result in a reduced gait cycle time; the subject instead lengthened his stance phase to balance the decrease in swing phase. This resulted in a smoother, more symmetric gait.</p> <h3>Conclusions</h3> <p>Limited conclusions can be made based on this single-subject study. However, it appears that decreasing the natural swing period of the shank by shifting the center of mass proximally results in a faster swing phase during gait. In one subject this led to an increase in stance phase for the prosthetic side towards normal values, and considerably reduced left-right asymmetry for this subject. Improved symmetry should lead to a more energy efficient, natural appearing gait. No increase in cadence or walking speed was observed. It is possible that longer wear of the limb might have permitted the subject to naturally increase his cadence; this could not be evaluated with the present limb design.</p> <p>The outcome of this study indicates that weight distribution in the prosthetic shank/foot has a significant impact on gait. This suggests that future prostheses should be designed to minimize distal shank/foot weight.<br /><br /><em><b>*David J. Jendrzejczyk, CP. </b> Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111.<br /><br /></em><em><b>*Ramona Hicks, R.P.T., M.A. </b> Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111.</em><br /><br /><em><b>*Scott Tashman, M. Eng. </b> Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111.</em></p> <p><b>References:</b></p> <ol> <li>James, U., and Oberg, K., "Prosthetic gait pattern in unilateral above-knee amputees," <i>Scand J Rehab Med</i>, 5:35-50, 1973.</li> <li>Godfry, C. M.; Jousee, A. T.; Brett, R.; and Butler, J. F., "A comparison of some gait characteristics with six knee joints," <i>Orthotics and Prosthetics</i>, 29(3):33-38, 1975.</li> <li>Murry, M. P., "Gait patterns of above-knee amputees using constant-friction knee components," <i>Bull Prosthet Res</i>, 17(2):35-45, 1980.</li> <li>Hoy, M. G.; Wiring, W. C; and Zernicke, R.F., "Stride kinematics and knee joint kinetics of child amputee gait," <i>Arch Phys Med Rehabil</i>, 63:74-81, Feb 1982.</li> <li>Drillis, R., "Objective recording and biomechanics of pathological gait," <i>Ann NY Acad Sci</i>, 74:86-109, Sept 1958.</li> <li>Sutherland, D. H.; Olshen, R.; Cooper, L.; and Woo, S., "The development of mature gait," <i>J Bone Joint Surgery</i>, 62A:336-353, April, 1980.</li> <li>Zarrugh, M. Y., and Radcliffe, C. W., "Simulation of swing phase dynamics in above-knee prosthesis," <i>J Bio-mech</i>, 9:283-292, 1976.</li> <li>Wallach, J., and Saibel, E., "Control mechanism performance criteria for an above-knee leg prosthesis," <i>J Bio-mech</i>, 3:87-97, 1970.</li> <li>NYU Medical Center, <i>Lower-Limb Prosthetics</i>, pp. 145-163. Prosthetics and Orthotics, New York University Post-Graduate Medical School, 1980 revision.</li> <li>Murray, M. P.; Mollinger, L. A.; Sepic, S. B.; Gardner, G. M., and Linder, M. T., "Gait patterns in above-knee amputee patients: Hydraulic swing control vs. constant-friction knee components," <i>Arch Phys Med Re-habil</i>, 64:339-345, 1983.</li> <li>New York University Medical Center, "The ISNY PTB Socket," <i>Lower-Limb Prosthetics</i>, 1980 revision, pp. 107-108.</li> <li>Hicks, R.; Tashman, S.; Cary, J. M.; Altman, R. F.; and Gage, J. R., "Swing Phase Control with knee friction in juvenile amputees," In press, <i>J Orthop Res</i>.</li> <li>Gage, J. R., "Gait Analysis for decision-making in cerebral palsy," <i>Bull Hosp Joint Des</i>, 43:147-163, 1983.</li> <li>Gage, J. R.; Fabian, D.; Hicks, R.; and Tashman, S., "Pre- and postoperative gait analysis in patients with spastic diplegia-a preliminary report," <i>J Ped Orthop</i>, 4:715-724, 1984.</li> </ol> Page Number(s) 23 - 28 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 7 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of a Prosthetic Shank with Variable Inertial Properties Creator An entity primarily responsible for making the resource Scott Tashman, M. Eng. * Ramona Hicks, R.P.T., M.A. * David J. Jendrzejczyk, CP. * https://staging.drfop.org/files/original/ff93388a2b326482cd23ab1fe7b0530f.pdf 56f90f8e21d338b8b528570d124e7f89 https://staging.drfop.org/files/original/dcdfac18ac5ac3022676315508cf5d48.jpg dbee38bac224a96a2c011cb17d7d6a9f https://staging.drfop.org/files/original/e19ee311b0e20a0019bbf64b23a2defd.jpg 709d5e732087fd5a57d43b48a0652c1c https://staging.drfop.org/files/original/ff5fb16a3b6eb4327a31bb1992c94add.jpg 634c592b76ea73a55e13cf93c72ae7ca https://staging.drfop.org/files/original/dd03140d20e3ea247047a03394d6be8f.jpg 9801ffc457b82c0e5e04953cb4376b90 https://staging.drfop.org/files/original/1c887547c6cbac99872483f954e8b43a.jpg 056339fc83108b1608ab7864990f343f https://staging.drfop.org/files/original/8c92a0c6606452d4426b8a44d4f4bff6.jpg 3f5ae3451b2192b7ea3f4231b3f169e8 https://staging.drfop.org/files/original/32fdad7b172199d9b720f189835bc3c9.jpg 9710e54f4022a14c41497f00812a7a4c https://staging.drfop.org/files/original/aa48e315ac77e0e2136d3931d68f5e2e.jpg f8768c064188a404312b028d7fff4829 https://staging.drfop.org/files/original/b5bef2c3795da5096649620616ab5554.jpg 7bf997809b8206a66916590c0d7b404b https://staging.drfop.org/files/original/b19587d2238d7d8b888d85da0d64eef4.jpg aeafbf39f3d3f61b596eddca5ba9ffaf https://staging.drfop.org/files/original/c1ce590718115f39e52684aee441de8f.jpg d5ae4663e0a01f258e869afed35cbd4a https://staging.drfop.org/files/original/c7a6dde19f351a434ecf52aabd0334d3.jpg 65cdb5dd9ad39d3da6951490f7ee16f8 https://staging.drfop.org/files/original/cf1809077913f566b86fa7e5199c3c20.jpg 4530478b27ca832a157266ebe524bb10 https://staging.drfop.org/files/original/37824783f3fe6a952766ec00f7dd01d9.jpg b11bbffa4e419db31441af1f803b4640 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_004.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 4 - 14 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Münster-Type Below-Elbow Socket, an Evaluation.</h2> <h5>Sidney Fishman, Ph. D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p> Short stumps have always presented fitting problems in both upper- and lower-extremity amputation sites for the obvious reasons of small attachment area and a lack of useful range of motion. In an attempt to alleviate these problems for upper-extremity amputees, Drs. O. Hepp and G. G. Kuhn<a></a> of Münster, Germany, developed fitting techniques for the below-elbow and the above-elbow amputee, respectively, that provide a more intimate encapsulation of short stumps. </p> <p> For the below-elbow amputee, the general characteristics of this technique (<b>Fig. 1</b>) are: </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Münster-Type fitting for below-elbow ampute. A, Lateral view ondicating the preflexion angle; B, anterior view indicating high trim line; C, posterior view indicating olecraron fit and the small tricep pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The elbow is set in a preflexed position (average 35 deg.). Because of the reduced range of useful motion, the socket is flexed so as to position the terminal device in the most generally useful area.</li><li>A channel is provided at the antecubital space for the biceps tendon to avoid interference between socket and biceps tendon during flexion.</li><li>The posterior aspect of the socket is fitted high around the olecranon, taking advantage of this bony prominence to provide attachment and stability to the socket.</li></ol> <p>For the above-elbow amputee, the characteristics of the technique are: </p> <ol> <li>The socket is fitted high on the acromian, utilizing this bony structure to retain the socket in position and provide stability. </li><li>The axillary section of the socket conforms closely around the tendons of the pectoralis major and latis-simus dorsi muscles to enable the patient to exert the force of these major muscles in moving his prosthesis.</li></ol> <p> In an earlier study<a></a>, amputee clinics reported a favorable experience in fitting preflexed arms (that is, arms bent to provide a certain amount of preflexion) to children with short and very short below-elbow stumps. Since the Hepp-Kuhn technique seemed to represent an improvement in fittings of the preflexed type, New York University initiated a preliminary investigation of the procedure for adult amputees of this type. This study took place in the early part of 1961 and was limited to two short-below-elbow subjects. This exploratory study yielded generally positive outcomes in terms of function and comfort. One short-above-elbow amputee was also fitted with encouraging results. </p> <p> The present evaluation is an extension of the initial study with major emphasis given to below-elbow fittings. Concurrently, further exploration of the above-elbow fitting technique was undertaken and is continuing, although not reported in this article. </p> <p> For lack of a better term, the fitting procedures employed in this study are referred to as the "Münster-type" techniques. It should be emphasized that no claim is made that the techniques are identical to those followed by Drs. Hepp and Kuhn. New York University personnel witnessed a demonstration of the techniques given by Dr. Kuhn in 1960 and had available the cited reference. However, none of the New York University fittings were either directly or indirectly supervised or checked by the developers. </p> <p> Both logic and prior experience suggest that the greatest benefit from the Münster-type below-elbow fitting technique may accrue to subjects with short and very short below-elbow amputations in that the step-up hinges and split sockets characteristic of typical United States fittings for these categories could be eliminated. Historically, step-up hinges have lacked durability. Moreover, a price is paid for the step-up characteristic by a corresponding decrease in lifting power. Contrariwise, it is apparent that the range of elbow flexion is reduced by the Münster-type fitting. This reduction may or may not be significant in terms of amputee function (<b>Fig. 2</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Comparison of split socket and Münster-type fitting of very short below-elbow case. A, Very short below-elbow stump-3-1/4 in.; B, split socket with step-up hinge provides 140 deg. of elbow flexion; C, Münster-type fitting permits less elbow flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Sample</h3> <p> The sample in this study consisted of eight adult below-elbow amputee subjects (including one bilateral amputee) whose stumps were relatively short-from 3-1/4 in. to 5-1/2<i> </i>in. measured from the medial epicondyle to the end of the stump. The physical characteristics of the sample and a description of their previously worn prostheses are given in <b>Table 1</b> and <b>Table 2</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Methodology</h3> <p> The Münster-type techniques for fitting below-elbow prostheses, as understood by New York University personnel, were followed in fabricating experimental arms for the eight subjects in the sample. In one case (WP), however, the anterior trim line (channel for biceps tendon) was reduced in order to provide this bilateral amputee with a greater range of elbow flexion. All prostheses incorporated triceps pads, leather hinges, and figure-eight harnesses. Six of the eight subjects (OB, PL, TM, WP, ES, and PW) were fitted with polyester porous sockets fabricated in accordance with the technique developed at the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory)<a></a>. The other two subjects (DC and QS) were fitted with nonporous plastic sockets. </p> <p> The evaluation consisted essentially of a "before" and "after" comparison of status. The prosthetic status of all subjects in this study was assessed prior to their fitting with the Münster-type prosthesis in order to obtain a basis for later comparison. At one month and at six months after delivery of the experimental prosthesis, the prosthetic status of the subjects was reevaluated and comparisons between the conventional and experimental prostheses were drawn. </p> <p> The stumps of all subjects were examined prior to the experimental fitting in order to identify their condition (scars, irritations, discolorations, etc.). This examination was repeated at the specified intervals to see what effect, if any, the experimental socket had had on the physical condition of the stump. </p> <p> Two self-administering rating scales completed by all subjects elicited their opinions regarding prosthetic comfort, function, and cosmesis. A questionnaire was administered prior to the experimental fitting to assess the amputees' opinions regarding their conventional prostheses. A comparative questionnaire was administered in the post-fitting evaluations to compare the experimental and the conventional prosthesis in the factors previously rated. </p> <p> A prosthetic-usefulness schedule<a></a> was applied to the six subjects who had previously worn a functional prosthesis to investigate their opinions concerning the relative value and comparative ease of performance of the conventional and experimental prostheses in the areas of work, home tasks, social life, dressing, and eating. </p> <p> Three evaluation procedures were administered to the six subjects who had previously worn functional prostheses, as follows: </p> <ol> <li>The angles of preflexion and maximum flexion were measured on both conventional and experimental prostheses, as well as the amount of vertical downward force the amputees could resist with their elbows flexed at 90 deg. (live lift) and fully extended (axial load). </li><li>The accuracy of positioning control exhibited by the amputees was measured with both conventional and experimental prostheses. Scoring of performance on the positioning control test<a></a> was in terms of accuracy and speed</li><li>The amputees' ability to perform a series of 12 bimanual practical activities was rated on a seven-point scale. For each activity, six factors were rated independently but simultaneously by two experienced examiners. This evaluation was administered initially to the amputees with their conventional prostheses and then repeated with the experimental prostheses at the one-month and at the six-month post-fitting evaluations.</li></ol> <h3>Results</h3> <h4>Stump Examinations</h4> <p>In all cases a period of two to three weeks was required for the subjects to become adjusted to the more intimate fit of the Münster-type socket. During this initial wear period, the usual complaint was of an irritation in the medial epicondylar area, which was corroborated by visual examination. However, after this adjustment period, the experimental socket had no observed or reported effects on the amputation stump, although amputees were generally aware of increased pressure on the olecranon when the forearm was flexed. </p> <h4>Amputee Reactions</h4> <p> Comparative reactions to the conventional and experimental prostheses were obtained from the eight subjects in the sample. The factors investigated and the amputees' ratings are presented in (<b>Table 3</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> It is clear from (<b>Table 3</b>) that, with few exceptions, the amputees reacted very favorably to the Münster-type prosthesis. Sixty per cent of the responses were favorable toward the experimental item while only five per cent were unfavorable. The two factors which brought forth negative reactions were comfort (two subjects) and adjustments (two subjects). These negative reactions reflect difficulties experienced by these two amputees in adjusting to the intimate fit of the Münster-type socket. However, all seven subjects in the sample who had previously worn rigid hinges of one type or another cited the elimination of these hinges as a definite contribution to comfort. </p> <p>No differences in reactions which could be attributed to socket porosity, or lack of it, were noted. The fact that the wear period for most of the subjects was confined to the winter months may explain this lack of difference. </p> <p>The data on effort and control are of particular interest. All subjects in the sample reported improvement in these factors as a result of wearing the experimental prosthesis. Further questioning revealed that the amputees' opinions regarding improved prosthetic control with less expenditure of effort appeared directly attributable to the more intimate fit of the Münster-type socket. This reaction was commonly expressed by such statements as: "The prosthesis feels a part of me" and "I feel right-handed again." Several subjects reported that the Münster-type sockets did not tend to slip off their stumps under load, as was the case with their conventional sockets. One subject cited the more secure fitting of the Münster-type socket to be particularly advantageous in performing overhead activities because his stump did not slip out of the socket when he performed a pulling motion with the prosthesis. </p> <p>The reactions of the two subjects (ES and PL) who had previously worn nonfunctional prostheses (for 15 and 20 years, respectively) are noteworthy. Neither became especially skillful prosthesis users in the course of the study, but both did come to use their terminal devices for grasp, which they had not previously done. Their highly positive responses to the experimental item and the fact that it changed their prosthetic status from that of nonusers to users after so long a period were considered quite unusual. Since both patients were fitted with porous laminate sockets, the role of the Münster-type fitting is not completely "pure" but, at least, must be regarded as contributory. </p> <p>Of the six subjects who had previously worn functional devices, five were able to perform the same number of activities with the experimental prostheses as with the conventional, while one subject reported increased prosthetic function with the Münster-type prosthesis (for example, he was able to carry a coat on his flexed forearm and was able to use his prosthesis in steering a car). However, all six amputees indicated that activities were easier to perform with the experimental prosthesis because the close-fitting socket afforded better control and the elimination of the rigid hinges provided greater freedom. </p> <p>In no case was there any evidence that the decreased range of motion with the experimental prostheses caused an appreciable decrease in prosthetic function. Since unilateral amputees routinely use their prostheses as assistive devices, there are few activities that are performed prosthetically at the extreme ends of the flexion-extension range. Bilateral subjects, however, are dependent on their prostheses for all upper-extremity functions and therefore require a greater range of motion. To provide the bilateral subject in our sample with an increased range of elbow flexion on his dominant side (40 deg. to 120 deg.), the anterior trim line was lowered. In addition, a wrist-flexion unit was provided to facilitate the performance of tasks close to his body. </p> <h4>Functional Evaluation</h4> <h5><i>Biomechanical Data</i></h5> <p> The Münster technique provides an intimate encapsulation of the amputated stump which results in a decreased range of motion. Forearm rotation is virtually eliminated, and the elbow flexion-extension range is significantly reduced. However, this type of fitting frequently increases the amputees' ability to resist moments about the elbow and to sustain axial loads. </p> <p> A comparison of the flexion ranges of the conventional and experimental prostheses is presented in (<b>Table 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The preflexion angle of the Münster-type socket ranged from 20 deg. to 45 deg., with an average of 35 deg. The exact preflexion angle was planned for each subject contingent on such factors as stump length, natural elbow motion, and amputee preference. Maximum flexion of the experimental sockets ranged from 85 deg. to 120 deg. with an average of 105 deg. </p> <p> <b>Table 5</b> compares the maximum holding forces that amputees (the six who had previously worn functional prostheses) were able to maintain with both prostheses. "Live lift" refers to the amount of vertical downward force (applied at the terminal device) that an amputee can resist while maintaining his elbow at 90 deg. (<b>Fig. 3</b>). To allow for different forearm lengths, the data are expressed in foot-pounds. "Axial load" refers to the amount of vertical downward force applied at the terminal device that an amputee was able to resist with his elbow in an extended position. A complaint of pain or one-inch slippage of the socket on the stump was taken as the maximum tolerable load (<b>Fig. 4</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. live-lift test </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. axial-load test </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In all cases the amputees were able to resist a greater force in the live-lift test with their Münster-tvpe prostheses than with their conventional prostheses. For three subjects (DC, WP, and PW) the differences were very significant. In subject DCs case, this difference can be readily understood since he had previously worn a split socket and step-up hinge with an inherent mechanical disadvantage. For subjects WP and PW (prior single-pivot and flexible-hinge wearers, respectively), it is speculated that their improved lifting power was directly related to the more intimate fit of the experimental sockets. However, it is not clear why the same ratio of improvement did not obtain for the other subjects. </p> <p> Four of the six subjects were able to resist a greater axial load with the Mtinster-type prostheses than with their conventional prostheses. The maximum axial load on the experimental prosthesis for the other two subjects was limited by stump pain, particularly in the epicondylar area. </p> <h5> <i>Positioning Control Test</i> </h5> <p> The positioning control test investigated the amputees' ability to control their prostheses; that is, to bring the terminal device to a desired location in space with measured speed and accuracy. Specifically, it tested the skill of the amputees in striking designated targets in the vertical (on the wall) and horizontal (on a table) planes. Three different sequences were applied in the vertical plane and two in the horizontal. Accuracy was measured by the distance of a mark (made by a pencil held in the terminal device) from the target. Superior prosthetic performance therefore is indicated by the lower scores and performance times. <b>Table 6</b> and <b>Table 7</b> present the data for the three vertical and two horizontal sequences of the positioning control tests, respectivelv. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Analysis of the data of the positioning control test reveals minimal differences between the conventional and the experimental prostheses. In the vertical sequences, these differences favored the experimental prostheses slightly, with regard to accuracy, but the reverse is true regarding speed. In the horizontal sequences the experimental prostheses were slightly favored in both accuracy and speed. However, none of the differences proved statistically significant. </p> <h5> <i>Practical Activities Test</i> </h5> <p> Comparative performance data were obtained on five subjects in the sample. Two of the remaining three subjects were not tested because they had no prior experience with a functional prosthesis. The third subject (WP) had previously worn English-made components (terminal devices, wrist units) which it was not possible to duplicate in his experimental prosthesis. Since these different terminal devices would have introduced an extraneous variable into the experimental situation, the data from this subject are not included here. </p> <p> Performance data were obtained on a 12-item practical activities test. The activities were: using a pencil sharpener, tying a necktie, tying a shoelace, carrying several packages, filing a fingernail, hammering a nail, opening a jar, putting on a glove, using a can opener, using a paper clip, using a telephone and taking a message, and removing bills from a wallet. Six factors, each rated on a seven-point scale, were considered for each test activity. The factors were: position of the prosthesis for use, grasp of the object (secure or insecure), position of object for use (efficient or inefficient), maintenance of position of object during use (efficient or inefficient), appearance of performance (natural or unnatural), adequacy of general performance (efficient or inefficient). The average scores for each subject in these six factors are presented in (<b>Table 8</b>), with the higher scores reflecting better performance. The average performance times for each subject are shown in (<b>Table 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The data from (<b>Table 8</b>) indicate that there were apparently no significant differences in performance between the Münster-type and conventional prostheses, and the time comparisons in (<b>Table 9</b>) present no clearcut patterns. Two implications of these findings are of interest. First, the obvious and measurable decrease in range of forearm flexion imposed by the Münster-type fitting has no discernible effect on the bimanual performance of unilateral amputees. Second, the highly favorable reactions of subjects to the function and control aspects of the experimental arm were not corroborated by the performance-test data. This apparent lack of agreement may derive from two factors, either singly or in combination: some subtle but important differences in performance did exist but were not detectable by the observational testing procedures applied, or the more intimate and perhaps better fit of the experimental prosthesis (as compared to the conventional) created a "halo" effect which positively affected opinions concerning other aspects of the prosthesis. That is to say, since the prosthesis felt better, it must necessarily perform better. </p> <h3>Applicability of the Technique</h3> <p> Since it was hypothesized that the experimental item might have prime applicability to amputees whose stumps fell into the very short or short categories, attention was focused in the study on the fitting of such subjects. However, it was also of interest to investigate the range of stump lengths (or types) for which the Münster-type fitting might be suitable. </p> <p> In the New York University sample the shortest stump fitted was 3-1/4 in. To investigate the possibility of fitting stumps <i>shorter </i>than this, a cast and check socket were made for a bilateral amputee with a 2-1/2 in. below-elbow stump on one side (currently wearing a stump-actuated elbow lock) and an above-elbow stump on the other side. Since the below-elbow stump virtually disappeared at 90 deg. of flexion, it was thought that this was the absolute maximum flexion angle that might be obtained. This limitation was not considered acceptable for the dominant prosthesis of a bilateral amputee. It was also considered that this stump length was very near the lower limit for acceptable fitting, even for a unilateral amputee. </p> <p> With respect to maximum stump length, two limiting factors are observed: </p> <ol> <li>Stumps of mid-length and longer usually have some amount of pronation-supination which can be harnessed in a conventional below-elbow socket (with flexible hinges), but not in the Münster-type socket. </li><li>The configuration of the Münster-type socket (proximal opening at a sharp angle to the shaft) presents progressively increasing difficulty to donning and doffing as stump length increases (<b>Fig. 5</b>).</li></ol> <p> In the New York University series, in which the longest stumps fitted were <i>5-1/2 </i>in. (two subjects), neither of the above considerations was significant in either case. It is estimated, however, that the slumps of these two subjects were approaching the upper length limit to which the Münster-type socket could be applied without sacrifice of residual pronation-supination, or modification of the proximal socket to facilitate donning and doffing. </p> <p> Subject to further study, therefore, it appears that the Münster-type socket can be applied to the range of below-elbow-stump types for which rigid hinges (step-up, multiple action, and single-pivot) are typically prescribed at present. Some consideration probably should be given to the development of a prosthesis that will permit stump-actuated pronation and supination of the terminal device, yet retain the stability afforded by the Münster-type socket. </p> <h3> Summary and Conclusions</h3> <p> The applicability of Münster-type fittings was investigated by New York University. The sample for this study consisted of eight subjects with below-elbow amputations ranging from 3-1/4 in. to 5-1/2 in. (34 to 52 per cent). The results of the evaluative procedures, which included interview techniques and performance testing, indicated the following: </p> <ol> <li>A brief "breaking-in" period was required by all subjects to adjust to the more intimate fit of the Münster-type socket. After this initial period of adjustment, the experimental sockets had no observable or reported effects on the amputation stumps except a slight increase in pressure on the olecranon during lifting activities. The use of soft (Silastic) inserts over the epicondyles and olecranon to ameliorate these factors is under investigation at New York University.</li><li>The subjective opinions of all subjects were heavily in favor of the Münster-type prostheses.</li><li>The decrease in flexion range had no appreciable effect on prosthetic function for the unilateral amputees. For bilateral subjects, modification of the anterior trim line and provision of a wrist-flexion device may be necessary for performance of tasks close to the body. </li><li>The lifting and holding forces demonstrated by the amputees were generally better with the Münster-type prostheses.</li><li>The data from the positioning control and practical activities testing were inconclusive.</li></ol> <p> The evidence suggests, therefore, that the Münster-type prostheses are functionally advantageous with considerable cosmetic and comfort appeal for amputees with very short to medium below-elbow stumps. </p> <h3>Recommendations</h3> <p> Based on the results of this study, it is recommended that: </p> <ol> <li>The Münster fabrication technique be accepted as a satisfactory means of fitting below-elbow amputees. Prime applications would be for patients with unilateral losses whose stump lengths were classified in the short and very short categories.</li><li>Upon completion of the detailed fabrication manual now being prepared by New York University, the Münster below-elbow fabrication technique be introduced into the curricula of the Prosthetics Education Programs.</li></ol> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. View of Münster-type socket showing sharp angle of the proximal opening in relation to shaft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Hepp, O., and G. G. Kuhn, <i>Upper extremity prostheses</i>, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces, and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</li> <li>Hill, James T., and Fred Leonard, <i>Porous plastic laminates for upper-extremity prostheses</i>, Artificial Limbs, Spring 1963, pp. 17-30.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, <i>The "Münster" type fabrication technique for below-elbow prostheses</i>, June 1964.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, <i>Preflexed arm study</i>, November 1960. </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>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 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>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 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>2.</b> </td><td class="clsTextSmall">Hill, James T., and Fred Leonard, Porous plastic laminates for upper-extremity prostheses, Artificial Limbs, Spring 1963, pp. 17-30.</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">New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, Preflexed arm study, November 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper extremity prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces, and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</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>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 252 Seventh Ave., New York, N.Y. 10001.</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>Sidney Fishman, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-01.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-02.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-03.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-05.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-3.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-4.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-06.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-07.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-08.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-09.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Münster-Type Below-Elbow Socket, an Evaluation. Creator An entity primarily responsible for making the resource Sidney Fishman, Ph. D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/6480fc01f37b5e97a22a6791c3a18bc9.pdf 8cadb11a4c01808e922c22cffe349ece DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_088.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 88 - 93 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/1958_01_088.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_088.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>Studies of the Upper-Extremity Amputee IV. Educative Implications</h2> <h5>Sidney Fishman, Ph.D. <br /></h5> <p>From the foregoing discussions, it will be apparent that one of the major purposes of the Upper-Extremity Field Studies was to introduce certain influences into the professional activities of the several groups (physicians, therapists, prosthetists) concerned with the care of the amputee and his reintegration into society. It was anticipated that changes in methods of patient care arising from these influences would in turn affect the welfare of the amputee group. In this sense, therefore, a major aspect of the Field Studies was the educative process involved in the attempt to change the operational patterns of those responsible for amputee care by strengthening the philosophies, attitudes, and skills which had been taught during the short-term courses of instruction. Continued encouragement, assistance, and guidance were required to habituate these groups to the procedures proposed during the instructional courses.</p> <p>The second phase of the Field Studies, the results of which will be discussed in the next issue of Artificial Limbs (Autumn 1958, Vol. 5, No. 2), is most properly considered a research activity. The purpose in this phase of the program was to attempt to evaluate the effects of these efforts on the over-all status of the amputee through the use of objective and subjective measurements. To accomplish this second phase, detailed studies were made of the status of the group of amputees prior to their treatment by the prosthetic clinic and again at a time after the completion of treatment.</p> <p>In approaching the task of estimating the effectiveness, or lack of effectiveness, of a two-pronged (research and education) program of this type, a number of problems arise. In this particular case, fortunately, we have the opportunity of deferring evaluation of the second phase, the research activities, until after those results are presented in a second installment.</p> <p>The results of the educative effort are perhaps best considered in terms of Jesus' parable of the sower, as set forth in <em>The Gospel According to St. Matthew </em> (Chapter 13):</p> <blockquote><p>3 ... Behold, a sower went forth to sow;<br /> 4 And when he sowed, some seeds fell by the way side, and the fowls came and devoured them up:<br /> 5 Some fell upon stony places, where they had not much earth: and forthwith they sprung up, because they had no deepness of earth:<br /> 6 And when the sun was up, they were scorched; and because they had no root, they withered away.<br /> 7 And some fell among thorns; and the thorns sprung up, and choked them:<br /> 8 But other fell into good ground, and brought forth fruit, some an hundredfold, some sixtyfold, some thirty fold.<br /> 9 Who hath ears to hear, let him hear.<br /></p> </blockquote> <p>In some few places and among some persons, no effects are to be noted. Among others minor temporary changes evolved, and in still other instances important permanent improvements were brought about. We may consider these effects under three broad categories-impact on the medical management of the amputee, impact on public and private rehabilitation agencies, and impact on social attitudes.</p> <h3>Impact on the Medical Management of the Amputee</h3> <p>It has been emphasized consistently throughout the foregoing sections that a "prosthetic-clinic approach" to the problem of the amputee was a basic tenet of the field-studies program. In this approach, the fundamental decisions relating to the rehabilitation of the patient were made in concert by a group consisting minimally of a physician or surgeon, a physical and/or occupational therapist, and a prosthe-tist. Whenever possible, vocational counselors and other personnel trained in the psychosocial aspects of rehabilitation also were included.</p> <p>The second aspect of the prosthetic-clinic approach involved an attempt at considerable standardization of the process of patient care and usually included eight more or less formal treatment steps-preprescription examination, prescription, preprosthetic therapy, prosthetic fabrication, initial checkout, prosthetic training, final checkout, and follow-up. As a consequence of these efforts, three major changes occurred in the medical care of amputees- introduction of prosthetic-clinic procedures, staff and patient education, and upgrading of existing services.</p> <h4>Introduction Of Prosthetic-clinic Procedures</h4> <p>Although similar clinical procedures have been developed and practiced in the treatment of other disabilities, and even occasionally in prosthetics, the attempt at systematic introduction of such procedures on a broad basis was a novel one. In addition, experimental exploration and validation of the essential adequacy of such procedures is hardly ever available. As a major outcome of the Field Studies, however, the basic validity of the clinical procedures in the field of upper-extremity prosthetics has been established. In addition to these accomplishments, certain other changes occurred with respect to the patient-care activities of each of the specific professions-the physician and surgeon, the physical and occupational therapist, and the prosthetist-concerned with the handling of the upper-extremity amputee.</p> <h5><i>The Physician and Surgeon</i></h5> <p>As a result of the principles and procedures instituted under the program, the period during which the amputee is considered a patient under medical management was extended significantly. Formerly an amputee was a patient during surgery and through a limited period of postoperative care. Today, the period of medical supervision continues through the entire process of limb prescription, fabrication, training, and evaluation.</p> <p>As an additional outgrowth, a subspecialty within the fields of orthopedic surgery and physical medicine has been developed. A limited number of physicians have become expert in the field of limb prosthetics. Since the amputee represents a relatively small portion of the total population requiring medical service, it is not feasible for large numbers of physicians to specialize in this field. But in order to provide competent service for amputees it was essential that a few physicians in each major population center be thoroughly equipped to provide the care required. Physician specialization in the very restricted field of prosthetic restoration has come about as a direct result of the program.</p> <p>Through the program the physician has learned much concerning the technical specifics of prosthetic restoration. As a result of this education, his respect for the contributions made by the skill and experience of the therapist and prosthetist in the process of amputee rehabilitation has increased. The interdisciplinary approach to the problem of amputation and prosthesis has become accepted and appreciated as a significant forward step in the medical management of the amputee. As a general consequence, the physician has been able to acquaint himself with, adapt, and then apply modern-and gradually higher-standards of prosthetic care for his patients. Knowing, perhaps for the first time, what constitutes and what is involved in providing a good prosthesis, the physician is now able to require a standard of service not previously possible.</p> <h5><i>The Physical and Occupational Therapist</i></h5> <p>For the therapist, the short-term courses in upper-extremity prosthetics filled a gap left by the usual curricula in schools of occupational and physical therapy. Perhaps for the first time, a systematic approach to the amputee problem was taught and practiced. As a result, the therapist has been able to carry out the major responsibility of amputee training with a background of general technical knowledge directly relating to artificial limbs. In addition, closer professional liaison developed between the therapist, the physician, and the prosthetist with regard to the amputee. As a result, in most instances upper-extremity amputees are now routinely referred to the therapist for instruction in the use of the artificial limb, whereas in the preprogram days the number of therapists qualified to give this service and the number of amputees availing themselves of it were both insignificant.</p> <h5><i>The Prosthetist</i></h5> <p>The program sought and helped to provide a proper professional role for the prosthetist. As a group, prosthetists were for the first time exposed to formal university instruction and to closer relations with medical, paramedical, and psychosocial disciplines. Thus the prosthetist has been helped toward a redefinition of his status on a higher professional level.</p> <p>This progress in the direction of a more professional role was aided in no small measure by the acquisition of a new technology involving the use of biomechanical principles, plastics fabrication, and principles of harnessing and controlling artificial limbs. This improved knowledge has resulted in improved service, increased status, and greater interprofessional satisfactions.</p> <p>One cannot say at this early stage in the evolution of this field just what the ultimate or proper interrelations may be between the professions concerned. Certainly the appropriate relationships will tend to vary from location to location, depending upon personnel and situational considerations. There can, however, be no gainsaying the facts that a period of growth has been stimulated, that the adequacy of the present treatment situation far surpasses that of the old, and that there has been developed a climate which gives every indication of providing additional professional status for the prosthetist.</p> <h4>Staff And Patient Education</h4> <p>A second value provided by the studies relates to the matter of staff and patient education. It is as true in limb prosthetics as in the other healing arts that there are no standard procedures which will apply with equal effectiveness to every patient. Moreover, limb prosthetics is still a field in which the contributions of each of the specialists are but partially understood by the others. Consequently, there is an important need for a cross-fertilization of ideas and a distillation of the best thinking for a given patient by the process of group activity. In this sense, an important achievement of the prosthetic clinic may be considered the intraclinic education of the team members.</p> <p>Equally important is the role that the clinic must play in the education of the patient. Most amputees, when arriving for prosthetic care, are subject to wide and varied misunderstandings and misinterpretations as to the procurement and ultimate use and value of a prosthetic device. Clinic personnel have become more effective in educating the patient concerning realistic goals and anticipations, in addition to providing him with the best type of prosthesis for his particular needs.</p> <h4>Upgraing Of Existing Services</h4> <p>In the process of applying and studying clinic procedures experimentally, the last important result evolved-that of an upgrading of existing services, as well as the establishment of services where none had existed previously. In this respect, the major contribution apparently has grown out of the introduction of a coordinated pattern of treatment.</p> <p>Previously, it had not been uncommon for a prosthetist, physician, and vocational counselor, for example, to proceed with the care of an amputee independently of one another. This procedure was often adopted in spite of the fact that in any situation where an individual is receiving treatment from more than one specialist, and where the anxieties are such as to provoke some degree of patient discontent, there is a noticeable tendency for some patients to distort the intentions and contributions of each profession in relation to the others. Such problems are further aggravated in those instances where the patient himself is called upon to act as the means of communication between the professions involved, since we may be sure that there will always be a certain degree of distortion of the patient's perceptions of the treatment processes. The clinic procedures were especially effective in reducing this troublesome method of communication between the specialists.</p> <p>We may also anticipate that the behavior and demeanor of the patient toward the pros-thetist will differ from that he exhibits toward the physician, therapist, or counselor. These differences in overt behavior patterns may easily and logically suggest different patterns of treatment to each of the individual professions. Yet it should be clear that these varying behaviors on the part of the patient are transitory and that the real solution lies in a uniform treatment plan rather than in a number of discrete ones. It therefore becomes clear that, in order to provide amputees with the best available medical and prosthetic service, the contribution of each of the professional specialties is best coordinated and amalgamated with that of each of the others. The prosthetic-clinic procedures, introduced through the studies, permitted a more uniform evaluation of the patient and assisted in circumventing the problems inherent in uncoordinated care.</p> <h3>Impact on Public and Private Rehabilitation Agencies</h3> <p>Many groups who have as their adopted or assigned mission the reintegration of the handicapped individual as a productive member of society have long been aware of the significance of the process of prosthetic restoration as a link in the over-all process of rehabilitation. As a direct consequence of this awareness, and as a necessary outgrowth of their over-all responsibilities in the rehabilitation field, federal agencies such as the Veterans Administration, the Armed Forces, and the Department of Health, Education, and Welfare, the state divisions of vocational rehabilitation, workmen's compensation, and health and public welfare, and such nongovernmental agencies as the state societies for crippled children and adults, rehabilitation centers, insurance companies, and a number of other private agencies have become the largest purchasers of prosthetic services in the United States.</p> <p>Through the NYU Field Studies these groups have been made increasingly aware of the potentialities of prosthetic restoration and have responded by raising their standards in the field of upper-extremity prosthetics. Having been provided with professionally competent avenues for the processing of their beneficiaries through prosthetic prescription, fabrication, training, and evaluation, these agencies have begun to insist that their clients be treated by special amputation teams headed by physicians who are experts in the field. Since these agencies may be considered "consumers" in the sense that they most frequently pay for the prosthetic services provided, they have been instrumental in raising the standards by rejecting prostheses and services that do not meet the minimum standards first set up through the program.</p> <p>A by-product is that the groups mentioned tend more and more to order prostheses from those prosthetists who have fully qualified themselves by virtue of training and experience. In a good many instances, these agencies have shown themselves willing to spend the additional monies required to obtain services of the highest quality. In some instances the program has been instrumental in stimulating the inauguration of local services to avoid the necessity for these rehabilitation agencies to contract for prosthetic services from distant sources. The widespread introduction of the clinic-team concept to the field of limb prosthetics provided the means for greater liaison between rehabilitation agencies and those persons medically responsible for the process of prosthetic restoration. Since the clinic-team meetings ordinarily involve a conference of all of the participants in a given case, the agency itself is frequently represented at such conferences by a professional staff member. This, of course, makes for considerable improvement in the continuity of the rehabilitation process.</p> <h3>Impact on Social Attitudes</h3> <p>Beyond their influence on the medical and rehabilitation agencies, the effects of the Upper-Extremity Field Studies also permeated through other facets of our social structure, although as one departs further and further from the professional groups directly responsible for the care of the amputee the impact of the effort becomes more diffused and less specific. Nonetheless, a number of significant effects remain to be noted. They may be viewed as influencing the attitudes and thinking of sponsoring agencies, scientists concerned with physical disability, other groups of disabled, and society at large.</p> <h4>Sponsoring Agencies</h4> <p>Perhaps one of the most important contributions was the demonstration that within a relatively brief period of time research and development can be accomplished and the benefits therefrom made available to the average patient with a disability. It should be recalled that the entire upper-extremity research program did not get under way until several years after the close of World War II and that the major prosthetic design improvements depended upon several years of fundamental biomechanical research. Thus the entire concept and technology of the care of the upper-extremity amputee has been revolutionized within a remarkably brief period of six or seven years.</p> <p>Such demonstrable progress is of inestimable value to those whose prerogatives require that they decide where substantial private or public monies should be spent in medical or rehabilitation research. Although it is always important to verify or evaluate the results of a broad program of research, this is not always possible. Yet this is precisely what the Upper-Extremity Field Studies have done.</p> <p>In the first instance, scientific evidence has been provided concerning the over-all value and contribution of the six or seven years of research and development. Secondly, and from a more technical point of view, information was brought forth concerning those aspects of the care of the upper-extremity amputee which had progressed most satisfactorily and those phases which require continuous improvement and attention.</p> <h4>Scientists Cconcerned With Physical Disability</h4> <p>The program of research and education also assisted in the general growth of scientific thinking on problems of human disability. Some detailed discussion of these research considerations will be included in the next issue of Artificial Limbs (Autumn 1958, Vol. 5, No. 2), which will deal with the research aspects of the studies. The discussion of the educative aspects of the Upper-Extremity Field Studies would be incomplete without note being taken of the progress that has occurred in the attitudes and thinking of researchers in the field of physical disabilities. These advances have been summarized at the recent conference on the Contributions of the Physical, Biological, and Psychological Sciences in Human Disability sponsored by the New York Academy of Sciences (page 125).</p> <h4>Other Groups Of Disabled</h4> <p>It is clear that a special service was performed for those individuals who have incurred disabilities related to, but not identical with, amputation. These groups are perhaps best typified by those disabilities which require functional restoration by use of braces or other orthopedic appliances.</p> <p>Until the time of these studies, there was very little overt expression of the need for progress in the field of bracing. The prevailing situation was one that had remained static for decades. With limited exceptions, personal unvalidated opinion, professional and otherwise, pervaded and still characterizes the entire field.</p> <p>Partially as a consequence of the broad educative aspects of the Upper-Extremity Field Studies, a spontaneous development of interest and desire for systematic progress arose in this related field, which is often served by the same doctors, therapists, and pros-thetists-orthotists. People who were suffering from these types of disabilities and those who cared for them generated a new feeling of hope and enterprise. The results of these changes in attitudes are just now being translated into planning for active research and education.</p> <h4>Society At Large</h4> <p>Further evidence was provided that the systematic treatment of the disabled is a fundamentally effective and socially desirable process. The "collective concern" which society experiences concerning the physically handicapped tends to be reduced with the knowledge that constructive things can be done, and have been done, for this group in an orderly, scientific manner. Associated with this growth in knowledge is a reduction in anxiety and prejudice concerning the physically handicapped and a corresponding increase in their acceptance by society.</p> <br /> 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 Studies of the Upper-Extremity Amputee IV. Educative Implications Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D.  https://staging.drfop.org/files/original/c0d0eca6feaf1da610d7cb20b544cd80.pdf 4ab0cc41972a01f65f7db078a1de828c https://staging.drfop.org/files/original/b6d2f7ed0ba556ec7090952c752fbbc5.jpg 41c792470fa9bf7060831ecdd6c6bebc https://staging.drfop.org/files/original/a3f76296fb4dd3889147b7e76d279fd1.jpg 7fdba66f3090467035423319664668ed DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_117.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 117 - 127 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/1958_02_117.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_117.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>Studies of the Upper-Extremity Amputee VIII. Research Implications</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It was the purpose of the NYU Field Studies to explore the matter of the upper-extremity amputee in a broad and comprehensive way. To this end there was devised a research program consisting of three phases-survey studies, clinical studies, and evaluation studies. The first of these consisted of the single examination of each of 1630 upper-extremity amputees for the purpose of developing normative, descriptive data concerning the status of the upper-extremity-amputee population at the beginning of the research program. Through the vehicle of an organized program of prosthetic management, 769 of the 1630 amputees surveyed were provided in the clinical studies with what at the time was a new type of upper-extremity prosthesis, the purpose being to study the varieties of prostheses provided, the prescription procedures used, the preprosthetic treatment employed, the adequacy of prosthetic fabrication and fitting, the effects of training, and the results of initial and final checkouts. Finally, in the evaluation studies, the prior status, mental and physical, of 359 individuals selected from the clinical study was compared with their corresponding status after participation and treatment. The procedures used in each of these studies, and the objectives sought in the work, have all been discussed in detail in Section I of this series (Artificial Limbs, Spring 1958, p. 4).</p> <p>While the variety, scope, and degree of completeness of the resulting data all increased as work progressed from the survey studies through the clinical studies and on to the evaluation studies, the size of the experimental sample decreased. The survey studies were limited to the normative data that could reasonably be gathered by means of a onetime interview and examination of the largest possible sample of upper-extremity amputees. The clinical studies supplemented the normative data with observational information concerning 769 amputees receiving prosthetic treatment. The evaluation studies included normative, observational, and research procedures. Only in the last series of studies did control of any research variables become possible. The major focus of the evaluation studies was, then, to obtain information on possible changes in the individual resulting from the application of new and experimental procedures in the management of the upper-extremity amputee.</p> <p>The types of information sought in each of the three phases fell into one or more of five broad categories:</p> <ol> <li><i>The physical and personal characteristics of the amputees.</i>Included identifying data (age, height, weight, residence, marital status); educational level; vocational, avocational, and recreational pursuits; amputation etiology; amputation type; and the strength, ranges of motion, and general characteristics of the stump.</li><li><i>The prosthetic components and fabrication techniques utilized.</i>Included information concerning the functional and mechanical characteristics as well as the advantages and disadvantages of each component of the artificial arm.</li><li><i>The treatment factors.</i>Included data concerning the frequency of prescription of various components, pre-prosthetic therapy, prosthetic training, and checkout.</li><li><i>Amputee performance.</i>Concerned with testing the individual's proficiency in accomplishing the basic activities of prehension, positioning, and release of objects from grasp and with amputee reports concerning the usefulness and importance of the prosthesis in various practical activities of daily living.</li><li><i>Psychological considerations.</i>Involved an assessment of amputee attitudes and personality factors as they affect reactions to prosthetic restoration as well as the social consequences of living with a disability.</li></ol> <p>While data within these five areas of interest were gathered in all three phases of the investigation, the comprehensiveness and sophistication of the measurement techniques varied from phase to phase. In view of the wide range of matters investigated, it is clear that the problems involved in their accurate measurement were considerable. Some factors <i>(e.g.,</i>mechanical characteristics of prosthetic components, results of checkout, certain personal identifying data, etc.) lent themselves rather conveniently to so-called "objective measurement," while in the light of presently available techniques other factors could be appraised only through subjective observation and rating by trained observers <i>(e.g.,</i>amputee performance, quality of prosthetic training, quality of prosthetic fabrication, etc.). Still other factors <i>(e.g.,</i>attitudes, personality factors, opinions concerning prosthetic components and treatment methods, etc.) could only be inferred from the verbal reports of the amputees themselves. As a consequence, the resulting data are of three kinds-objective measurements, observations and ratings, and amputee verbalizations. It should, however, be pointed out that no relationship necessarily exists between the significance and value of various data and their objectivity. Quite often the most objective data are the easiest to obtain but are also the least revealing. Yet certain data obviously subjective and barely capable of meeting any standards of precision provide the greatest insights and understanding.</p> <p>With several relatively minor exceptions, all five subject areas have individually been the topic for separate analyses and discussions and have culminated in five corresponding articles (Sections II, III, V, VI, and VII) in this series. Section II (Artificial Limbs, Spring 1958, p. 57) dealt with the descriptive characteristics of the sample. Section III (Artificial Limbs, Spring 1958, p. 73) was concerned with the evaluation of the treatment process. Section V (page 4) reviews the specific components and fabrication techniques that go to make up a prosthesis. Section VI (page 31) describes the performance or functional capabilities of the amputee subjects, while Section VII (page 88) analyzes the psychological attributes of the amputee group.</p> <h3>Studies Completed</h3> <h4>The Sample (Section II)</h4> <p>The initial point of interest is that there were in the nationwide, somewhat urban sample almost as many above-elbow as there were below-elbow amputees (41 percent as compared with 51 percent). The remaining cases consisted of shoulder-disarticulation amputees (5 percent) and bilateral arm cases (3 percent). Within each of these four basic amputee types, a further detailed breakdown is presented. For example, the below-elbow cases are classified and discussed as very short, short, medium, and long, and as wrist disarticulations. A similar breakdown is offered for the above-elbow and shoulder-disarticulation groups.</p> <p>It is important to emphasize that 73 percent of the participating subjects were veterans of military service who had lost limbs in World War II, a matter having a strong influence on the characteristics of the sample- on age, height, weight, educational level, and vocational status as well as on other physical characteristics.</p> <p>Although certain amputees continued to pursue agricultural and mechanically oriented occupations, amputation generally resulted in a shift away from agricultural, manual, and mechanical occupations toward clerical, sales, and managerial activities, and there was in addition a very significant increase in the extent of unemployment (from 1 percent to 19 percent). Such a finding raises the question whether these shifts are caused chiefly by the physical inability to perform and compete in certain activities or primarily by socioeconomic factors.</p> <p>An overwhelming majority of the subjects were found to have in their residual anatomy sufficient strength and sufficient range of motion to use an upper-extremity prosthesis. Despite this physical potential, 25 percent of the below-elbow, 39 percent of the above-elbow, and 65 percent of the shoulder-dis-articulation amputees were not wearing arm prostheses at the time of the survey studies. Typically, those who did wear prostheses used Dorrance hooks, Miracle or APRL hands, and friction-type wrist units. The below-elbow prostheses typically consisted of a leather socket, rigid metal elbow hinges, and a figure-eight harness. The above-elbow and shoulder-disarticulation prostheses had in general plastic or leather sockets, manually operated or harness-controlled elbows (in about equal proportions), and chest-strap harnesses with shoulder saddles.</p> <h4>The Treatment Process (Section III)</h4> <p>Before the advent of the Upper-Extremity Field Studies, only some 17 percent of the group had had arms prescribed for them by a clinic team consisting of a physician, a therapist, and a prosthetist. In the NYU program, where prescriptions were written and filled in this manner routinely, all the professional groups concerned and 94 percent of the amputee subjects heartily approved of the multidisciplinary, clinical approach.</p> <p>With respect to prosthetic components utilized there were several very significant shifts, such as the tendency toward the use of the APRL hook (from 12 percent to 61 percent of the sample) and toward the APRL hand (from 11 percent to 80 percent of the sample). There was also a marked increase in the use of positive-locking wrist units as compared with friction types, a strong shift toward the use of flexible hinges instead of rigid hinges for the below-elbow amputees, and an increase from 46 percent to 100 percent in the proportion of above-elbow amputees wearing harness-operated elbows. Plastic laminates were used exclusively for fabrication of the nonoperating parts of the prostheses, and the harness patterns tended to be of the figure-eight type. In point of fact, it may be said that the whole pattern of prosthetic prescription for the upper-extremity amputee was revolutionized in the course of the Upper-Extremity Field Studies.</p> <p>Introduction of the checkout procedures met with considerable success. Clinic personnel considered checkout a valuable management tool, and more than 90 percent of the amputees thought it useful. Whether initial checkout or final checkout, almost 70 percent of the arms passed on the first trial. The remaining cases required two or more visits to resolve all problems, the major deficiencies uncovered being in the areas of socket fit, harnessing, and alignment of control systems.</p> <p>Application of the training procedures was not nearly so successful. Some 40 percent of the group thought that the results of training could be improved by extending the instruction over a longer period and by including more and varied practice in the regimen. The finding that during the training period 54 percent of the sample needed adjustments or corrections in the prosthesis suggests the great value of supervised training-that is, of training in a situation so controlled that specific difficulties can be uncovered and resolved with a minimum of difficulty. Although the length of the training period was greater for bilateral cases than for shoulder disarticulations, greater for shoulder disarticulations than for above-elbow amputees, and so on, the time allotted for shoulder disarticulations and for above-elbow cases over that allowed below-elbow cases did not seem to be in keeping with the increase in operating difficulty known to accompany loss of the natural elbow.</p> <p>All in all, the system of amputee management introduced as part of the Field Study was accorded a high degree of acceptance both by the amputees and by the professional personnel charged with their care. Perhaps the strongest recommendation for the management procedures lies in the fact that, with appropriate revisions and variations, they are now in widespread use in amputee clinics throughout the country.</p> <h4>The Armamentarium (Section V)</h4> <p>The data concerning the prosthetic armamentarium tend to be encyclopedic and documentary. Each component of the upper-extremity prosthesis has been considered in terms of appearance, usefulness, ease of operation, and weight, and this information has been supplemented by data on the ranges within which the components functioned and on the magnitudes of the activating and resulting forces. The adequacy of the fabrication techniques utilized in making the upper-extremity prosthesis was also reviewed. These data provide the biomechanical basis upon which to revise a number of the checkout standards.</p> <p>Lastly, the new components that go to make up the present armamentarium (terminal devices, wrist units, elbow hinges for below-elbow arms, elbow joints for above-elbow arms, control systems, and harnessing equipment) have been compared with corresponding components in the prior art. Amputee reactions toward the conventional preprogram arms have been compared with the reactions toward the new program prostheses. The amputees felt that the program prostheses are characterized by:</p> <ol> <li>Higher, better-fitting, and better-appearing sockets.</li><li>More useful and easier-operating elbows.</li><li>Improved efficiency of force transmission reflecting better cable alignment and more stable materials.</li><li>Lighter, freer, and more comfortable harnessing.</li><li>A marked increase in terminal devices offering improved control of grasp force.</li></ol> <p>Of the 290 amputees who had an opportunity to wear both types of arms, 261 preferred the new, 25 the old, while 4 expressed no preference.</p> <h4>Amputee Performance (Section VI)</h4> <p>Section VI has been concerned with the functional value of arm prostheses, the uses to which they are put, and the skill and efficiency with which arm amputees can utilize them. From interrogation of the subjects, it became apparent that the usefulness of an arm prosthesis varied considerably from activity to activity in the five broad areas of daily living (work, home, recreation, dressing, and eating). In the numerous activities that go to make up work, recreation, and home life, prostheses tended to have wide applicability and to be most helpful to the wearer. As a matter of fact, use of the prosthesis in a variety of jobs and hobbies was much more extensive than is usually recognized, and we must therefore conclude that the functional potential of the upper-extremity amputee is also a good deal greater than commonly thought. But in the activities of dressing and eating, which for the most part involve a limited number of relatively difficult operations performed close to the body, prostheses tended to be considerably less useful. An interesting note is that, as regards the performance of any one given task, prosthetic usage tends to be on an all-or-none basis. Either the amputee uses his prosthesis every time he is confronted with a given task, or else he never uses it for that task. "Sometimes" usage is reported infrequently.</p> <p>To shed further light on the comparative values of below-elbow, above-elbow, and shoulder-disarticulation prostheses, 20 selected bimanual activities, considered both by the examiners and by the amputees to be significant in terms of frequency of occurrence and of importance, were used in an attempt to determine how widely prostheses were used. In summary, the results showed that:</p> <ul> <li>Over 50 percent of the below-elbow amputees always used their prostheses for 19 of the 20 tasks.</li> <li>Over 50 percent of the above-elbow amputees always used their prostheses for 13 of the 20 tasks.</li> <li>Over 50 percent of the shoulder-disarticulation subjects always used their prostheses for 8 of the 20 tasks.</li> <li>Over 50 percent of the bilateral arm amputees always used their prostheses to accomplish 15 of 18 tasks (two tasks not applicable).</li> </ul> <p>These and other data show clearly that the higher the level of amputation for which an arm prosthesis is intended the less the utility of the prosthesis. The sharp distinction between the usefulness of prostheses for below-elbow amputees and that of prostheses for above-elbow and shoulder-disarticulation amputees can be explained readily in terms of the limited function to be had from the mechanical elbow and the concomitant need for a comparatively high order of skill in order to use it properly. The difference in apparent usefulness is clearly due to the loss of the normal anatomical elbow. This circumstance re-emphasizes the need for more practically oriented and more extended training for above-elbow and shoulder-dis-articulation amputees.</p> <p>While contemporary below-elbow prostheses appear to be more useful than are the corresponding prostheses for above-elbow amputations and for shoulder disarticulations, arms for the higher levels of limb loss still offer a significant measure of utility. It should also be noted that not all amputees of a given type use their prostheses to the same extent or for the same activities. Obviously, then, the prosthesis varies in value and convenience for the individual wearer, and this factor also helps to determine the amount of use made of the limb by the individual wearer.</p> <p>Through a series of tests of abstract function (prehension and positioning viewed as ends in themselves) and of the performance of practical activities of daily living, a systematic, observational method of rating amputee performance was developed. Although the tests are not as precise as might be desired, an initial step in the measurement of amputee function has been taken. One direct result has been the establishment, for the upper extremity, of a set of norms which may be used as a point of comparison in evaluating amputee performance and in setting reasonable goals for prosthetic training.</p> <p>The data from these tests clearly indicate that, in general, more could be accomplished with the new arms than with the old and that more skillful and more natural performance with the new prostheses was usually obtained without any increase in performance time.</p> <p>The advantages of the experimental arms over the older, conventional arms were most noticeable in above-elbow and shoulder-disarticulation prostheses, less so in below-elbow prostheses. In the below-elbow case, apparently, prosthetic function is very much less dependent upon the quality or precision of arm fabrication, or on the specific components included in the prostheses, or both.</p> <p>While in general the results point up the inadequacies of even our most advanced devices and techniques and thus emphasize the continued existence of much room for improvement, they also show that present-day upper-extremity prostheses are quite useful devices despite the inadequacies, especially for those types of amputees heretofore thought incapable of deriving much benefit from any prosthesis. Since we seem now to have exploited the existing concepts of upper-extremity prosthetics, there would seem to be little more to be gained by continued redesign of current prosthetic equipment. Instead, there is now a need for dramatic, if not drastic, new concepts in approaching the problem of rehabilitating the upper-extremity amputee.</p> <h4>Amputee Attitudes And Reactions (Section VII)</h4> <p>Section VII attacked the problem of prosthetic restoration from the point of view of the psychological characteristics of the amputee and tried to evaluate the subjects on the basis of nine personality variables, to explore a number of factors influencing prosthetic wear and function in social situations, and to study the amputees' attitudes toward prosthetic wear before and aftei fitting with a prosthesis The predominant finding as regards the personality functioning of the amputees was that, no matter which aspect was studied, the subjects appeared to try consistently to maintain feelings of bodily integrity and adequacy by denying many of the personal, vocational, and social consequences of amputation. They consistently de-emphasized their physical difficulty, rejected notions of abnormality, and set their cosmetic and functional desires in line with those of normal people. Superimposed on this general positive tone of the amputees' statements concerning adjustment was the additional positive effect of the treatment program on many of the personality variables, as evidenced by consistent indications of some decrease in expressed feelings of sensitivity and frustration, increased feelings of functional and social adequacy, and greater acceptance of their disability.</p> <p>One problem associated with this aspect of the study was that, because of the limitations of the experimental design, the data were based entirely upon the voluntary expressions of the subjects themselves, who consistently tended to color their responses by hiding any attitudes which might be viewed as "negative." Aware of this difficulty in the measurement of the social and functional factors affecting prosthetic wear, the experimenters attempted a somewhat more indirect approach in the form of cartoons depicting a series of ambiguous, potentially sensitive, situations. The amputees were asked to respond to these situations, the expectation being that they would "project" their attitudes in a less inhibited form. Probably the major finding of this line of inquiry developed from the answers given when the amputees were requested to react to the cartoons as prosthesis wearers and then as nonwearers. The data show consistently positive attitudes toward prosthetic wear, the feeling being expressed that the prosthesis makes the amputee more effective and independent functionally, more self-reliant, more secure, more self-accepting, less shy, less easily embarrassed, and more adaptable. One may, of course, ask whether the amputees held these attitudes fundamentally or whether they were merely expounding an expected "cultural norm." On the basis of the available data it is not possible to answer the question.</p> <p>In a comparison of the preprosthetic expectations of amputees with the actual degree to which these expectations were fulfilled after fitting, it was concluded that:</p> <ol> <li>Normally, little prosthetic information is available to the new amputee, and this deficiency encourages the development of unrealistic expectations concerning prosthetic wear.</li><li>Anticipations which tended to be overly optimistic were in most cases modified downward (with considerable personal disappointment and regret) after the individual had an opportunity to wear a prosthesis.</li></ol> <p>The last question studied had to do with whether or not the postfitting behavior of the amputee toward his prosthesis is related to, and whether or not it can be predicted on the basis of, his prefitting attitudes, a matter that would seem to have significant practical implications. Should preprosthetic attitudes turn out to exercise a determining or controlling influence over later prosthetic acceptance, performance, and use, it would be desirable to attempt to influence early attitudes so as to obtain the best possible rehabilitation results. Investigation did indeed show that those amputees holding favorable attitudes before ever having had a prosthesis tended to maintain favorable attitudes after wear and use; those at first negatively disposed continued to react negatively after receiving a prosthesis.</p> <h3>Future Studies</h3> <p>Although the amputees in the NYU Field Study have thus far been assessed rather thoroughly in terms of five broad areas (physical and personal characteristics, prosthetic components and fabrication techniques, treatment procedures, prosthetic performance, and psychological orientation), little has yet been done toward exploring the relationships that may exist either within or between the several categories of data. As a matter of fact, the data reported and discussed here constitute a phenomenological picture of observed events and are therefore basically descriptive in nature. While data of this type are valuable in that they focus attention on significant occurrences and reveal what is taking place and what is changing during the period of observation, the reasons why the events occur, and the nature of the causal train producing them, can be learned only by more detailed and more definitive study.</p> <p>The only studies of this more detailed variety which have been performed thus far are as follows:</p> <ol> <li>A substantial segment of the findings concerning the unilateral amputees have been analyzed and presented in terms of the three basic amputee types- below-elbow, above-elbow, and shoulder-disarticulation amputees. But there is still a need for further analyses of this variety using finer categories in the amputee-type classification system (such as wrist disarticulation, long below-elbow, medium below-elbow, short below-elbow, very short below-elbow, etc.).</li><li>A number of attitudes toward prosthetic wear held by the amputees prior to prosthetic fitting have been studied and presented in relation to postfitting attitudes and psychological adjustment.</li></ol> <p>Whatever cross-correlations are attempted, however, it must be remembered that the subject matter deals with the complex interactions between a human being, the patient, and an involved environmental process, the treatment procedure. Man is not composed of a series of discrete traits and attributes, nor does he represent the simple sum of such features Taken as a whole, the configuration is more exponential that additive. Similarly, the treatment procedures at any given level of observation may represent a series of obvious events simply measured and simply described, or they may be seen more subtly as sets of behavior of professional people- physicians, prosthetists, therapists, others- directed toward another individual, the amputee. In this light, distinctions and comparisons drawn between the patient, the treatment process, and the restorative result are unavoidably arbitrary to the extent that they tend to be abstractions from the intricate network of human behavior. Since in practice, however, analyses must be performed at some level not fully reflecting the human interactions at work, attempts at further study require some kind of conceptual framework within which to consider the data.</p> <h4>A Conceptual Framework</h4> <p>When the mass of available data is reviewed,<a style="text-decoration:none;">*</a> the individual elements fall naturally into two groups-those which describe the factors contributing to the over-all result of prosthetic restoration and those which describe the result itself. The data in the first category, those dealing with the causal factors, seem in turn to constitute two separate subcategories-the individual characteristics, which the patient brings to the restoration regimen, and the treatment process, which describes the management procedures applied. Together the interaction of these two contributing factors (variables) produces the over-all result of prosthetic restoration. Thus:</p> <p>Amputee Characteristics + Treatment Process = Over-All Result of Prosthetic Restoration</p> <p>But each of these three broad factors consists, again in turn, of a number of more specific considerations that were the subject of investigation in the NYU Field Studies. It is therefore possible to recast the formula into somewhat more specific terms, whereupon the three factors in the original relationship are found to consist of seven different types of data. Thus: <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Further expansion of such a breakdown leads to <b>Table 1</b>, which reflects in greater detail the kinds of information available. All told there are some 60 variables on which data have been collected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The data having been thus classified, it is now necessary to find the means with which to develop whatever significant interrelationships may exist within and between the various categories. Analyses may be performed at any of the three levels of complexity, but those best undertaken first would tend to consider the segmented types of data listed in the lower portion of <b>Table 1</b>. Contrary to first impression, they are in reality by far the simplest to investigate. To study the earlier, more general, and apparently less complex relationships shown in the first two formulae will require the development of suitable means for consolidating individual sets of data in some meaningful way to describe the composite concepts utilized. Accordingly, analyses of the data will vary in complexity depending on whether we wish to study the relationships between discrete variables or those between increasingly composite, and therefore complex, conceptualizations. As the chosen formulation becomes clinically more meaningful, the complexity of the statistical analysis increases. Conversely, the simple selection of a pair of variables and the study of their interrelationship is easiest to effect statistically.</p> <h4>Two-Variable Analyses</h4> <p>When the available data are considered, the area of primary interest that comes at once to mind concerns the question of what factors in the amputee and/or in the treatment process tend to influence the over-all restoration result in a significant way, positively or negatively. Since the final level of prosthetic restoration is a composite measure made up of two different types of data, we can study various individual factors, one at a time, as they influence one segment of the rehabilitation result (use of the prosthesis by the amputee) or the other segment (the amputee's postfitting patterns of psychological adjustment). In the study of these relationships, the data concerning prosthetic performance (or those concerning amputee adjustment, one or the other) are organized and then compared systematically with data describing a variety of possible causal factors.</p> <p>Since any of some 40 individual factors may influence either segment of the final result of prosthetic restoration, it becomes a matter of judgment as to which of the many possible relationships are worth checking. On the basis of previous experience, the prefitting considerations which seem to have the greatest potential significance, and which would seem to be most worth while exploring in relation to each part of the prosthetic restoration result, are as follows:</p> <p>I. Personal characteristics: age, residence, education, marital status, vocation, hobbies, recreational activities.</p> <p>II. Psychological characteristics: acceptance of loss, identification with the disabled, functional adequacy, independence, sensitivity, acceptance by others, sociability, frustration, optimism, security, prosthetic expectations.</p> <p>III. Physical characteristics: etiology, dominant or subdominant loss, amputation level, stump strength, stump motion.</p> <p>IV. Prosthetic-component characteristics: voluntary-opening <i>vs.</i>voluntary-closing terminal devices, canted <i>vs.</i>lyre-shaped fingers, range of pinch forces, friction <i>vs.</i>locking-type wrist units, step-up <i>vs.</i>nonstep-up elbow hinges, single-axis <i>vs.</i>polycentric hinges, figure-eight <i>vs.</i>shoulder-saddle harnesses, quality of prosthetic fabrication (as revealed by checkout).</p> <p>V. Management procedures: extent of training, time lapse before training, extent of preprosthetic therapy, behavior and attitudes of clinic personnel (physician, therapist, prosthetist).</p> <p>In this analysis, the factors included under headings I through V may be considered "predictor" variables, while the data listed under headings VI and VII may be looked upon as "criterion" information. If firm relationships can be established between the data in the first group of categories (I-V) and those in the second group (VI-VII), the former information may be used as a basis for predicting the outcomes of the prosthetic restoration process. The choice of predictor variables to be studied depends, of course, upon the segment of the prosthetic restorative result (prosthetic use or psychological adjustment) selected for study. It is, for example, quite enlightening to relate stump factors to prostehtic usage, but there would be less reason to select stump factors when we are interested in predicting psychological adjustment. Whatever variables are ultimately selected for study, however, the basic analytic approach remains unchanged.</p> <p>A second important type of two-variable analysis can very well involve a study of what relationships exist between the two aspects of the post-treatment result itself (prosthetic use <i>vs.</i>psychological adjustment). Is there, for example, any relationship between an amputee's sense of independence and the extent to which he uses his prosthesis? Is the quality of prosthetic performance related to the individual's social sensitivity? Any number of relationships of this variety could be the subject of study, and the results would contribute to the solution of one of the problems of amputee rehabilitation. Does extensive prosthetic usage of high quality imply good general adjustment, or does good adjustment give rise to efficient prosthetic use? Or is there in fact no significant relationship between these two important aspects of successful amputee rehabilitation?</p> <p>A third variety of two-variable analysis stems from the fact that even within the individual areas of prosthetic usage and of amputee behavior there are important relations to be studied. How, for example, does the amputee's performance with a prosthesis relate to the importance which he attributes to a given activity? What is the relationship between the efficiency of prosthetic use as reflected by tests (actual usage) and the efficiency as reported verbally by amputees (reported usage)? In the psychological area, what is the relationship between an amputee's feelings of sensitivity and his sense of identification with the disabled? To what extent do feelings of frustration affect the amputee's sense of functional adequacy? All these are examples of significant relationships which may exist within the given segments of the prosthetic restoration result and which may very well be amenable to study.</p> <p>In addition to all these possibilities, there remains a fourth type of two-variable analysis, one concerned with the relationships between the various amputee characteristics and data concerning the treatment process. Do amputees with similar occupations, hobbies, and/or recreational pursuits receive similar prosthetic prescriptions, or is the prescribed prosthesis unrelated to these matters and more dependent upon the personal attitudes of the clinic personnel? Are the variations in prescription, training, and checkout procedures based on geographic factors, age of patient, etc.? Relationships such as these are also worth exploring.</p> <p>There is no question but that a considerable amount of knowledge is to be gained from the segmented type of analytic approach described. But a major limitation and a fundamental weakness is inherent in these techniques. When correlations are limited to no more than two factors at a time, the variables concerned are unavoidably isolated out of the large complex of continuously interacting forces known to exercise control over the final result of prosthetic restoration in any given case. In separating, out of the entire data, pairs of variables that may happen to interest us, we ignore the well-known clinical observation that the whole result of prosthetic rehabilitation is the consequence of a number of simultaneous, interdependent influences. In effect the other factors are treated as "constants" at any given time, an expedient admittedly not in keeping with the facts. Were the data made up of a large number of independent variables (factors independent of other influences in a situation), the difficulty would be less critical. But we find in fact that only comparatively few of the items are truly independent of one another.</p> <p>Although this limited analytical approach will not provide the ultimate in understanding of the prosthetic restoration process, it will provide information concerning the more salient relationships existing within the data. The technique of two-variable analysis can be carried one last step by combining selected distributions of data in order to develop indices of more general factors in the prosthetic-restoration complex. Data concerning performance on prehension tests, positioning tests, practical-activity tests, and reported use of the prosthesis may, for example, be combined to provide a composite measure of amputee performance. This combination factor may then be studied in relation to other discrete variables or other composite factors. But before one goes very far along this path he comes face to face with the desirability of attempting a "global analysis."</p> <h4>Global Analysis</h4> <p>In view of the weaknesses in the two-variable approach, it would seem desirable to be able to explore the interaction of all the various factors, each with the others. That is to say, it would be helpful to be able to gauge the extent to which each factor in the prosthetic-restoration complex affects the others and to determine to what extent the total pattern of interdependence affects the final result. In any such study of interactions of variables, we are of necessity drawn to relatively sophisticated methods in statistics, such as multiple correlation, analysis of variance, and possibly factorial analysis. That analysis by these methods would be completely fruitful is by no means assured. For unless the relationships within the data are reasonably clear-cut, the statistical procedure may not be discriminating enough to bring them to light. Deficiencies in the sampling, weaknesses in the measuring instruments, and other technical shortcomings would also tend to obscure the results.</p> <p>This known risk notwithstanding, such an effort is clearly worth while and will be undertaken in view of the <i>possibility</i>of approximating the significance to be afforded various considerations involved in the prosthetic-restoration potential of an individual. Success in this more ambitious approach would shed light on the relative influence that various factors, within the amputee and within the treatment process, have on the final result. Although it is well understood clinically that not all patient characteristics or all treatment methods influence the final outcome equally, no scientifically validated picture of the relative significance of the causal factors exists to date. From further studies, one might hope to learn what combinations of amputee characteristics and treatment procedures make for the best prosthetic-restoration results and, by the same token, what combinations dictate poor results. An understanding of these matters would permit reasonable predictions as to the probable success of the restorative effort, suggest modifications of the treatment process the better to fit the needs of the individual patient, and make it possible to identify and to grade "optimum" restoration results in any given case.</p> <h3>Conclusion</h3> <p>It is clear then that this presentation constitutes an overview of the information evolving from the NYU Field Studies and suggests that a considerable amount of additional data analysis will be required before the available material will have made its final contribution to the field of upper-extremity prosthetics. Many of the remaining analyses are already in process, and it is planned to publish these results as the work is completed. It must, however, be recalled that the NYU Field Study was essentially research "in breadth" and that this approach should not be expected to answer all questions relating to the upper-extremity amputee. For many of the issues needing resolution, research embracing the study of individual cases "in depth" will be required. Meantime, it is in order to express appreciation for the singular opportunity of studying such a large group of upper-extremity amputees. Because of the nature of the disability associated with arm loss, it usually is very difficult to gather large numbers of arm amputees in any one location, and it is almost impossible to be able to subject such a group to a systematic pattern of treatment. Although it would be gratifying if it could be said that the most had been made of the unusual opportunity afforded, afterthought and hindsight tell otherwise. Unfortunately the problems of research into the unknown do not cast their shadows before, and the path to discovery remains exceedingly narrow. Until better methods of dealing with the complicated manifestations of the human being become available, we must be content with studies and analyses that can shed even small light on the challenging problems of prosthetic restoration.</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">Almost all of the data developed during the NYU Field Studies have been codified and punched on IBM (International Business Machines Corp.) cards, and all of the major analyses presented in this (Vol. 5, No. 2) and the preceding (Vol. 5, No. 1) issue of Artificial Limbs have been performed through the use of IBM electromechanical data-sorting techniques. Any future analyses may be accomplished conveniently through the same means.</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>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic Devices Study, Research Division, College of Engineering, New York University; Director, Prosthetics Education, NYU Post-Graduate Medical School; Adjunct Professor of Psychology, Fairleigh-Dickinson University, Rutherford, N. J.; member, Committee on Prosthetics Research and Development and Committee on Child Prosthetics Problems, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_117/aut1958-117-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_117/aut1958-117-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee VIII. Research Implications Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * https://staging.drfop.org/files/original/527872ee9190fb7a616b0cc70410fbe0.pdf f629c37fa67f701c4b6aea78de76a2a8 https://staging.drfop.org/files/original/a6f09a9bde0aec6c464fbc7043e3fe3b.jpg 8ddc8354987eee1ddb5c98b5d7c77ca5 https://staging.drfop.org/files/original/626f567e943aaa264fa84b5f0333edda.jpg 63014457b9280ffcc858cd9079ba37fd https://staging.drfop.org/files/original/01833bc5541285c909871999020cb9b4.jpg 5fa7af520e891c8f39caf1685065aa51 https://staging.drfop.org/files/original/c3e424fe1ec3be458e58896700d78c4d.jpg 989474fa8119838ea695f94be3cd81cc https://staging.drfop.org/files/original/7a548b290f3da58ff06158588e81e48b.jpg bbbff8ef694a7d53e8ff5f8cf4f70251 https://staging.drfop.org/files/original/4c93630c0224b3c1f43af6f6fbfba87d.jpg 70057c8df762d2494a1232ee7ec2e860 https://staging.drfop.org/files/original/9eabbcd76d348b28f55b9cd7bd0c370a.jpg 03f397225e0cf2ba7432c561fb26e3c9 https://staging.drfop.org/files/original/d3a357f008aed8a49e631b01e0fc41f2.jpg ab424dfa71fd3027cd0b18f150597dc7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_028.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 28 - 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/1964_01_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_028.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>Acceptability of a Functional-Cosmetic Artificial Hand for Young Children, Part I</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>The need for a functional and cosmetically acceptable artificial hand for juvenile amputees has existed for many years. A voluntary-opening hook which has been available for a number of years in a variety of sizes was until recently invariably prescribed for children. In response to the demand on the part of both children and parents for a functional device with a more natural appearance, the Army Prosthetics Research Laboratory (now known as the Army Medical Biomechanical Research Laboratory) undertook in 1958 to develop a child's voluntary-opening hand. Earlier studies<a></a> had shown that a spectrum of five sizes should satisfy the needs of the entire arm-amputee population from childhood to maturity. Size No. 1 was the designation given to the smallest. Because it was hoped that a mechanism developed for the Size No. 1 hand might be suitable for use also in Size No. 2 and perhaps in Size No. 3, the smallest size was given the first priority. The Sierra Engineering Company<a style="text-decoration:none;">*</a> contracted to manufacture this hand and two other companies (Kingsley Manufacturing Company<a style="text-decoration:none;">*</a> and Prosthetic Services of San Francisco<a style="text-decoration:none;">*</a>) were enlisted to manufacture suitable cosmetic gloves.</p> <p>Following preliminary testing of a prototype model, modifications to eliminate certain shortcomings were incorporated in 50 production models. A field test was initiated in April 1960 with evaluation of the cosmetic gloves included as an integral part of the study. Preliminary findings based upon experiences in fitting 20 children indicated that the hand was acceptable cosmetically and provided satisfactory function in the activities typically performed by children.<a></a> The general workmanship and cosmesis of the gloves provided by both manufacturers had also achieved a satisfactory level after certain initial fabrication difficulties. However, several problems had been identified, the most serious of which was a lack of glove durability. Ridges and sharp edges on the exterior of the hand apparently contributed to rapid glove damage.</p> <p>Accordingly, the original production-model hands were modified and then refitted to the subjects of the field study. Modifications included eliminating the glove-cutting edges, strengthening the floating-finger attachments and the spring mechanism of the thumb, and raising the cable exit. In November 1960 "old" hands revised in this manner began arriving at New York University Child Prosthetic Studies, and in April 1961 the manufacturer produced a series of new hands which incorporated all the modifications.</p> <p>An Interim Report<a></a>, summarizing the results of the field study to mid-May 1961, was prepared for the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development, and the results reinforced earlier findings concerning the acceptability of the hand and gloves. The APRL-Sierra Child-Size No. 1 Right Hand was accepted as satisfactory for general use by child amputees on the basis of this report, and the study was terminated in the latter part of 1961.</p> <p>Following the generally successful outcome of the evaluation of the Size No. 1 Right Hand, manufacture of the Size No. 1 Left Hand was initiated. In May 1961 NYU Child Prosthetic Studies reported the results of a preliminary examination of two units manufactured by the Sierra Engineering Company<a></a>. The hands appeared to be of excellent quality and workmanship with minor exceptions, and in June 1961 the manufacture of 55 additional left hands was authorized for field-test purposes.</p> <p>During September and October 1961, NYU Child Prosthetic Studies received two shipments totaling 40 hands from the manufacturer. These were found to be unacceptable because of engineering deficiencies, and all were returned for modification. In February 1962, 37 hands were finally accepted for use in the field study. Another 14 hands submitted later were also found to be acceptable, making a total of 51.</p> <p>Another Interim Report<a></a> on the status of the field study was submitted at the October 1962 meeting of the Subcommittee on Child Prosthetics Problems. It was reported that the APRL-Sierra Child-Size No. 1 Left Hand was considered to be essentially satisfactory both mechanically and functionally, although more rigid quality control in manufacture and assembly was desirable. The recommendation of this report that the hand and cosmetic glove be approved for commercial distribution was accepted by the Subcommittee and the study was terminated in January 1963.</p> <h3>Purposes of the Studies</h3> <p>The APRL-Sierra Child-Size Mo. 1 Hand (both right and left) was developed to provide the juvenile amputee with a cosmetically acceptable terminal device which would closely resemble the normal hand in size, shape, and coloring. Maximum function-commensurate with cosmesis, simplicity of operation, adequate strength, and reasonable cost-was a concomitant objective.</p> <p>Since the field study of the left hand was essentially an extension of the study of the right hand, the general goals of both evaluations were identical:</p> <ol> <li>To introduce the hand into clinical use.</li><li>To corroborate findings of laboratory studies.</li><li>To determine the acceptability, utility, application, and durability of the production-model hand and glove.</li><li>To investigate indications and contraindications for prescription.</li></ol> <p>In the light of the experience gained in the study of the right hand, three considerations were given closer attention in the study of the left hand:</p> Performance differences between the experimental hand and the hooks previously worn were investigated in greater detail than was the case in the study of the right hand. The short wear-life of the cosmetic gloves used in the study of the right hand presented a definite and challenging problem. In the course of the study, the exterior of the experimental hand was extensively modified to eliminate sharp edges which might contribute to glove damage. The effectiveness of these changes was of particular interest in the study of the left hand. The effect of wearing the hand on the child's school behavior was a planned aspect of the study of the right hand. Data secured on this significant subject were limited, however, since the study overlapped two school years. With the earlier commencement of the study of the left hand (February 1962), these data were obtained for some children fitted during March and April 1962. <h3>Description of the Hand</h3> <p> The APRL-Sierra Child-Size No. 1 Hand (both right and left) consists of a monocoque hand shell of cast aluminum, articulated index and middle fingers, a "two-position" thumb, and nonarticulated but flexible ring and little fingers. A voluntary-opening type of mechanism is housed within the hand shell and the entire unit is covered with a thin plastic glove that can be replaced as warranted ( <b>Fig. 2</b> ). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. APRL-Sierra Child Size Model No. 1 Hand.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The index and middle fingers each consist oi three aluminum castings which, along with a portion of the hand shell, form a four-bar linkage to provide coordinated articulation at points corresponding to the metacarpophalangeal and the proximal interphalangeal joints ( <b>Fig. 3</b> ). This arrangement results in a minimum amount of glove distortion through the range of motion required. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3. Cutaway views of the APRL-Sierra Model No. 1 Hand (3). When no tension is applied to the control cable B, spring D forces the index and middle fingers toward the thumb to provide prehension of the three-jaw-chuck type. Tension in the control cable B causes the quadrant C to rotate about point A, a point displaced from the true center of quadrant C. The cam action thus provided by the outer edge of the slot in quadrant C against roller G forces lever E to rotate counterclockwise about point F, in turn causing the index and middle fingers to open. A small brass plate is mounted within lever E in such a fashion that, when little or no tension is applied to the control cable, the plate wedges against the periphery of the quadrant C. The wedging action, known as "Bac-Loc," resists opening of the fingers when force is introduced through the finger linkage but has no effect on the system when force is applied through the control cable.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The thumb is an aluminum casting mounted to the hand shell through a locking mechanism that permits it to be held in either of two positions-one for maximum opening between fingers and thumb, the other for a smaller opening for conservation of excursion.</p> <p>The ring and little fingers, the two consisting of a one-piece casting of foam rubber, are simply fastened to the hand shell and left to move with the cosmetic glove.</p> <p>A threaded stud (1/2 x 20) attached to the wrist section of the hand is provided for use with currently available wrist units.</p> <p>Maximum allowable weight is 6 3/4 oz. (without the glove). Less than 9 lb. of tension in the control cable (measured at the point of entry into the hand) is needed to open the fingers and a minimum of 2 lb. of prehension force is provided.</p> <p>Cosmetic gloves for the hand are available in a minimum of seven Caucasian and six Negroid shades from each manufacturer.</p> <p> <b>Sample</b> </p> <p> The sample, which included a variety of upper-extremity types, consisted of 77 subjects, one of whom was fitted with hands bilaterally. All the children in the study, except two, had previously worn Dorrance-type hooks ( <b>Fig. 4</b> ). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4. Boy wearing Dorrance hook.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A total of 39 children, of whom 36 were unilateral arm amputees, were fitted with the right hand ( <b>Table 1</b> ). Of the three remaining subjects one (with bilateral shoulder-disarticulation amputations) was fitted with a right hand only and continued to wear a hook on the left side; one (with right above-elbow and left short below-elbow amputations) was also fitted with a right hand and retained a hook on the left; and a triple amputee (with bilateral long below-elbow and left knee-disarticulation amputations) was given hands on both sides. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This last subject was included in both the right- and left-hand samples.</p> <p> Thirty-nine children, of whom 36 were also unilateral arm amputees, were fitted with the left hand ( <b>Table 2</b> ). Of the three remaining subjects one amputee (with bilateral shoulder-disarticulation amputations) was given a left hand only; a triple amputee (with bilateral long below-elbow and right below-knee amputations) received a left hand and kept a hook on the right; and the third subject was the aforementioned triple amputee who was included in both samples. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <b>Procedures</b> </p> <p> The fittings in both the Right- and Left-Hand Studies were conducted through the clinics participating in the Child Amputee Research Program. <a style="text-decoration:none;">*</a> In order that wearers of the hand might secure the longest possible wear period before growth of the child caused an objectionable size discrepancy, it was recommended that the clinics select candidates whose nonamputated hand size was such that they should be able to wear the experimental hand for at least a year. </p> <p>The experiences of the clinics were evaluated on the basis of: first, the reactions of the children, their parents, and others to the experimental hand and to other previously worn terminal devices; second, observations of classroom behavior during the treatment period; third, ratings of the children's performance of standard prehensile tasks using the experimental and old terminal devices; and fourth, maintenance.</p> <p>In the course of the studies the children were required to make four visits to the clinic servicing them during a minimum period of five months.</p> <p> <b>First Clinic Visit: Screening</b> </p> <p>A screening session was conducted during the first visit. The children and their parents were oriented to the purpose of the survey, the number of visits required, and the need to follow through with experimental procedures.</p> <p>Parents and children expressing a willingness to participate selected glove shades from shade guides provided by both manufacturers. Neither the experimental hand nor a complete cosmetic glove was shown to the patients or their parents during the first visit. A selection form, recommending the child as a participant in the study and furnishing information concerning him, was completed and sent to the NYU Child Prosthetic Studies.</p> <p>The candidates were evaluated on the basis of information provided on the selection form and sampling requirements. Upon approving a candidate NYU sent the clinic a hand and glove for the child and a questionnaire to be completed by the child's classroom teacher prior to fitting the experimental hand.</p> <p>The questionnaire pertained primarily to the child's psychosocial adjustment to the school environment. The teacher was asked to fill out the questionnaire before the experimental hand was fitted and to fill out a similar form at the conclusion of the study. The purpose of this procedure was to determine whether the child's behavior or performance with a prosthesis in school was affected as a result of wearing the experimental hand. In order to provide comparability of data, it was important that the same teacher provide both pre- and post-fitting observations.</p> <p> <b>Second Clinic Visit: Fitting</b> </p> <p>At the second clinic visit a prosthetic performance test utilizing the old terminal device was administered and the reactions of children and parents to the old device were ascertained. The child was fitted with an experimental hand and initial reactions to the new component were secured from child and parents. The child and parents were then given instructions that the experimental hand was to be worn exclusively until the next clinic visit two months later.</p> <p> <b>Third Clinic Visit: Two-Months Post-Fitting Evaluation</b> </p> <p>Two months after the fitting the reactions of child and parents to the new component were again recorded at the clinic. Comparisons between old and new terminal devices with respect to weight, ease of operation, and usefulness were noted, and a prosthetic performance test, in which first the new hand and then the old terminal device were evaluated, was also conducted. The parents were then told to permit the wearing of either the old or the new terminal device as the child desired and were scheduled for a further clinic visit two months later.</p> <p> <b>Fourth Clinic Visit: Final Evaluation</b> </p> <p>The final evaluation was conducted four months after the initial fitting. The reactions of child and parent to the new hand were again obtained, and the old and new devices were compared in the same manner as earlier. The clinic summarized its data on a form provided for the purpose, and the child's classroom teacher was asked to complete another questionnaire.</p> <h3>Results-Subjective Reactions</h3> <p> <b>Parent and Child Preferences</b> </p> <p>At the conclusion of the test period, the 77 children participating in the study and their parents decided almost unanimously in favor of retaining the experimental hand with only seven rejecting it completely. In contrast to these seven rejections, 21 children expressed a desire to wear the hand exclusively. The remaining 49 children took intermediate positions ranging from a predominantly-hand to a predominantly-hook preference. All in all 42 children and their parents clearly preferred the hand; 15 were ambivalent or offered contradictory opinions; 20 preferred the hook.</p> <p> <b>Hand Used Exclusively</b> </p> <p>Of the 21 children (13 girls and 8 boys) who chose to wear the hand exclusively, 20 were prior hook wearers, one had previously worn a Becker Plylite hand, and one had never worn a prosthesis before because his parents had refused to accept a hook. Cosmesis was extremely important to this group and was often the only factor mentioned by the child.</p> <p>JM, a long below-elbow amputee who was 6 years and 11 months old at the initiation of the study, is typical of the children in this category. When asked what he liked about the hand after four months' wear, he replied, "I like it-the way it looks." He disliked the appearance of the hook and could think of nothing favorable to say about it or anything unfavorable to say about the hand. The hand functioned better, he said, and was important to him for use at school. Schoolmates stared at first, but liked it. JM's mother thought he had better function with the hook, but only because he had not had the new hand very long. She also remarked that he should wear the hand all the time because "it gave him more confidence." The hook's only contribution was that it prepared the child for the hand, she said.</p> <p>Sandra, a short below-elbow amputee, was 5 years and 9 months old at the beginning of the study. She cited better function as the reason for preferring the hand: "...can move things better-holds lots of things better." She disliked nothing about the hand, liked nothing about the hook, and said she wanted to wear the former all the time. Her mother preferred the hand for reasons both of appearance and grasp; schoolmates found it easier to hold on to when playing games, and it didn't slip when the child tied her shoes. Sandra should not wear a hook at her age, her mother declared.</p> <p> <b>Hand Used Predominantly</b> </p> <p>The hand was the terminal device of choice for an additional 21 children (15 girls and 6 boys). The hook was preferred for rough outdoor activities in which hook function was superior.</p> <p>Typical of the group was Curtis, age 5, a very short below-elbow amputee, who liked "everything" about the hand: it resembled his other hand, held paper when he wrote, and grasped a baseball bat better. However, he felt that the hook was lighter, was easier to open, and superior for playing with certain toys. His mother was pleased with the appearance of the hand, Curtis's attitude toward it, and the fact that other children were willing to hold it in games. However, she thought he should wear the hook at home for activities that might damage the glove. During the last two months of experimental wear, when parents and children could choose which device would be worn, Curtis used the hand exclusively, except when repairs were required.</p> <p>Diana, age 5, a short below-elbow amputee, expressed a desire to wear the hand most of the time and the hook only for swimming (sic!). The reason for her preference was that "it looks like my other hand." Earlier she had found the hand somewhat harder to operate and had experienced difficulty releasing it from bicycle handles. Her mother was concerned about tears on the glove fingers, but Diana said, "It doesn't matter what the glove looks like." Her mother agreed that the hand should be worn in most circumstances, but thought the hook could be used for swimming and as a replacement in case the hand broke.</p> <p> <b>Hand and Glove Used About Equally</b> </p> <p>Seven children (5 girls and 2 boys) and their parents desired to retain both hook and hand and to use them on an approximately 50-50 basis. For example, Carol, an 8-year-old short below-elbow amputee who lived on a farm, preferred the appearance of the hand: "It gives me another hand and people don't stare"; and the function of the hook: "I don't drop things with the hook or worry that someone might bump into me and knock them out of my grasp." She also was concerned about tearing the glove. Carol chose to wear the hand both to regular and Sunday school and the hook for farm chores and play. Her father agreed with the child's viewpoint. He thought the glove not rugged enough, but the hook handy and sturdy.</p> <p> <b>Parent and Child Disagreement</b> </p> <p>There were eight children (6 boys and 2 girls) whose primary choice of terminal device differed from that of their parents. In five instances, the child chose the hand and the parent the hook; in the other three cases, the positions were reversed. The basis for disagreement was usually a relative emphasis upon appearance and function.</p> <p>Michael, age 6, whose partial hand amputation was fitted as a wrist disarticulation, was pleased that the hand "looked like my other one," but acknowledged that the hook was lighter and easier to use. If he could retain only one device, he would choose the hook, since he could do much more with it; however, his mother and friends preferred the hand.</p> <p>The latter were sometimes afraid of the hook. Michael's father preferred the hand for cosmetic reasons and cited other advantages: "... more chance to play cowboy and wrestling . . . children not afraid . . . danger of bumping into others when playing with the hook."</p> <p> <b>Hook Used Predominantly</b> </p> <p>Six boys and seven girls preferred the hook for daily use and the hand for dress occasions. Five of the children were under 5 years of age (one, age 3 and four, age 4), and four of these had not yet attended primary school, kindergarten, or play school. Eleven of these children rated the hook function better and ten specifically said the hand was heavy or hard to operate; one older boy complained that the hand did not afford a tight grasp and a younger girl said the hook held things in a better position. Parents of twelve of these children declared hook function was better; the other parent expressed no preference.</p> <p>Danny, with an elbow disarticulation and split-ray hand, was the youngest child in the study-barely 4 years of age when fitted with the hand. To open it, he had to hold his elbow completely extended with maximum tension on the cable. Even in this position, full opening required more effort than he typically cared to exert, although he was pleased that the hand looked like his natural one. Danny stated that the artificial hand was heavier and harder to operate than the hook and did not pick up objects as well. The hook was better for grasping a swing chain and for holding his bread to push food. The child's mother hoped that his skill with the hand would improve, but after four months she reported that he wore it only for "going visiting." She thought the hand would be of greater use when he was older.</p> <p> <b>Hand Rejections</b> </p> <p>In view of the fact that complete rejection of the experimental hand was rare, it is interesting to note the instances when it occurred. Seven children rejected the hand completely; four of these were 4- or 5-year-old boys, one was a 7-year-old girl with bilateral shoulder disarticulations, and the other two were a boy and a girl, both 9 years old, who were excellent users of their hooks and apparently were not concerned with the appearance of this device. Various factors contributed to these rejections. Several of the younger boys and the 9-year-old boy and girl obtained better function with the hook and seemed relatively unmindful of appearance. The bilateral shoulder-disarticulation amputee was a marginal user of any prosthesis and found the increase in operating forces and the difficulty of positioning the hand without a wrist-flexion unit intolerable. Three children experienced excessive hand malfunctions and two others, because of frequency of glove damage or difficulty in getting replacements, wore unsightly gloves for prolonged periods.</p> <p> <b>Age and Sex in Relation to Acceptance Level</b> </p> <p>The data contained in the last two categories of acceptance level (Hook Used Predominantly and Hand Rejections) suggest that age is a strong consideration governing hand or hook preference. Such a relationship would not be surprising, since younger children may be expected to: first, experience difficulty with hand weight and operating forces because of limited physical development, and second, be more careless in their use of a device, less concerned with the niceties of appearance, and would not be subject to the social pressures of the school environment.</p> <p> Age, however, cannot be regarded as an absolute criterion, since several of the children in the study who selected the hand as their primary choice were 4-year-olds. In fact, when the age and sex of the children are tabulated against indicated levels of preference ( <b>Fig. 3</b> ), sex appears to be more significantly related to choice of device than does age. Thus, girls of all ages for whom the hand is of appropriate size appear to be potentially the best candidates for the No. 1 Hand, while younger boys would seem to be less likely to accept the device. </p> <p> <b>Effects on School Adjustment</b> </p> <p>The questionnaire to be completed by the classroom teacher was designed to secure pertinent information concerning the behavior of the child in school while wearing the old terminal device and the experimental hand respectively. It was hypothesized that the child's classmates and teacher might react more positively to a hand than they had to a hook and as a result adjustment of the child to the school situation would show discernible changes. This type of improved behavior had been noted previously when a child who had been a nonprosthesis wearer was fitted for the first time.<a></a></p> <p>Historically, two significant problems frequently encountered by juvenile amputees wearing hooks to school have been the indignity of being called "Captain Hook" and similar names by classmates and refusal by other children to hold their hooks in hand-holding games. Elimination or reduction of these difficulties was anticipated when the child was fitted with a functional terminal device that closely resembled a normal hand.</p> <p>The teacher's opinion was obtained concerning various aspects of the child's school behavior: attendance, homework, conduct, friendships, social participation and leadership, and extent of use of the prosthesis. As provided in the study plan, the teacher's questionnaires were to be completed twice: once while the child was still wearing a hook, and again after four months of hand wear when the child would presumably have acquired sufficient skill in the use of the hand, and changes in school behavior would have had an opportunity to develop.</p> <p>When it became apparent that a majority of the children in the Left-Hand Study would not have worn the hand for four months before the end of the 1961-1962 school year, the original plan was modified to provide for completion of the second questionnaire just prior to the end of the academic year regardless of length of time the hand had been worn.</p> <p>Unfortunately, comparable hook-and-hand questionnaires (that is, both completed by the same teacher) are available for only 16 of the 77 children in the sample. The majority of the remaining 61 children were of pre-school age or were fitted with the hand toward the end of the school year or during the summer, so that they did not have the same teacher at the beginning and the end of the study. The data from the teachers' questionnaires were, therefore, supplemented by information concerning school and personal adjustment from other sources wherever available.</p> <p> <b>Reactions and Representative Comments</b> </p> <p>Of the 29 boys and 21 girls in the sample who were 6 years of age or over, 26 boys and 21 girls were either wearing the hand in school at the termination of the experiment or stated that they intended to do so when the fall term began. Included in this group were four of the children whose preferred device was the hook. Nevertheless, they wore the hand to school. One boy, age 8, summarized the opinion of these four children when he said, "I wear it because the kids like it better."</p> <p>As mentioned previously, a number of children reported that prior to using the hand they had been called "Captain Hook" by other children and that this had disturbed them. There is considerable evidence that the effects of this name-calling can be quite destructive to social relations among children. One girl, in fact, refused to wear the prosthesis to school after such an incident. When the hand was worn these difficulties tended to disappear. The essence of the reaction to and acceptance of the hand may be gathered from the large number of favorable comments made by playmates, schoolmates, teachers, and others.</p> <p> Representative statements <i>reported by the children</i> included the following: </p> <p> "My schoolmates were excited about the hand because I have five fingers on the left hand now." <br /> "It smells nice, looks nice, and works nicer than the hook." <br /> "I like the feel of the hand; it looks real." "One little girl thought my hand had grown back." "They said it was prettv. The girls aren't scared of it." <br /> "I wanted to look at it. I always wanted to know when I was going to get it. It drives me out of my mind." "My school friends stared at first; they liked it." "At school they all liked the looks, especially how real it looked, including the fingernails." <br /> "Kids like to see the way I can bend the fingers (floaters) all the way back. They like to feel it. One boy bit it to see what it would do." </p> <p> Representative reactions <i>reported by the parents</i> included these remarks: </p> <p> "They were surprised when they found out he could move the fingers and thumb." <br /> "Children in school were not aware of his prosthesis until he wore a short-sleeved shirt. They displayed curiosity and then seemed to be very casual." <br /> "In many cases the fact that it is not a natural hand has had to be brought to their attention, even when it was worn without long sleeves." <br /> "Danny will start school this fall and the principal was amazed to see the hand. He said he had to look twice to make sure it was the same child. Danny's playmates were sure he had gotten a 'real' hand." <br /> "His friends are afraid of the hook. But with the hand, they will take hold of it and play games." <br /> "The child said she used to like the hook and wore it all the time, but now some of her friends don't like it and are afraid of it." <br /> "Her schoolmates noticed the change and they completely accepted it. Her sisters were quite proud and anxious for their friends to see she had a new hand." <br /> "When he played games with other children, most of them were afraid to hold his hook. Since he's worn the hand they aren't afraid." <br /> "Cindy is happy about the better attitude of the children around her, especially in school." <br /> "She said that one of her best friends 'almost fainted,' she was so delighted to see her with two hands." <br /> "The appearance has done wonders for her at school." <br /> "The children at school crowded around him and asked to see how it worked." <br /> "Her friends had called her 'Captain Hook' (when she wore the hook). Little ones cried and would run away from her, afraid. We actually had to bribe her to wear the hook to school. Now we have no difficulty getting her to wear her arm with the hand all the time." <br /> "Children don't call him names ('Captain Hook')." <br /> "School children are delighted and fascinated with the hand." <br /> ". . . interested because it is different; want to see how it works. Betsy will show it." <br /> "It is easier to hold on to when playing games." <br /> "The change from the hook to the hand caused a lot of questions to be asked at first. But it was soon accepted." <br /> "Danny wore the hand every day for two weeks and some of his classmates were not aware that it was not his own hand." </p> <p> Only a few <i>children</i> volunteered negative remarks: </p> <p> "His brother got scared of the hand, but later liked it." <br /> "Sister afraid of it at first." <br /> "Pammy (sister) thought it was a 'weirdy.' " </p> <p> <b>Attendance, Preparation, and Conduct in Class</b> </p> <p>The teachers' reports concerning the children's attendance, preparation, and conduct in class yielded very little information of significance. Only one child (a triple amputee) was considered below average in attendance as a result of absences related to his prosthesis. The factors of preparation for class and conduct showed slight changes in ratings from the first to the second questionnaire, but there were no differences specifically attributable to hand wear.</p> <p> <b>Friendships, Participation, and Leadership</b> </p> <p>Ten of the 16 children for whom teachers' questionnaires were available appeared to have achieved excellent to adequate adjustment and participation in class with both the hook and the experimental hand. Despite these satisfactory relationships, these children still found the appearance of the hand advantageous in the school setting as a means of decreasing social prejudice. Several of these 10 children remarked that their classmates were now more willing to hold hands in games and seemed friendlier. This pattern of increased acceptance tended to enhance the self-concept of the children in the study.</p> <p>Five children were reported as improved in class participation or friendships after being fitted with the artificial hand, although the prosthetic performance of two of this group was considered to have deteriorated. However, the improvement in appearance was obviously more important than the decrease in function. For this small group of children regardless of their skill in or amount of hand usage there was a discernible change in the type and extent of their social interactions. This took the form either of an increased number of social contacts with various children or of an improved relationship with one or two selected classmates.</p> <p>An example of the personal importance attached to the hand is apparent in the report of one child's physical therapist which describes his behavior after being fitted:</p> <p>"On the way back on the train, Randy patted his hand against his face and scratched the tip of his nose several times before settling down to sleep. Until then, he couldn't keep his eyes off it, and when he lay down he put the hand on his chest 'for all the world to see.' As we neared Bloomington, he wondered if we shouldn't go by the school because 'perhaps Mrs. Sheveland (the teacher) will still be there.'</p> <p>"After dinner he put his prosthesis on and toured the neighborhood to show everyone his hand. His mother reportedly was greatly pleased; so much so that she could not hold back the tears on more than one occasion during the evening, so that when Randy said his prayers, she had to leave the room. He wanted to wear his hand to bed but when his mother explained that it had to be put into the plastic bag, he accepted the explanation.</p> <p>"This morning he arrived at school in 'clam-digger' pants and a long-sleeved shirt. He had told his father yesterday that if he wore long-sleeved shirts no one would ever know his hand was not real."</p> <p>Other examples of the significance of the hand follow:</p> <p>"The teacher said the boy is actually using the hand more than he had ever used the hook. (This was in spite of the fact that all reports indicated that his functional capabilities with the hook were greatly superior.) His mother said, 'We were very pleased that he had the hand for his first Holy Communion.'</p> <p>"The nun said Randy did not need to hold hands in prayers or going to and from the altar, since she thought this might be a difficult thing to do, but he did as the other children were doing and was very proud."</p> <p>Another child, Sheila, had reconciled herself to the reluctance of other children to hold the hook:</p> <p>"Some children don't like to touch it (the hook), but I know a girl who has long fingernails and I don't like to touch her hands, either. When I first got it, I thought the kids in school will be surprised. They will think I don't belong in a crippled children's school!"</p> <p>Another child, Philip, used his artificial hand to shake hands.</p> <p>The last of the 16 children for whom data were available, a girl of 6, did not have a good relationship with her teacher or with the other children. There was no discernible improvement in the situation after she was fitted with a hand. Still, by the time of the second questionnaire report, she was somewhat more willing to display her prosthesis in public and make use of it.</p> <p> <b>Conclusion</b> </p> <p>Although there was no clear-cut evidence of widespread, dramatic changes in behavior attributable to the use of the APRL-Sierra Hand, the data all point in the direction of improved self-perceptions as well as better social attitudes and relationships. With the exception of the 10 per cent of the sample who rejected the hand for a variety of reasons, the remaining amputee children and their parents, teachers, and classmates reported a variety of positive social consequences related to hand wear. For the most part these reports referred to improved feelings, opinions, and attitudes of the subjects, although a small number of positive behavioral changes could also be documented. In general, the children themselves as well as their classmates and parents were socially more comfortable as a result of the introduction of the hand.</p> <p>The functional limitations of the hand in comparison to a hook will be documented in a subsequent article in Artificial Limbs. In contrast, the evidence concerning the cosmetic benefits of the device, particularly its concomitant psychosocial implications, is most impressive.</p> <h3>Results-Prescription Considerations</h3> <p> <b>Size of Sound Hand and Age</b> </p> <p>For the purposes of the Right-Hand Study, the No. 1 Hand was hypothesized as being appropriate for child amputees between the ages of 4 and 10. Consequently, experimental wearers were selected on the basis of this age range rather than of size. In the course of the study, however, it became apparent that the hand was undersized for many of the children selected.</p> <p>The clinics were then requested to report the following dimensions in all cases of noticeable discrepancy: circumference at the metacarpophalangeal knuckles, excluding the thumb, with hand in closed position (5% in, on the No. 1 Hand); and the length from the styloid process of the radius to the tip of the thumb (3 5/8 in. on the No. 1 Hand). Several clinics also reported hand dimensions of children for whom the No. 1 Hand was considered of appropriate size.</p> <p> <b>Table 4</b> presents the measurements of sound hands of children in the Right-Hand Study for whom the No. 1 Hand was too small; small, but acceptable; and well matched, according to the opinion of clinic personnel. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It would appear difficult to derive a precise range of sound-hand sizes or ages for which the No. 1 Hand provides an acceptable match. In one case, where the sound hand was 6 5/8 in. in circumference and 4 1/2 in. in length, the clinic rated the hand as unacceptably small, but in another instance it was considered suitable for a child whose hand was 7 1/4 in. in circumference and 4 1/2 in. in length. It should also be noted that while the majority of the "oversized" children were 8 years of age or older several younger children fell into this category. Furthermore, even hands regarded as unacceptably small by the clinics were retained by the children and worn, at least for dress, for several months longer.</p> <p>In the selection of candidates for the Left-Hand Study dimensions of the children's sound hands were taken into consideration. In general, an effort was made to accept as wearers only those children with a sound-hand circumference of not over 6 1/4 in. and a length up to 3 7/8 in. It was also anticipated that the majority of such children would fall into the age range of 4 to 8 years. As a consequence, there were few complaints about size in the Left-Hand Study.</p> <p>Christine, age 10, had sound-hand dimensions of 6 3/8 in. circumference and 3 7/8 in. length at the time of selection. These became 6 1/2 in. and 4 1/2 in. by the time of the four months' check and the clinic was then of the opinion that the hand was too small. Christine and her parents agreed, but strongly preferred even a poorly matched hand to the alternative of a hook. There were six other children in the sample with sound hands of excessive circumference or length, i.e., larger than 6 1/4 in. in circumference and 3 7/8 in. in length. There was indication that all the children in this group were not completely satisfied with the size of the No. 1 Hand, but their lack of enthusiasm was generally expressed in the comment, "a little small, but still all right."</p> <p>Thus, as a general guide in considering the prescription of a No. 1 Hand, it is possible to state:</p> <blockquote><p>For children whose remaining hand dimensions do not exceed 6 1/4 in. in circumference and 3 7/8 in. in length, the No. 1 Hand can probably be fitted without objectionable size disparity. Naturally the closer the children are to this level when fitted the faster they will outgrow the No. 1 Hand. 2. Children with these hand dimensions will typically fall into the age range from large 3-year-olds to small 8-year-olds, with a predominance of 4- to 6-year-olds. However, considerations of hand weight and operating forces may exclude some children at the lower end of this age range.</p> </blockquote> <p> <b>Clinic Opinions</b> </p> <p>Clinic opinions concerning various aspects of the No. 1 Hand were obtained in both phases of the study. Clinic personnel were also asked to express themselves on the question: "Are there any contraindications to prescribing this hand (age, sex, performance, etc.)?" Responses, however, were confined primarily to the experiences of the particular child under observation as each questionnaire was completed. Hence the comments made were essentially confirmatory of information gathered from other sources.</p> <p>Expressions of a general attitude toward prescription and use of the No. 1 Hand were relatively rare. Thus, it is possible that the typical reaction of the clinics participating in the study was one of reservation concerning the experimental item-of not wishing to take a strongly positive or negative position until more experience had been acquired and "all the returns were in."</p> <p>This situation reflects the fact that the majority of the clinics participating in the program appeared to be "functionally oriented," some of them strongly so. Hence, a device which historically and in fact provides lesser function was likely to be viewed with skepticism. Some clinics were also concerned about the initial cost of the hand and glove and the expense of repairs and replacements particularly of the glove.</p> <p>If this interpretation of the prevailing frame of reference is correct, such comments as were made concerning "contraindications to prescription" take on added significance by their infrequent occurrence. To cite the Left-Hand Study data again: For only nine of the 36 children discussed was dissatisfaction with some aspect of the hand strong enough to be mentioned as a possible contraindication to use. These instances were:</p> <table> <tbody><tr> <td> <p><b>No. of Children</b></p> </td> <td> <p><b>Contraindications</b></p> </td> </tr> <tr> <td>2</td> <td> <p>Discrepancy in size</p> </td> </tr> <tr> <td>2</td> <td> <p>Frequent breakage or malfunction</p> </td> </tr> <tr> <td>2</td> <td> <p>Force requirements excessive for particular child</p> </td> </tr> <tr> <td>1</td> <td> <p>Functional limitation as compared with hook</p> </td> </tr> <tr> <td>1</td> <td> <p>Rapid wear of glove a possible contraindication for a wry active child</p> </td> </tr> <tr> <td> 1 <a></a> </td> <td> <p>Emotional difficulty</p> </td> </tr> </tbody></table> <p>Excerpts from a letter written by one of the clinic chiefs might be appropriate as a summary statement of prescription considerations. His comments not only reaffirm reactions to the hand which appear to have been fairly typical, but also express an approach to prescription which seems to be conservative yet reasonable:</p> <p>"The mother's comment with regard to cosmesis is that the hand is 'beautiful.' She is perfectly willing to go to all extremes in cosmetic appreciation. The mother feels that the child's reaction to the appearance of the hand was one of 'being proud of it.' This was exemplified by the child's desire to always wear the hand at school. It was interesting to me that, after approximately six months of wear, Debra was anxious to wear the hand all the time and not to wear the hook any more. However, in the recent episode, when the hand became no longer functional, she was perfectly agreeable to return to the use of the hook. This is particularly interesting to me, because the mother feels that Debra actually lost no function in the transition from the hook to the hand.</p> <p>"At age 6, Debra learned to operate the thumb adjustment and, as a consequence, was able to continue with the prosthetic hand as the assisting side at school in such functions as holding a book while reading so that she could turn the pages with her normal hand; holding papers while writing; and holding papers while cutting. At home, she was able to hold fork and knife with the prosthetic hand but, at age 7, is still able to cut only soft meat, such as a hamburger. She uses the hand in all bi-manual activity.</p> <p> "Our own opinion here is that we will prescribe this hand for children who are already using a hook. In the unilateral case where there is reasonable dexterity, I feel that with the prosthetic side being the assisting side we can sacrifice the minimal loss of function which one <a style="text-decoration:none;">*</a> probably gets in the transition from hook to hand. The only criticism is the amount of force necessary to operate the hand." </p> <h3>Acknowledgments</h3> <p>The late Dr. Carleton Dean, former Director of the Michigan Crippled Children Commission, played a prominent role in the early stages of the child's hand program, particularly in the procurement of the experimental units. Colonel Maurice J. Fletcher, Dr. Fred Leonard, Colonel John Butchkosky, and Victor T. Riblett, of the Army Prosthetics Research Laboratory, were responsible for the development of the hand and assisted in the resolution of problems encountered in the study. To all these gentlemen, we express our appreciation.</p> <p>We also acknowledge the valuable cooperation and assistance of the children and personnel associated with the clinics participating in the Child Amputee Research Program.</p> <p>Roberta Bernstein, Alfred Brooks, Herbert Bursky, Bertram Litt, Deborah Osborne, and Dr. Edward Peizer, staff members of New York University Child Prosthetic Studies, have also made significant contributions at various stages during the development and testing of the APRL-Sierra Child Size No. 1 Hand and in the preparation of the report upon which this article and a subsequent article to appear in the Autumn 1964 issue of Artificial Limbs are based.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Child holding swing with artificial hand.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector VV. Kay,<i>Acceptability of a functional-cosmetic artificial hand for young children</i>,Child Prosthetic Studies, Research Division, College of Engineering, New York University, January 1964.</li> <li>Fletcher, M. J., and Fred Leonard,<i>The principles of artificial-hand design</i>, Artificial Limbs, May 1955, p. 78.</li> <li>National Academy of Sciences-National Research Council, Final <i>summary report, APRL-Sierra Child-Size Hand, Size 1, Model A,</i> March 1961.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, field test-APRL-Sierra Child Size No. 1 Hand {right)</i>, October 1960.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, field test-APRL-Sierra Chili Size Model 1 hand (right)</i>, May 1961.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, APRL-Sierra No. 1 Hand {left)</i>, October 1962.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Memorandum report: preliminary considerations of the APRL-Sierra Child Size Model 1A Hand (left)</i>, May 1961.</li> <li>S. Peizer, Edward,<i>The clinical treatment of juvenile amputees, 1953-1956</i>, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">One clinic felt strongly that prescription would be a dubious practice where cosmesis was highly important for child and parent if the next larger hand size was unavailable later.</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">S. Peizer, Edward,The clinical treatment of juvenile amputees, 1953-1956, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</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">S. Peizer, Edward,The clinical treatment of juvenile amputees, 1953-1956, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</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">Area Child Amputee Center, Michigan Crippled Children Commission, Grand Rapids, Mich. Amputee Clinic, Childrens Division, Institute of Physical Medicine and Rehabilitation, New York, N. Y., Amputee Clinic, Newington Hospital for Crippled Children, Newington, Conn., University of Illinois Amputee Clinic, Chicago, Ill., Birmingham Child Amputee Clinic, Birmingham, Ala., Duke Orthopedic Amputee Clinic, Duke Medical Center, Durham, N. C, Georgia Juvenile Amputee Clinic, Crippled Childrens Service, Emory University Branch, Atlanta, Ga., Amputee Clinic, Childrens Rehabilitation Center, Buffalo, N. Y., Child Amputee Prosthetics Project, University of California Medical Center, Los Angeles, Calif., Amputation Clinic, Kernan Hospital, Baltimore, Md., Child Amputee Prosthetic and Congenital Deficiency Clinic, Childrens Orthopedic Hospital, Seattle, Wash., Juvenile Amputee Clinic, Florida Crippled Childrens Commission, Orlando, Fla., Amputee Clinic, Home for Crippled Children, Pittsburgh, Pa., Child Amputee Clinic, State Hospital for Crippled Children, Elizabeth-town, Pa., Juvenile Amputee Clinic, Crippled Childrens Hospital, New Orleans, La.</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">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, APRL-Sierra No. 1 Hand {left), October 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Memorandum report: preliminary considerations of the APRL-Sierra Child Size Model 1A Hand (left), May 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, field test-APRL-Sierra Chili Size Model 1 hand (right), May 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, field test-APRL-Sierra Child Size No. 1 Hand {right), October 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>Footnote</b></td></tr><tr><td class="clsTextSmall">San Francisco, Calif.</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">Costa Mesa, Calif.</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">Sierra Madre, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fletcher, M. J., and Fred Leonard,The principles of artificial-hand design, Artificial Limbs, May 1955, p. 78.</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>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York 10, N. Y.</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>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York 10, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-02.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-03.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-04.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-05.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-06.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-01.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-07.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 Acceptability of a Functional-Cosmetic Artificial Hand for Young Children, Part I Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/2ba44c5f9ec8c60d3a6423ce01cae5b9.pdf a43fa5236221ccee26a9e5f795227879 https://staging.drfop.org/files/original/9847a895cbb0e47c889cc46b60067737.jpg 174af1515ac8068d3ba651a0676237c2 https://staging.drfop.org/files/original/54cec80f0cecce2e15a82d15081386fa.jpg 268a5deb1dfa2e91ec39e0cda5df9553 https://staging.drfop.org/files/original/cfb040cf84ed9ddf06a4f4bd0d669e8e.jpg 03e8d28df85de2b168de9603bde28d7a https://staging.drfop.org/files/original/318951cdb08cfadc6743ddec4e2731bd.jpg b3cd9eccd9455a345c9ad40f33434a7b https://staging.drfop.org/files/original/62b69d04e8bccad2110030b6b195b6da.jpg c8cdc886c8007ff14e3b4a6fb297c18b https://staging.drfop.org/files/original/6e618a8e4eb7f870507fc74e9dee010f.jpg cccc1fb60da16baf073ba3b9ab9c9710 https://staging.drfop.org/files/original/cd1a4279ea6056e85574a9669843fcd4.jpg 2498b1a659d3ba96b364efe3b8d49b3e https://staging.drfop.org/files/original/bf816b1898815a58c6d64beee92479d4.jpg 8b9e0b5f10a159cb742c129c41ede96f https://staging.drfop.org/files/original/a897c85ba11ff91431544e7f1b757f99.jpg f74eb3b7381ab64121ff3a6577980d2e https://staging.drfop.org/files/original/798f29058b5c15bebdfda8ba6af5110d.jpg 3d0d619d882104d2335f773d7cd1d622 https://staging.drfop.org/files/original/46d27e76db81864a24330ff3846bd3c9.jpg 2b88d140aa0566a6759afdc3509eecac DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_015.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 15 - 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/1964_02_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Acceptability of Functional-Cosmetic Artificial Hand for Young Children, Part II</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p> In the study of the APRL Sierra No. 1 right hand, which preceded that of the left, the results of comparative performance testing indicated that there was little difference between the hand and the hook on the various test activities. Statements of children participating in the study and of their parents indicated a relatively high level of performance with the experimental hand, but advantages and disadvantages were not clearly defined. </p> <p> These results appeared to be at variance with past clinical impressions, which indicated that a significantly less functional terminal device than a hook. Hence, in the Left Hand Study the performance tests were repeated to check the results of the earlier study. An attempt wa hand wasas also made to delineate more completely the relative usefulness of the two devices by obtaining data concerning their effectiveness in a wide variety of activities. </p> <h3> Performance Tests</h3> <p> As indicated in Part I of this two part series of articles, the child amputees participating in these studies were required to make four visits to the clinics servicing them, during a period of five months. The first visit was a screening session to select suiTable candidates; on the second visit the child was fitted with the experimental hand; the third visit, two months after the fitting, was for the purpose of making evaluative comparisons between the old and the new terminal devices; and the purpose of the fourth visit, four months after the fitting, was to make a final evaluation. </p> <p> A prosthetic performance test, utilizing the old terminal device, was given the child on the second visit. On the third visit the same performance test was administered, utilizing first the APRL Sierra hand and then the old terminal device. The prosthetic performance test required the child to perform six activities, upon each of which he was timed and rated. The activities were: </p> <ol> <li>Unscrewing and reassembling five small plastic barrels ("Kitty in the Kegs") (<b>Fig. 1</b>)</li><li>Drying a wet cup, saucer, and dinner plate, using a dish towel (<b>Fig. 2</b>). </li><li>Putting on a shirt or dress as appropriate and shoes and socks (<b>Fig. 3</b>). </li><li>Assembling a jointed doll ("Loony Links") (<b>Fig. 4</b>). </li><li>Cutting out a printed figure and pasting it to a piece of paper (<b>Fig. 5</b>). </li><li>Eating ice cream from a paper cup, using a metal spoon (<b>Fig. 6</b>). </li></ol> <p> Typically, the test was administered by an occupational therapist. The rating scale employed ranged downward from a score of 5 for performance approximating that of a nonamputee to 1 for performance in which the terminal device was not used, in accordance with the following subjective criteria: </p> <table> <tbody><tr><th><p>Rating</p> </th><th><p>Criteria</p> </th> </tr><tr><td> <p> </p><p>5</p> <p></p> </td> <td> <p> </p><p>A nearly normal bilateral performance in which the terminal device seems essential; that is, it is used to perform active functions in addition to and more advanced than holding, such as grasp and transportation and manipulation of the object. </p> <p></p> </td> </tr> <tr><td> <p> </p><p>4</p> <p></p> </td> <td> <p> </p><p>A bilateral pattern in which the terminal device is a significant aid in grasping or hooking.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>3</p> <p></p> </td> <td> <p> </p><p>The terminal device is used for occasional grasping only, alternating with passive use.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>2</p> <p></p> </td> <td> <p> </p><p>The terminal device is used passively for pushing, weighting, or support, but not for grasp.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>1</p> <p></p> </td> <td> <p> </p><p>The terminal device is not used, although the elbow and forearm may be used as an aid. Ratings of 1.5, 2.5, 3.5, and 4.5 were interpolated to indicate performance whose quality was between two categories.</p> <p></p> </td> </tr> </tbody></table> <p> Each child's performances with hook and hand were compared on the basis of best scores obtained while utilizing each device. In the Left Hand Study performance times with each device were also obtained. The comparative data are presented in Tables <b>Table 1</b>, <b>Table 2</b>, and <b>Table 3</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There are obvious limitations to these data, in that the tests may have differed with individual children (the type of clothing donned, for example), and there were undoubtedly differences in the frames of reference employed by different therapists in rating a given performance. Since the data themselves are of doubtful precision, the application of tests of statistical precision is not indicated. Within these limitations, however, there is evidence that: </p> <ol> <li>Mean performance ratings in all activities were higher for the hook (<b>Table 1</b>), which clearly appeared to be the better device functionally. Its superiority was most evident in the test activities of "Put on Clothes" and "Cut and Paste." The smallest differences in mean ratings were found in the "Kitty in the Kegs" and "Loony Links" tests. Both of these latter activities involve the grasping of objects for which the active fingers and thumb of the hand are relatively well adapted.</li><li>In a total of 408 hook and hand performance comparisons shown in (<b>Table 2</b>) (68 children performing 6 activities with each device), hook performance was rated as superior in almost half the instances (189 times). Interestingly enough, however, hook and hand performances were rated as equal almost as frequently (184 times), although hand performance was considered better in only a relatively insignificant number of cases ²⁹. In this tabulation of the data also, the superiority of the hook appears less marked in the same two test items "Kitty in the Kegs" and "Loony Links." </li><li>The comparative time data (<b>Table 3</b>) indicate that in the majority of instances hook performance was faster as well as more effective than hand performance, although again the results are by no means unanimous.</li></ol> <p> It is interesting to note (<b>Table 1</b> and <b>Table 2</b>) that in the Left Hand Study the performance ratings more clearly reflected the functional superiority of the hook than was the case in the tests with the right hand. For example, only seven children of 32 were rated as performing the "Kitty in the Kegs" test better with the hook in the Right Hand Study. In contrast, 17 of 36 children had better ratings utilizing the hook in this activity in the Left Hand Study. A similar marked difference in comparative ratings is evident in the "Loony Links" task. In the other test activities, the differences diminished until in the "Eat Ice Cream" item the right and left hand data are almost identical. </p> <p> The reasons for these differences are not clear. The subjectivity of the rating scale may, of course, have been a consideration. However, since the trend of the data is consistent, that is, favoring higher comparative hook ratings in the Left Hand Study, it would appear that other than chance factors are operative. </p> <p> Handedness might possibly be a factor, but unfortunately data on this variable were not obtained in the study. It is also possible that in the earlier Right Hand Study the raters were affected by a "halo" factor which had diminished by the time of the later Left Hand Study. </p> <h3> Functional Preferences</h3> <p> In studying child and parent opinions concerning the function provided by the No. 1 hand in comparison to that available in standard hooks, the task is complicated by the strong emotional factors involved. In many instances the excellent acceptance of hand appearance clearly tended to influence the answers to questions concerning its function. In interpreting the responses of children and their parents, therefore, it must be borne in mind that the hand was almost three times as heavy as the hook previously worn by the children; and although operating forces to initiate opening were only somewhat higher than for the hook, the forces required to obtain full opening were significantly higher two factors which should make use of the hand more difficult.<a style="text-decoration:none;">*</a> Pertinent comparative data are presented in (<b>Table 4</b>). Thus, when children report, as some do, that the hand is lighter and easier to operate. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The presentation which follows is based primarily on data from the Left Hand Study, but these are supplemented where appropriate by evidence from the preceding Right Hand Study. </p> <p> All 39 children and parents in the Left Hand Study were asked, "With which terminal device is the child able to perform more activities?" The answers were: </p> <table> <tbody><tr><td> <p> </p> </td> <td> <p>  | Hook |</p> </td> <td> <p>| Hand |</p> </td> <td> <p> | No Preference |</p> </td> </tr> <tr><td> <p>Children</p> </td> <td> <p>    18</p> </td> <td> <p>  14</p> </td> <td> <p>   7 </p> </td> </tr> <tr><td> <p>Parents</p> </td> <td> <p>    16</p> </td> <td> <p>  9</p> </td> <td> <p>  14</p> </td> </tr> </tbody></table> <p> However, two children and two parents in the no preference category added statements which suggested that the hook provided more function and that their no preference choice was motivated by a balance between hook function and the cosmetic appeal of the hand either to the child or to the parent. Furthermore, some children who rated the function of the hand as better than that of the hook made comments indicating the reverse. Joseph: "The hand is heavier and harder." Robin: "The hand can do a couple of things but not too many things." Linda: "The hand is heavier and harder but I like the way it works." The therapist said that this girl's answer was motivated by a strong desire to keep the hand. </p> <p> However, several children who preferred the function of the hand were able to back up their choice by specific examples. Susan, a young above elbow amputee, said the hand was easier to don, better for washing dishes, for holding paper, and to pick things up. Rodney, also an above elbow amputee with an unfitted paraxial hemimelia (ulnar) on the contralateral (right) side, said the hand was heavier but easier to operate. His therapist said the hand did not afford Rodney greater function but he was much more eager to use it. This greater enthusiasm was also noted in Susan, the above elbow amputee previously mentioned. The greater motivation to use the hand on the part of both these youngsters may have actually resulted in a higher level of functioning! </p> <p> Fourteen of the 39 children fitted with the No. 1 left hand reported it to be as heavy as or heavier than their hook, and 17 found it hard to open or otherwise more difficult to operate than their hook had been. There seemed to be a significant relationship here with age, as indicated by the fact that of 17 children, ages 3 to 5, eight found the hand heavy, while of 22 children, ages 6 to 10, only six reported that the hand was heavy. Of those who stated that the hand was difficult to operate, ten were in the 4 to 5 age bracket and only five were in the 6 to 10 age group. </p> <p> A relationship to amputation level was also apparent. The one shoulder disarticulation amputee found the weight accepTable but the hand too hard to operate. He retained the hand, nevertheless, for cosmetic reasons. Of the five above elbow amputees, four found the hand heavy and difficult to operate, and the remaining child rejected it after less than two months' wear. In contrast to these negative reports, two above elbow amputees, only 5 years old, were among those who were most highly motivated to use the prostheses with the hand device. </p> <p> The combination of youth and a higher level of amputation made the use of the hand much too difficult for the youngest child in the study, an elbow disarticulation case who was barely 4 years old when fitted. Consequently, at the conclusion of the study he was wearing the hand only for special occasions. Of the four wrist disarticulation amputees, the two 4 year olds found the hand a little heavy and difficult to operate, while two 8 year olds advised that both weight and operating forces were satisfactory. </p> <h3> Specific Types of Grasp </h3> <p> In the Right Hand Study a general comparison of the functional qualities of hand and hook, based on child and parent opinions, had yielded indecisive results. Therefore, in the Left Hand Study children and parents were requested to rate the suitability of both the old terminal device (hook) and the No. 1 hand, not only for grasping objects in general but also for eleven specific types of grasp or activity areas. Explanatory comments concerning terminal device use for each specific function were also solicited. The eleven activity areas were: </p> <ol> <li>Carrying objects, such as school bags, purses, lunch pails, etc.</li><li>Grasping or picking up very small elongated objects, such as pins, paper clips, etc,</li><li>Grasping or picking up small elongated objects, such as pencils, scissors, etc.</li><li>Grasping paper.</li><li>Grasping or holding soft objects, such as sandwiches, toothpaste tubes, etc.</li><li>Grasping or holding a drinking glass.</li><li>Using silverware while eating.</li><li>Grasping large bulky objects, such as paste jars, books, balls, etc.</li><li>Grasping objects such as bicycle handles, swing chains or ropes, etc.</li><li>Putting on clothes, such as shirts, blouses, etc.</li><li>Putting on shoes and socks.</li></ol> <p> Many of these areas involve the performance of a number of discrete activities. Hence, the data obtained not only provide bases for comparison of hand and hook functions but also supply considerable general information concerning the activities of children with upper extremity prostheses. Since this information may be of significance to clinic personnel, especially to therapists and to persons concerned with the development of devices for children with arm amputations, the data relating to each of the activity areas are presented in some detail (<b>Fig. 7</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Carrying a school bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Carrying objects, such as school bags, purses, lunch pails, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   0</p> </td> <td> <p>   6</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   4</p> </td> <td> <p>   8</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   0</p> </td> <td> <p>   3</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p>Approximately four fifths of the children reported the hook as satisfactory for carrying objects with handles, while only half found the hand satisfactory. Parents, on the other hand, believed the hook and hand functioned about equally well for holding these objects. Where difficulty was experienced with the hand, it was usually because the objects carried were too heavy for the amount of "Bac Loc" provided. Illustrative comments follow. Betsy: "The hand doesn't let me hold heavy things." Linda's mother: "Buckets, lunch pails, and anything of metal or plastic that is heavy slip from her grasp." Gabriel's mother: "The hand is satisfactory provided the handle is not too thick and the object not too heavy." </p> <h5><i>Grasping or picking up very small elongated objects, such as pins, paper clips, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   23</p> </td> <td> <p>   4</p> </td> <td> <p>   9</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   15</p> </td> <td> <p>   13</p> </td> <td> <p>   6</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   20</p> </td> <td> <p>   11</p> </td> <td> <p>   6</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   12</p> </td> <td> <p>   16</p> </td> <td> <p>   10</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> More than half the subjects and parents rated the hook as satisfactory for picking up very small objects. The hand was considered adequate for this function by only about a third of the children and parents. Some children pointed out that the hand was satisfactory for holding very small objects but not for picking them up (<b>Fig. 8</b>). One parent suggested that the child's vision was blocked by the rest of the hand, another that the floating fingers were in the way. Some of the illustrative remarks are quoted. John: "Nails but not pins." Susanne: "I have to hold the object in the other hand to pick it up." Danny's mother: "Too much effort and concentration."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Holding a safety pin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping or picking up small objects, such as pencils, scissors, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   30</p> </td> <td> <p>   1</p> </td> <td> <p>   4</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   26</p> </td> <td> <p>   7</p> </td> <td> <p>   2</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   2</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   6</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Three fourths of the children and parents considered the hook satisfactory for this function, while a slightly smaller proportion also found the hand satisfactory. The objects given particular attention within this category of use were scissors, pencils, crayons, hammers, and put together toys. </p> <p> It was apparently impossible to cut with ordinary scissors held in either a hook or an artificial hand. Thus, unilateral amputees held scissors in their good hand, while bilaterally involved children could not use them at all unless the scissors were especially modified. </p> <p> Concerning pencils, the reports were mixed, with some children rating the hook better for picking up and holding pencils, but with more subjects preferring the hand (<b>Fig. 9</b>). Some illustrative comments follow. Jeff: "I can hold a pencil better with the hook." Danny: "The hand holds a pencil better for sharpening." Randy: "I can pick up pencils easier with the hand." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Holding a pencil. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Only one or two of the children with unilateral amputations made reference to writing with the prosthesis, although this was, of course, necessary for bilateral amputees. In general, the hook was favored for writing. Gail: "I can write better with a hook." Randy's teacher: "He is more secure doing written work when he wears hooks." (Randy is a bilateral upper extremity amputee.) </p> <p> There were only two references to hammers, one favoring each terminal device. Concerning put together toys there were two statements, both favoring the hook. </p> <p> In summary, scissors appeared to be difficult, if not impossible, to grasp with either hook or hand, pencils somewhat easier to handle with the hand, and put together toys easier with the hook, and possibly writing also. </p> <h5><i>Grasping paper</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   37</p> </td> <td> <p>   0</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   30</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   34</p> </td> <td> <p>   2</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p> Nearly all children rated both the hook and hand as satisfactory, with only four rating the hand as unsatisfactory (<b>Fig. 10</b>). Almost all the parents considered both devices satisfactory. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Grasping paper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The comments indicated that grasping paper was not one function but several, each calling for a different application of the terminal device. Involved were such tasks as holding paper for cutting with scissors, holding paper on a desk for writing, picking up paper, selecting one sheet from many, holding playing cards for card games, etc. </p> <p> Two children cited holding paper to cut with scissors to explain their rating of the hook as satisfactory, but in both cases they considered the hand also suiTable for this purpose. The therapist of a third child (Susan) felt that the hand was less helpful: "When cutting paper, Susan usually places the paper in the hook. With the hand she seldom places the paper in the hand; it seems to crush the paper and hold it in an awkward position." Susan herself regarded both devices as satisfactory for grasping paper. </p> <p> The hand was considered better for holding paper on a Table or desk while writing (<b>Fig. 11</b>). Sean's mother: "With the hook the paper tends to slip resulting in ragged print." Danny: "The hand holds down paper better for writing." Gail's mother: "School paperwork seems to be neater with the hand because the paper doesn't slip." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Holding paper while writing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Several remarks seemed to indicate that the hand was better for picking up paper, but one bilateral amputee mentioned difficulty in selecting one sheet from many. </p> <p> Concerning holding playing cards for various games, Susan's therapist made the following comment: "Playing card games is an activity which is performed better with the hand. It is in a better holding position and the cards come out easier when she is taking them from the hand." </p> <h5><i>Grasping or holding soft objects, such as sandwiches, toothpaste tubes, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   20</p> </td> <td> <p>   9</p> </td> <td> <p>   9</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   13</p> </td> <td> <p>   10</p> </td> <td> <p>   12</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   21</p> </td> <td> <p>   10</p> </td> <td> <p>   5</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   24</p> </td> <td> <p>   9</p> </td> <td> <p>   5</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p>Half the children rated the hook as satisfactory, but the number dropped to a third for the hand. Half the parents considered the hook as suiTable and a slightly greater number rated the hand as adequate. More children than parents reported that neither device was used for grasping soft objects. </p> <p>Picking up and holding a tube of toothpaste apparently presented no problem, but difficulties arose with sandwiches, cookies, candy bars, marshmallows, grapes, or raw eggs, all of which were usually held in the sound hand. The majority of the children experienced difficulty in holding soft objects with either device. Debra: "The hand squashes it and I can't eat it the hand squashes the sandwich." Joseph: "The hook might squash them; the hand can pick it up but I'll smash it." There were some children who made comments favoring the hand. Danny: "With the hand I can gel a sandwich better without squeezing it" (<b>Fig. 12</b>). Mother of Randy (triple amputee): "Eating sandwiches is a treat which he was unable to do with hooks." However, a larger number preferred the hook for this purpose. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Grasping a sandwich. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping or holding a drinking glass</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   8</p> </td> <td> <p>   8</p> </td> <td> <p>   18</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   7</p> </td> <td> <p>   12</p> </td> <td> <p>   16</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   13</p> </td> <td> <p>   8</p> </td> <td> <p>   13</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   12</p> </td> <td> <p>   11</p> </td> <td> <p>   15</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Less than a fourth of the subjects rated either hook or hand as satisfactory for holding a drinking glass. The parents were slightly more positive, a third of them rating both hook and hand as suitable. Several of the children who gave a rating of satisfactory explained that they would use a terminal device only to hold a glass by the rim when filling it with water or to carry it while setting the table. </p> <p> Comparisons between hook and hand were few. Some children stated that the hand did not open wide enough for available glasses or that the glass slipped. Two others, however, stated that the hand had a better grip and did not slip. Small opening and slippage were problems also reported with hooks. The general impression is that even children who rated a terminal device as satisfactory for holding a drinking glass were merely claiming they could hold a glass as a special feat, not as a commonly used skill (<b>Fig. 13</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Grasping a paper cup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Using silverware while eating</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   13</p> </td> <td> <p>   2</p> </td> <td> <p>   22</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   15</p> </td> <td> <p>   2</p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> <td> <p>   14</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   2</p> </td> <td> <p>   16</p> </td> <td> <p>   0</p> </td> </tr> </tbody></table> <p> Approximately a third of the children and half of the parents rated both hook and hand as satisfactory for holding silverware, while half of the children and a third of the parents indicated that neither device was used for the purpose. The slight differences favored the hand. With the exception of three bilateral arm amputees, the children who answered this question were left arm amputees. It appears likely that they used the terminal device only for holding a fork while cutting meat (<b>Fig. 14</b>), although one or two held a spoon in the terminal device also. Many children, even some who regarded a terminal device as satisfactory, reported that the parents usually cut their meat for them. Particular mention was made of problems of slippage, of difficulty of positioning, the better appearance of the hand performance, and the need for practice.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Holding a fork. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping large bulky objects, such as paste jars, books, balls, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   30</p> </td> <td> <p>   4</p> </td> <td> <p>   2</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   18</p> </td> <td> <p>   12</p> </td> <td> <p>   3</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   6</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Three fourths of the children rated the hook as satisfactory, but only half found the hand so. The same proportion of parents rated both hand and hook as satisfactory. </p> <p> The intention of the question was to determine whether the smaller opening provided by the hand was a disadvantage in actual use. The specifications of the No. 1 hand require that a minimum full opening of 2 in. be attainable with the thumb in the wide opening position, but most hands exceeded the specification to a maximum of approximately 2 3/8 in. However, there were indications that several children utilized the small, 1 1/2 in. opening only and did not bother to change the thumb position. A Dorrance 10X hook, by comparison, provided a 3 in. opening and the Dorrance 99X hook a 3 1/2 in. opening. </p> <p> A number of children and parents specifically mentioned holding baseball bats, balls, paste jars, books, boxes, dolls, and a see saw. Curtis: "With the hand, I can hold the bat better when I play ball." Glenda's mother: "Bats the ball using both hands now." Comments indicated that the hook was superior for throwing balls, but the hand was satisfactory for catching them in two handed fashion. In general, though, the children found it difficult to grasp balls with either the hook or the hand (<b>Fig. 15</b>). The hook was somewhat better for holding paste jars. Books, boxes, paper cups, and dolls (<b>Fig. 16</b>) were better held with the hook, but one boy said riding a see saw was easier with the hand. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Holding a large ball. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Holding a doll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping objects such as bicycle handles, swing chains or ropes, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   24</p> </td> <td> <p>   3</p> </td> <td> <p>   7</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   36</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   33</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p> Most children and parents rated the hook as suitable, but some children stated that the hand was unsatisfactory or not used for these activities. Confusion may have existed because of the separate uses; several of the children played on swings but did not ride a bicycle or tricycle. The hook was more often preferred for holding a swing chain, but preference was evenly divided for riding a bicycle (<b>Fig. 17</b>). Several parents felt that the hand grasp appeared more natural. There was concern about the danger of tearing the glove or breaking the thumb of the hand on a swing chain. Other activities mentioned under this heading were climbing monkey bars and holding a jump rope, a broom and a hoe, or a bow for archery. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Holding a bicycle handle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Putting on clothes, such as shirt, blouse, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   27</p> </td> <td> <p>   1</p> </td> <td> <p>   8</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   3</p> </td> <td> <p>   9</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   29</p> </td> <td> <p>   2</p> </td> <td> <p>   6</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   30</p> </td> <td> <p>   1</p> </td> <td> <p>   7</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p>Two-thirds of the children and parents rated the hook as satisfactory, but only half the children considered the hand as satisfactory for this purpose. Several children who considered both devices as satisfactory commented that they were usually dressed, or were assisted in dressing, by their mothers. There were more comments favoring the hook than the hand; the glove tended to stick to cloth and there was glove discoloration attributed to contact with clothing, particularly from red dyes.</p> <h5><i>Putting on shoes and socks</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   24</p> </td> <td> <p>   3</p> </td> <td> <p>   9</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> <td> <p>   11</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   29</p> </td> <td> <p>   3</p> </td> <td> <p>   6</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   3</p> </td> <td> <p>   7</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Two thirds of the children and the parents rated the hook as satisfactory, but less than half of the former considered the hand satisfactory (<b>Fig. 18</b>). A fourth of the children stated that they did not use either device to put on shoes and socks, and the number who did not tie shoelaces with prostheses was undoubtedly much higher. Timothy, for example, said that he did not know how to tie shoelaces and that his mother dressed him, but he and his mother rated both devices as suiTable for putting on shoes. Another reason given for parental assistance was that the child consumed too much time in dressing himself. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Putting on shoes and socks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Conclusions</h3> <p> In spite of the wide differences in the opinions expressed by the children and parents participating in the study, it was apparent that: </p> <ol> <li>The APRL Sierra No 1 hand was heavier and in most instances more difficult to operate than the previously worn hook, but for the majority of subjects in the sample these were not serious drawbacks. Those with shoulder disarticulation amputations and to a lesser extent some of the younger children and above elbow amputees were most likely to have difficulty with weight and operating forces. It is obvious, of course, that if the hand were lighter and had a more efficient operating ratio, it would be more accepTable to all.</li><li>The hand provided somewhat less pinch force than most of the hooks and a less precise grasp. The majority of children reported that they could perform more activities better with the hook; however, many could also specify a number of activities that were performed better with the hand. The latter was preferred somewhat more often for tasks such as picking up a pencil, grasping paper, and holding silverware for eating. The majority of the children and their parents considered the hand as "adequate" to "very satisfactory" for a wide range of activities.</li></ol> <h3>Acknowledgments</h3> <p> In Part I of this series of articles, grateful acknowledgments were made to the clinics participating in the Child Amputee Research Program and to a number of persons for valuable cooperation and assistance in the conduct of these studies and in the preparation of the report. We again express our sincere appreciation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "Kitty in the Kegs," a set of small plastic barrels, one inside the other. A picture of a kitten is in the innermost barre. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Drying Dishes </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Putting on clothes. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Loony Links." The child is asked to assemble a jointed doll and stand it on its feel, using a preassembled doll as a model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cutting and pasting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Eating ice cream. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, <i>Acceptability of a functional-cosmetic artificial hand for young children, </i>Child Prosthetic Studies, Research Division, College of Engineering, New York University, January 1964.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Actual pinch forces in the hooks worn by children in the study were not obtained. However, recommended forces for the age group are: below elbow, 3 1/2lb, above elbow, 3 lb. than the previously worn hook, the data must be questioned. Nevertheless, conservative interpretation of the available information does provide insight not only into hand usage but also into terminal device function in general.</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>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York, N.Y. 10010.</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>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St , New York, N.Y. 10010.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-07.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-08.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-09.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-10.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-11.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-12.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-13.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 Acceptability of Functional-Cosmetic Artificial Hand for Young Children, Part II Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/cb540e7ef43f29b8f2a54281780f08ca.pdf db1f8f57d64f091532e8e80aa08d9455 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_02_001.pdf Text Any textual data included in the document <h2>The Nature of Orthotics Practice</h2> <h5>Sidney Fishman, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Joan E. Edelstein, M.A.&nbsp;<a style="text-decoration: none;">*</a><br />Lynn Michaelson, B.S.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>How typical is YOUR orthotics practice? How extensively are plastic orthoses being utilized? How many KAFO wearers utilize a knee lock, and what kind? Examining the experience of a larger number of certified orthotists regarding these and other prescription issues is a logical way to gain perspective on contemporary orthotics management. Some time ago New York University Post-Graduate Medical School conducted a pilot survey of approximately sixty orthotists who were attending several short-term courses. While the sample was small and drawn largely from the Eastern seaboard, the completed questionnaires revealed a number of interesting trends regarding patient population, orthotic designs, and materials.</p> <p>Among the most important of the preliminary findings is the overwhelming predominance of lower limb orthotics (LLO) practice over spinal (SO) and upper limb (ULO) activities by a ratio of 5 to 1 to 1; the continued preference, although small, for metal rather than plastic materials, especially for LLO's. Lastly, middle aged adults with upper motor neuron disorders (stroke, etc.) constituted the largest single type of patients requiring services.</p> <h3>Population</h3> <p>Although orthotists reported that they treated substantial numbers of patients in all age brackets, about 55 % of the individuals fitted were between 18 and 60 years of age. Of the remaining 45% , the proportion of children below 18 years exceeded that of older adults (over 60) by a third.</p> <p>Patients presented a wide variety of disorders. Among LLO wearers, more than half had upper motor neuropathies; approximately 30 percent had skeletal disorders, and the remaining 20 percent had lower motor neuron diseases. In contrast, the greatest number of ULO's were worn by persons with lower motor neuron lesions (42%), while the remaining individuals wearing ULO's experienced upper motor neuron and skeletal disorders in nearly equal numbers.</p> <h3>Materials</h3> <p>The great majority (80%) of orthotists responding used both metals and plastics in their LLO practice, however 10 percent stated that plastics constituted the primary or sole material in all LLO's they made, while the remaining 10 percent used metals only. Overall, the ratio of usage of aluminum to plastic to steel was 5 to 4 to 1.</p> <h3>Lower Limb Orthotic Designs</h3> <p>Among the lower limb devices fabricated, 63 percent were AFO's while 37 percent were HKAFO's, KAFO's, and KO's. Forty-six percent were unilateral AFO's and 25 percent were KAFO's applied unilaterally; 17 percent of the LLO were AFO's fitted bilaterally.</p> <p>The solid stirrup was by far the most commonly used method of shoe attachment (42%), followed in turn by the split stirrup (20%), plastic shoe insert (18%), calipers (15%), and miscellaneous attachments (5%). About half of the LLO's prescribed permitted free or nearly free ankle motion of which 17 percent permitted free motion, and 37 percent utilized some form of motion assist, usually a coiled or wire spring. Approximately one-third of the ankle components limited motion in some way with 27 percent of such appliances utilizing stops, and 10 percent consisting of solid ankles. Such diverse components as dual action assists and double axis joints accounted for 11 percent of the orthotic ankles.</p> <p>In relation to specific AFO designs utilized, the most frequently identified were patellar tendon bearing, Denis Browne, posterior leaf spring (both Rancho polyethylene and TIRR polypropylene), VAPC shoe clasp and the NYU insert.</p> <p>As regards orthoses encompassing the knee and/or the hip, a single axis joint with drop lock, (with or without spring loading) accounted for nearly 70 percent of knee controls provided. Cam and plunger locks were very seldom used and only 13 percent of the orthoses had free knee joints, including single axis as well as offset and polycentric types. Regarding hip joints, the number of free single and double axis joints far exceeded that of any locking hip joints.</p> <p>Approximately half of the orthotists reported making fracture LLO's of one type or another. A third had fabricated both AK and BK fracture orthoses, while nearly 10 percent had made only BK fracture orthoses and 5 percent had fabricated AK designs exclusively.</p> <p>As for other specific KO and KAFO designs, orthotists constructed knee cages and trilateral Legg-Perthe's orthoses most commonly.</p> <h3>Upper Limb Orthoses</h3> <p>While as indicated, the survey focussed on LLO practice, several interesting facts concerning ULO management also emerged. The most frequently prescribed ULO was the opponens orthosis (70%), while 19 percent were provided with prehension orthoses with about 21 percent of this number being fitted bilaterally. External power was employed in only 3 percent of the fittings reported.</p> <p>Although these preliminary data indicate some interesting patterns there is no doubt that it is not possible, at the present time, to present a satisfactory overview of the nature of orthotics practice, with any degree of confidence. This fact presents particular problems for the educational institutions who are obliged to teach students those procedures and techniques which are most widely utilized by the practitioners. The same lack of information causes severe difficulties for potential researchers in relation to their ability to identify and undertake valuable and meaningful projects. Consequently there is a crying need for more comprehensive and reliable information than is presently available. We therefore propose to obtain such data from as many certified orthotics facilities in the country as possible. A revised questionnaire has been prepared which attempts to obtain the most important, precise information regarding lower limb orthotics practice.</p> <p>We request that each certified facility complete the questionnaire on pp. 8-10. It should take no more than 15-20 minutes. Return the completed form to Prosthetics and Orthotics, NYU Post-Graduate Medical School, 317 East 34th St., New York, NY 10016, by Sept. 15, 1980. Obviously only one questionnaire for each facility should be submitted, since any duplicate returns would tend to unbalance the information gathered. Lastly, in order to identify regional differences and to permit the possibility of follow-up contacts, we ask that each return be identified. In order to avoid any possible intrusion on confidential business statistics please note that all of the requested information is only in percentages of total practice.</p> <p>Following the necessary period of time to accumulate, tabulate and analyze the data, a report summarizing the results of the study will be published in a forthcoming issue of the Newsletter. At a later time similar surveys relating to spinal and upper limb practice will be undertaken.</p> <em><b>*Lynn Michaelson, B.S. </b> New York University Post-Graduate Medical School<br /><br /><b>*Joan E. Edelstein, M.A. </b> New York University Post-Graduate Medical School<br /><br /><b>*Sidney Fishman, Ph.D. </b> New York University Post-Graduate Medical School</em><br /> <div style="width: 400px;"></div> Page Number(s) 1 - 2 Year 1980 Volume 4 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Nature of Orthotics Practice Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Joan E. Edelstein, M.A. * Lynn Michaelson, B.S. * https://staging.drfop.org/files/original/76322a13e4393e786aa6cf728e59d575.pdf 39fce9c7a6f2005a4ab1a72a880e7a96 https://staging.drfop.org/files/original/6e81640a2432fc3ff431c866ed257b5c.jpg 8a184d6c2cd09aa48d4deaf1a96a38e6 https://staging.drfop.org/files/original/228636863105038050c9d1327b56b149.jpg 35aa8e8f4be17cb772ee210e3491fe14 https://staging.drfop.org/files/original/0af8fc502d0a1e956ea8f14b47d06604.jpg b909a129f28f2159f8e8bab0032ca6fb https://staging.drfop.org/files/original/fd19c2ac9eecfb1b3389a8f532f8e987.jpg 0ca302e2ee4871004f9413e5fe7590ca https://staging.drfop.org/files/original/540b3a9d46612360fc39147886c0b410.jpg 12dadbf7283c4ddccd4be09443d58a54 https://staging.drfop.org/files/original/53ce02b8b45bc077a8134a1eef613649.jpg c21f7b4c2c06da48794cd9b0e5701f7a https://staging.drfop.org/files/original/70e664f9f3fea8b660104097849c1575.jpg e7f5d7ce8648e996a99440c72aa5073b https://staging.drfop.org/files/original/10ac518f74cc982aa6c1487671310f26.jpg 43f03940f4c5e6f5d6af345c6f3cf534 https://staging.drfop.org/files/original/83efde55b3303296ae07e3355a5c7f07.jpg 4ecf3ea6aae70e48f884aa146992d924 https://staging.drfop.org/files/original/c81ea73ab2a49c1dd9aa85e2b3707800.jpg 31d0ff6607e8608783a11d5e22f5e813 https://staging.drfop.org/files/original/a7525b0e8bcf6995ccb0702172c1a8d1.jpg 7996d249ebcb7bd84bef604b6341e2fb https://staging.drfop.org/files/original/b479e667bfc97de15ecaee15bf7da57d.jpg c65f98e9c63b8a48493f0ae7bdad8ca3 https://staging.drfop.org/files/original/74d334c8eaea06c0fd36087ec6c15ee3.jpg 9f96c0135add7753cc6cd00eae64cb3b https://staging.drfop.org/files/original/5ad5ea26960beed46a890e753e0587b6.jpg 33b17a56e9879d4754892185ca02332d https://staging.drfop.org/files/original/e1c7350ac7ddb0982d6b99fd1e5e0e6c.jpg e32301edc95c253b8417babecef0e710 https://staging.drfop.org/files/original/29f1c3079e19139973951937d38dbc96.jpg 1b5c5363292cde70bf72f725ca443206 https://staging.drfop.org/files/original/2b643269f7fa8020dd0bb4fd44dfdf3e.jpg 89774b2094aa1a19bdc55dce84a80489 https://staging.drfop.org/files/original/9c808215701b321e9407b27c9bc39d47.jpg fc644c56a0bc85f0c8cbff07ba6870fa https://staging.drfop.org/files/original/5292a74440790c92d38b23c86b501fe7.jpg 2ea50f3af857e6a92f61a0e0e77220c7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_076.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 76 - 104 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_01_076.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_076.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Management of the Nonfunctional Hand Reconstruction vs. Prosthesis</h2> <h5>Sterling Bunnell, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>In the course of routine practice, the orthopedic surgeon is frequently confronted with the task of dealing with hands that are damaged by trauma or disease or that are otherwise nonfunctional owing to any of a variety of causes. In all such cases, he is called upon to decide whether or not to undertake amputation of parts of the hand or amputation through the wrist, with the expectation of later applying a suitable prosthesis, or whether, with the prospect of long continued treatment and the possibility of ultimate failure, to attempt surgical construction of a functional hand from such anatomical elements as can be saved. The considerations involved are many and varied, and rarely do two cases resemble each other in more than a remote way. Each individual case must therefore be evaluated on the basis of its own merits.</p> <p>There has been in the past dozen years a great advancement in the development of hand prostheses, so that in the case of major hand problems one might be inclined to choose wrist disarticulation over attempts at surgical reconstruction. But during the same period surgical reconstruction also has advanced remarkably, so that in judging any individual case there should be a careful analysis as to which procedure is the better to follow. Doing so usually results in a sort of compromise—reconstruction, if reasonably possible, being chosen first, a prosthesis being applied when proven necessary, major amputation being considered only as a last resort. It is the purpose here to attempt to extract from many years of clinical experience with hand surgery certain general principles that may offer guidance in making the choice. Generally, the current rule of "save all length possible," now applicable at most other levels of amputation, is applicable in the case of damaged hands also.</p> <p>The fundamental difference between a reconstructed hand and any present day hand prosthesis lies in the absence of direct sensation in the latter. Although the wearer of a modern hook or artificial hand may receive indirect sensory impulses through shoulder harness or cineplastic muscle pin, the conventional arrangement constitutes only a crude and inefficient signal system which must be supplemented and directed by sight. A hand prosthesis is of little use in the dark. In contrast, there is the exquisite appreciation we receive from the normal hand by feeling. By light touch, coarse touch, response to heat or cold, and compass point discrimination, we appreciate texture, and by muscle, joint, and tendon sense we appreciate size and shape. By combining these sense impressions in our cerebral cortex in the opposite parietal lobe, we can identify from memory an object held in the hand. This is stereognosis, a phenomenon replaced by no artificial hand now available. To quote Kirk,<a></a> "No hand is so badly crippled that, if it is painless, has sensation, and strong prehension, it is [not] far better than any prosthesis." This being the case, it is generally desirable to preserve any and all hand structures that can reasonably be counted on to have adequate nerve and blood supply. Eventual application of a prosthesis may or may not be indicated, depending upon individual circumstances and the particular demands of occupation.</p> <p>Before considering any hand amputation, then, one should weigh well the possibility of surgical reconstruction, especially with the idea of restoring natural sensation and strong prehension. Whenever reasonably feasible, surgical reconstruction of a damaged hand or arm should be attempted first. Often the result will be such that a prosthesis will not be necessary. In any case, a reconstructed hand stump is apt to be much better adapted to application of a prosthesis. As a matter of fact, reconstruction and use of a prosthesis are so interrelated that they should be considered together in each individual case. Every useful part of a limb, and every bit of skin that has sensation, should be preserved, thus giving more useful material for reconstruction and, finally, for the fitting, if necessary, of a prosthesis.</p> <p>Reconstruction may often be done in one operation; in other cases multiple operations are required over a period of a month to a year. But considering that the goal is to provide a useful hand for the remainder of an individual's life, it seems worth while. Nevertheless, it should not be undertaken unless there is reasonable assurance that a good practical result can be obtained.</p> <h4>Methods of Surgical Reconstruction</h4> <p>Although the hand does the work, the arm places and innervates the hand. Accordingly, if any particular hand is to be truly useful, it is necessary to have good shoulder, elbow, and wrist function and also good pronation and supination half furnished by the shoulder and half below the elbow. Because they supply the hand, the nerves of the arm are particularly important. In the hand itself there should be a good quality of sensation as well as mobile units that can work against each other with at least a pinch grasp or hook action to simulate normal prehension.</p> <p>Hands coming in for repair usually evidence partial amputations, stiffening in the position of nonfunction, flexion contracture from scar formation, malalignment of bones, loss of motion from injury to tendons and nerves, loss of sensation from injury to nerves, ischemic contracture, or painful states from vasomotor causes or from tender neuromata. Usually the surgeon's problem is composite, dealing with cover, joints, bones, nerves, and tendons.</p> <p>For each of these conditions there is much that can be done surgically.<a></a> For partial amputation, clefts between digits may be deepened, and digits can be built out and made to appose each other. Tender stumps may be corrected. For stiffening in the position of nonfunction, the joints may gradually be drawn around to the position of function by spring or elastic splinting and can be mobilized surgically. Scar tissue of flexion contracture can be replaced by good pliable skin giving good cover and improving nutrition. Malalignment of bones may be corrected so that the mechanics of tendon action are correct. Substitute thumbs may be formed. Tendons and nerves may be repaired or transferred, or new ones may be furnished. Ischemic contracture can be relieved so that a hand thus affected can regain some function. Painful states may be corrected by sympathectomy, and tender neuromata may be removed.</p> <h4>Partial Amputation</h4> <p>Arm stumps resulting from amputation through the wrist or through the carpometacarpal joint, or those without the thumb and with amputation through the metacarpals or proximal phalanges, require a prosthesis (<b>Fig. 1</b>). Hands retaining a good thumb working against one or more fingers (as in <b>Fig. 2</b>), or even against a surgically constructed post (as in <b>Fig. 3</b>), do not. Sometimes the usefulness of a sound thumb may be much enhanced by surgical procedures conducted on other remaining hand parts (as for example in <b>Fig. 4</b>). Other partial hands (like those shown in <b>Fig. 5</b> and <b>Fig. 6</b> for example) when reconstructed usually are more functional than a prosthesis. Some with a partial hand amputation use remnants of the hand for fine work and a prosthesis for heavy work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Levels of hand amputation requiring prosthesis. A, Wrist disarticulation, including removal of the distal prominences of radius and ulna; B, amputation through the carpometacarpal joint; C, transmetacarpal amputation; D, amputation through all proximal phalanges In B, some useful wrist motion may be retained. In C, hand remnant may be used as a wrist motor to power a prosthesis or simply to point one. In D, hand stump may be made to work against some prosthetic device, residual sensation offering a substantial advantage over A, B, or C. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Examples of partial hands requiring no prosthesis. When the thumb can work against one or more fingers, function usually is better than can be obtained with a hand substitute. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Partial hand (A) and result of reconstruction (B), no prosthesis needed. When, in the absence of all the fingers and much of the palm, a good thumb remains, it is possible, by means of pedicle and bone graft, to build up a post for the thumb to appose. Function thus obtained is likely to be better than that to be had from a hand substitute. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case M. S. Fingers lost between a sprocket and chain. Excised the tender neuromata of the stumps. Undermined and drew skin down for better coverage. Excised metacarpal of ring finger, covering sides of new digit by plastic maneuvers, in order to give more mobility (2 in.) to the metacarpal of the little finger. Deepened thumb cleft by Z plasty (Fig. 21, page 86). The patient obtained a strong and useful grasp between the thumb, the phalangized index and long "fingers," and the little "finger." From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case P. L. Hand caught between two rollers. Debrided and skin grafted. Later, pedicle flap applied, then interdigitation. Sensation gradually returned throughout. A useful hand was obtained. From Bunnell, Surgery of the Hand, 3rd ed , lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case B. P. Partial amputation by power saw. Split grafted next day. Pedicle graft applied and thumb cleft deepened. Index metacarpal removed for wider cleft. Rotary osteotomy done on all metacarpals for better apposition. Pinning with Kirschner wires. A good "hand," with good prehension, was obtained. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956. by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In partial amputations it is best, if possible, to retain the metacarpal heads and hence the full width of the palm for firm grasp of tools, but the metacarpal head of an index or of a little finger that has been amputated through the metacarpophalangeal joint is best beveled off so that it will not snag on entering a pocket. The metacarpal of an index or little finger off through the shaft is best removed obliquely at its base (<b>Fig. 7</b>). The interosseous muscle is then transferred to the adjoining digit to give abduction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Typical example of loss of fourth and fifth rays through the shafts of the metacarpals. In such a case, it is best to delete the stub of the fifth metacarpal and round the stub of the fourth. A corresponding procedure is advisable in the event of loss of the second digit, or of the second and third digits, by transmetacarpal amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A hand amputated through all metacarpophalangeal joints or proximal phalanges may be improved by mobilizing the fifth metacarpal, cutting the transverse metacarpal ligament, and perhaps removing the metacarpal of the ring finger and covering the cleft by a plastic maneuver (<b>Fig. 4</b>). The ulnar side of the hand thus becomes a movable part. Motion may be increased as much as 2 in. If the second and fourth metacarpals are deleted, there will remain three digits, consisting of the metacarpals of the thumb and of the long and little fingers, and the thumb cleft will be wide and deep. Phalangizing the metacarpals gives considerable useful mobility so that one can dress oneself, use knife and fork, and so forth. The metacarpals of the thumb and little finger are cut across at the base and bent toward each other for better grasp (<b>Fig. 8</b>). A similar osteotomy may be performed on a hand having only two remaining digits, as for example thumb and little finger (<b>Fig. 9</b>), or even when only one complete digit remains, as in (<b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Reconstruction procedure for loss of all digits through the metacarpophalangeal joints. A, Second and fourth metacarpals are deleted, clefts are covered by plastic maneuver, first and fifth metacarpals are osteot omized. B, Functional three finger "hand" results </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Angulatory osteotomy of first and fifth metacarpals to aid apposition of thumb and little finger. Sometimes it is necessary to effect a tendon T transfer also. See Figure 31, page 91. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Angulatory osteotomy of first and fifth metacarpals to bring thumb and ulnar side of palm into easy apposition. Tendon T transfer may be needed here also (Fig. 31, page 91). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Frequently a finger or hand stump is so hypersensitive from poor terminal padding and sensitive neuromata that it prevents all of the remaining parts of the hand from functioning. Crushing injuries to fingers present the most difficulty because, in such cases, the fingers usually have been damaged well proximal to the site of amputation. In revising such stumps, the digits must often be shortened enough to give good, well padded cover, but it is possible to swing a visor flap from the dorsum over the end of the stump and then to skin graft the dorsum. Still another possibility of furnishing good tactile cover over the end involves use of a cross finger flap and then skin grafting the back of the donor finger. Nerves in hands and fingers have a special tendency to proliferate. If they terminate in scar tissue or close under the skin, the neuromata formed may be extremely sensitive and give, on slight tapping, the sensation of an electric shock. These are corrected by uncovering the nerve, dissecting it well back, and cutting it off in good tissue free from scar. Neither alcohol injection nor ligation is used.</p> <h4>Stiffening in The Position of Nonfunction</h4> <p>Following injury, infection, or paralysis, a hand frequently stiffens in the position of non function so that the digits can no longer touch each other and the hand is therefore useless. In the position of function (<b>Fig. 11</b>), the wrist is extended<i>35 </i> deg., the joints of the fingers are moderately flexed, and the thumb is in moderate apposition, as in holding a baseball. In the position of nonfunction (<b>Fig. 12</b>), the wrist is flexed, the metacarpophalangeal joints are hyperextended, the remaining finger joints are flexed, and the thumb is at the side of the hand or even back of it. Although such a hand is totally useless, in general it should not be amputated. For if the joints can be pushed around into the position of function, the available motion will be useful for picking up and holding objects, and the hand will be used more and more from then on.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The position of function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. The position of nonfunction. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The first approach to hands stiffened in the position of nonfunction involves use of a system of elastic or spring splinting by which joints can gradually be drawn around into positions of function. Usually the joints are kept active and are not damaged, and the muscles and all tissues are activated, a matter which greatly improves their condition. If, however, the response to such treatment is unsatisfactory, surgical means are resorted to, starting with capsulectomies (<b>Fig. 13</b>) and, where there is damage to bone structure, resorting to arthroplasties.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case E. T. Top, preoperative position of nonfunction from shark bite on upper arm, severing nerves and vessels. Bottom, correction to a position of function by fusion of the wrist, capsulectomies and opening of the cleft of the thumb, and transfer of the extensors of the wrist to the flexors of the fingers. A tendon transfer through a pulley constructed at the pisiform was used to give apposition to the thumb. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Capsulectomies are usually performed on the meta carpophalangeal joints but sometimes also on the proximal interphalangeal joints. Usually the trouble is found to lie in the fact that the two collateral ligaments are too short and thick to permit the joint to flex. Excision of these structures makes flexion possible. Often it is necessary also to free the long extensor tendons (<b>Fig. 14</b>) and to clean out the volar pouch of the joint. In performing an arthroplasty, the metacarpal head is shortened and reshaped, and a hood of fascia is fastened over it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Case J. D. Left, old dislocation of metacarpals on carpus, upsetting muscle balance, thus resulting in the useless position of nonfunction. Right, dislocation reduced, restoring muscle balance in the position of function. A pedicle graft was applied to the dorsum of the hand and to the open thumb cleft. Freeing of the extensor tendons, together with capsulectomies, allowed the proximal finger joints to flex. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Arthroplasty is not often done on the wrist joint; arthrodesis is used instead. In many cases, however, removal of a mass of scar tissue from the volar aspect of the wrist allows the wrist to extend. When pronation and supination are retained, arthrodesis of the wrist or of the proximal finger joints into the position of function gives very little disability (<b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 15 Case A B Hand useless from birth pals)". Several operations had been performed, including fusion of the wrist. The proximal finger joints were lax and bent backward out of use Patient could not abduct at the shoulder, and the forearm was in supination. The shoulder was arthrodesed lo enable placement of the hand, and by osteotomy the ulna was rotated into pronation. The proximal finger joints were arthrodesed into the position of function. Patient gained much use of the hand and became self supporting. From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Flexion Contractures and Furnishing New Cover</h4> <p>Most reconstruction commences with excision of a big plaque of scar tissue that is drawing the hand into flexion contracture and strangling the rest of the tissue (<b>Fig. 16</b> and <b>Fig. 17</b>). The skin is then undermined and allowed to retract, thus freeing the hand for better nutrition. New cover is then provided, sometimes by a free graft but usually by a pedicle graft from the abdomen (<b>Fig. 18</b>), thus giving good, pliable skin with a layer of soft fat beneath. Doing so releases the whole hand and makes it possible to reconstruct the deeper parts joints, bones, tendons, and nerves. Although the refinements of stereognosis never return to such skin, eventually sensation to light touch and pin prick develops.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Case J. M. From birth the cicatrix from a tear at the ulnar side of the wrist so distorted the growth of the hand that there was no function. The scar was excised, the ulna elongated, and a pedicle applied. Two years later osteotomies were done on all metacarpals, the thumb cleft was deepened, and a pulley operation was performed to improve apposition. Three years later the hand was reported to be quite useful. From Bunnell, Surgery of the Hand, 3rd ed Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case D C. M. Hand severely burned in oil fire so that all digits pointed backward out of use. Fingers were webbed, and middle joints were exposed. There was no thumb cleft, the thumb being at the rear of the hand with the metacarpal arch reversed. In this position of nonfunction, the hand was entirely useless Excised all dorsal skin, including nails Sawed away exposed bone. Corrected webs. Established thumb cleft and positioned thumb. Positioned fingers by capsulectomies. Covered all with free skin graft. Patient returned to his job as locomotive engineer No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia. 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Case A. C. Hand badly crushed between rollers. Poor skin surface, position of nonfunction, entire hand and joints stiff, extensor tendons adherent, thumb at side, amputation contemplated. First operation: excised all skin from both dorsal and volar surfaces, covered with one large pedicle graft, and spread thumb from hand; brought joints around by elastic splints. Second operation: freed extensor tendons and placed fat beneath; did capsulectomies on proximal joints; used sublimis of long finger for apposition; freed flexor tendons, placing fat beneath; defatted pedicle. The hand made remarkable recovery in nourishment, function, and position. There was good grasping power and a complete change in the morale of the patient. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Skeletal Malalignment</h4> <p>The bones of the hand constitute the framework along which the muscles and tendons function in their proper planes. The joints allow the digits to flex and extend in their proper positions for adequate grasp. After fracture, bones often unite at such odd angles that the whole mechanics are thrown out of true. If, after healing, there is an angle of the bones along the length of the limb, the tendons over the convexity will be tight, over the concavity loose. Such a circumstance upsets the whole nicely adjusted muscle balance so that the joints are pulled into deformity all the way from the site of angulation to the end of the limb. To make the hand function properly again, realignment is necessary. The bones are chiseled or sawed across, a wedge being removed when necessary to place them in proper contact and alignment. They are then pinned so by Kirschner wires, the latter being withdrawn in two months when union is solid and the framework of the hand is restored.</p> <p>When the thumb does not entirely contact the ring finger or the little finger, the metacarpal of either or both may be severed at the base and the digits angulated toward each other in such a way as to provide for easy contact. Similarly, in the absence of a thumb, two or more fingers may be angulated and rotated to give them the ability to work against each other.</p> <p>When a metacarpal, including the soft tissues about it (tendons, nerves, interosseous muscles, and skin), is badly damaged, it may be excised. If it is one of the central rays, the metacarpal of the adjoining ray, either index or little, as the case may be, is cut across at its base, jogged over to the base of the excised metacarpal, and pinned near and parallel to the next ray (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Reconstruction procedure recommended in event of serious damage to (A) the fourth digit or to (B) the third digit. In A, delete the much injured fourth ray and jog fifth ray over to its place. In B, delete the much injured third ray and jog second ray over to its place. The result in either case is a functional four digit hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a metacarpal head is missing, the lack of support causes the adjoining metacarpals to rotate so that the fingers cross on flexion. In such a case, the metacarpal can be excised and one of the adjacent ones jogged over. Or the proximal phalanx of the ray in question can be recessed, or set back, so that its head will take the place of the missing metacarpal head.</p> <p>Often it is advisable to arthrodese a joint to place it rigidly in the position of function. This procedure can be carried out on either of the two distal joints of the fingers but rarely on the proximal joints. It is done on the wrist and can be done on the elbow. In the latter case, the choice must be made between arthrodesis, a block operation, muscle transfers, or the wearing of a prosthesis to activate a flail elbow. When the arm cannot be abducted at the shoulder but when muscles around the scapula are good, arthrodesis of the shoulder will allow the arm to position the hand for useful function (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 20. Case L. M. W. As a result of polio, arm was flail at shoulder, and there were no flexors in the hand Arthrodesed shoulder and wrist simultaneously so that the patient could place the hand. Transferred extensor carpi radialis to flex fingers, palmaris longus to abduct thumb, the long extensor of the ring finger for apposition. Slit the proximal pulleys so that long flexors could flex the proximal joints. Patient gained much use of hand, was able to grasp a piece of paper or a tumbler, could place the hand well, and occupied a position in a bank. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Thumb Problems</h4> <p>So essential to prehension is the thumb that every possible bit of an injured one should be saved. Amputation of the thumb through the metacarpophalangeal joint results in a partial digit almost loo short to be useful, but a new thumb cleft can easily be made by a Z plasty operation (<b>Fig. 21</b>), meanwhile scraping the adductor origin down from the third metacarpal. The thumb is thus made relatively longer. If the shaft of the index metacarpal projects into the web so as to interfere with grasping, it should be excised at its base to widen and deepen the cleft (<b>Fig. 22</b> and <b>Fig. 23</b>). Whenever possible, the tip of the third metacarpal should be preserved to provide a concave palm for the remnant of the thumb to work against (<b>Fig. 22</b>). Preservation of the broad tip of the third metacarpal is particularly desirable when a complete thumb remains (<b>Fig. 24</b>). The range of motion of a normal thumb extends from a position at the side and slightly back of the hand, with the nail at right angles to the palm, through a wide ellipse toward the volar aspect until it is opposite the fingers, the nail being then parallel to the palm. In the latter position, the thumb is available to participate with the fingers in grasping large objects. The motion is effected by the ten muscles long and short that control the thumb. In paralysis of the median nerve, in injury to the thenar muscles, in stiffness of the carpometacarpal joint of the thumb, or in flexion contracture on the dorsum of the web, normal range of motion of the thumb is lost. If the other parts of the hand are mobile, the ability to appose the thumb can readily be provided by a simple tendon transfer that draws the thumb toward the pisiform bone and pronates it. When this is not possible, the thumb may be held permanently in a useful position by a bone graft at the base of the first metacarpal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Phalangization of thumb cleft by Z plasty. Left, hand with short and more or less useless thumb stump. Middle, location of Z shaped incision; flap A is carried to fixed point X, flap B to fixed point Y, so that dorsal flap just covers defect on volar side while volar flap just covers defect on dorsal side; resulting suture line is as shown in insert. Right, end result, showing deepened thumb cleft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case C, H. Amputation by meat grinder. Thumb cleft deepened by Z plasty. Index metacarpal removed to give good grasp. From Bunnell, Surgery of the Hand, 3rd ed.. Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case H. G. Amputation, by power saw, of all digits through proximal phalanges, leaving a mitten hand but no thumb cleft By a plastic maneuver and removal of the index metacarpal, a thumb cleft 3/4 in. deep was constructed. It opened 3/4 in and closed against the hand. Patient could write and hold objects Limited facility can be combined with the use of a prosthesis. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Operative procedure for loss of the second and third digits. Excision of the second metacarpal, but with retention of the third, furnishes easy apposition for the sound thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a thumb is closely bound to the rest of the hand by scar, it can be spread away by excising the scar tissue and cutting across the cleft from a point opposite the hinge of the first two metacarpals on the dorsal side to the corresponding point on the volar side. The thumb is spread to the side and front of the hand, and the large denudation of skin is covered either by a large diamond shaped free skin graft or, better, by a pedicle graft from the abdomen. In three weeks, pedicle grafts are detached from the abdomen and laid smoothly on the hand.</p> <p>Although the thumb stump remaining after amputation through the metacarpophalangeal joint usually is not very serviceable, it may be built out by pedicle and bone graft. If a thumb is amputated proximal to the metacarpophalangeal joint, it should in any case be built out longer. If the thenar muscles and the stub of the metacarpal remain intact, the thumb will be quite movable. A short thumb is a good thumb. Various motions, such as apposition, extension, and flexion, may be furnished it by tendon grafts.</p> <p>In the case of total loss of the thumb, a new one can be supplied in various ways. The simplest approach is to raise a tube pedicle from the abdomen, attach the pedicle to the hand, and place in it a bone graft from the iliac crest (<b>Fig. 25</b> and <b>Fig. 26</b>). Although this expedient gives sensation, it does not provide much stereognosis. Nevertheless, a reconstructed thumb is apt to be very serviceable and considerably better than a prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Surgical construction of a new "thumb." A, Poorly functioning partial hand retaining digits four and five only. B, Serviceable partial hand made by constructing new "thumb" with pedicle and bone graft. Function is apt to be better than if a prosthesis were applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Case C. B. Injury from hand grenade. Pedicle graft covered the thumb, and arthrodesis was done on the trapezium by a graft from the ilium Abduction was furnished index finger by a proprius tendon graft A very useful hand resulted. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The graft should be grounded on some other bone rather than connected by a joint. It may be placed on the carpus to make a pad in the base of the palm, or it may be placed on the trapezium or on the stub of the metacarpal.</p> <p>The requirements of a new thumb are three in number—motion, sensation, and proper placement. The best new thumbs are made by pollicization of a finger, preferably the index linger but sometimes the long finger. Often, as part of the injury, the index finger is already somewhat shortened. In such a case, the finger, or a portion of suitable length, is transferred together with a bridge of skin and with its nerves, blood vessels, and tendons intact (<b>Fig. 27</b> and <b>Fig. 28</b>). It may even be transferred on a neurovascular pedicle circumscribing the skin all around (<b>Fig. 29</b>). When this procedure is possible, it makes for easy and exact placement. The tendons are brought over with the new "thumb" and joined up so as to give motion. The fingers should work directly against the new "thumb" and also, by their side motion, should pass to the side of it and close against the palm. Stereognosis and vascularization are provided by the neurovascular pedicle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 27. Pollicization of index finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Case H. W. W. First (1929) physiological reconstruction of thumb by pollicizing remains of the index finger. Metacarpal lashed to trapezium, nerves and vessels carried over, and all tendons and muscles connected up. "Thumb" had strong motion and normal sensation and was well positioned. Patient worked well as a carpenter for 20 years. Superior to prosthesis From Surgery, Gynecology, and Obstetrics, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Pollicization of index finger by neurovascular pedicle. Skin is circumscribed, and the index finger is pinned on to the stub of the metacarpal of the thumb in proper position. Tendons furnish motion, vessels nutrition, and nerves sensation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Should a newly constructed thumb not have sensation in its tactile area, a flap of skin may be exchanged for the nontactile skin by a Z plasty. Or tactile skin can be furnished by using a neurovascular pedicle passed beneath the skin at the base of the thumb. A living thumb, with motion, sensation, and proper positioning, is, of course, far superior to any prosthetic thumb.</p> <h4>Tendon Repair</h4> <p>Tendons are frequently lacerated, thus losing their function of transmitting muscle power to provide motion in joints. They can, however, readily be repaired (<b>Fig. 30</b>), the most difficult cases being the flexor tendons in the digits and in the distal part of the palm, where the resulting juncture tends to adhere to the surrounding parts. Frequently a tendon graft must be used to bridge the tendon over areas where adhesions are likely to form. Adherent tendons may be freed, and slippery material, such as paratenon and fascia, may be grafted between them and the bones so as to allow the tendons to glide again. Defects in tendons are readily bridged by free tendon grafts from spare tendons in other parts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case F. E. Charge from a shotgun entered palm and emerged dorsally, shattering the carpus and the lower radius and severing many tendons, extensors of the wrist, thumb, and fingers, and the median nerve. Debrided, filetted the index finger, and skin grafted. Considerable infection followed. First operation: excised scar and placed a pedicle. Second operation: furnished tendon grafts plus paratenon to extend thumb and fingers; freed the flexor tendon of the thumb; did a pulley operation for apposition; sutured median nerve to its four branches. The wrist became fused. But sensation, motion, and apposition returned, so that there resulted a very useful hand requiring no prosthesis. From Bunnell, Surgery of the Hand, 3rd ed. Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The upper limb interdigitates at the ends of the metacarpals, and the tendons normally have individual motion. If either an extensor or a flexor tendon is sutured over a finger stump, it will hold back all of the tendons pulled from the same muscle. But when all of the tendons are cut at the end of carpal or metacarpal stump, they should all be sutured together over the end to provide for movement of the stump.</p> <p>Isolated digits may be made to provide prehension if they are furnished with new flexor and extensor tendons. To make the fingers appose each other, the tendons can be placed diagonally across the hand, or a tendon T transfer, which consists of one cross bar tendon from digit to digit and a longitudinal one looped about the first, can be made (<b>Fig. 31</b>). When the muscle concerned is contracted, the "T" assumes the shape of a "Y," and the two digits are drawn toward each other. This procedure is particularly useful in median and ulnar paralysis, where it will provide adduction of the thumb and little finger while curving the metacarpal arch of the palm. When some digits have been amputated, great strength can be given to the remaining fingers by transferring in the forearm the tendons of the amputated ones to those of the remaining ones.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Lobster hand formed by tendon T transfer. A, Arrangement of tendons to form the "T." B, Contraction of the longitudinal tendon converts the "T" to a "Y" and thus effects apposition of thumb and little finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Especially in paralysis are tendon transfers useful. Good, strong muscle and tendon are transferred to the tendons of the paralyzed muscles. This operation may be performed, without fusing the wrist, to give very good return of function so that splints are discarded. In the case of any two nerves paralyzed high in the arm, the wrist can first be arthrodesed in the position of function, an expedient which results in very little disability. Thereupon the five tendons previously wrist movers become available as digit movers, and the resulting motion is more natural than that obtained using a prosthesis. The patient soon learns to adapt so that the motion becomes natural. A rule is to decide what movements are needed and then to consider the number of muscles available for transfer. For paralysis within the hand—that is, from the median and ulnar nerves—many transfers are available to restore muscle balance, thus correcting the position of the claw hand by substituting for the paralyzed intrinsic muscles.</p> <p>Another principle is tenodesis, a procedure in which the tendons that move the digits are fastened to the forearm bones. Then, when the wrist is flexed, the extensor tendons tighten and extend the digits; when it is extended, the flexor tendons tighten and cause the digits to flex so that thumb and fingers appose each other. These automatic movements are useful when only one or two strong muscles are available. When no muscles are available, the hand can be converted to a useful hook by tenodesis of the flexor tendons to the forearm bones.</p> <h4>Nerves</h4> <p>Movement and sensation in the hand, which are its two most important functions and which are of equal value, depend entirely upon the nerves. The three large nerves that course down the arm (the ulnar nerve, the median nerve, and the radial nerve) control the hand, and any injury to them is as damaging to the hand as is an injury to the hand itself. When a nerve is severed, it should be rejoined at once. Otherwise fibrous degeneration in both the lower portion of the nerve and in the muscles supplied by it will be so progressive that, after two years, muscle action will not return and, after five years, neither will sensation. A gap of several inches can be overcome and the nerve sutured directly. Even the little nerves in the hand itself can be repaired.</p> <p>After nerve suture, there is about 80 percent of functional recovery. Nerves can be sutured directly, transferred, or even free grafted. All of these procedures are successful, but nerve grafts must be used from the same person; if grafted from another person, they will melt away. From loss of nerve supply, the hand if neglected goes into the position of nonfunction, stiffens, and atrophies. Splinting should be by spring or elastic splints sufficient just to substitute for the paralyzed muscles and to hold the hand in the position of function so it can work. When the nerves are irreparable, as for example when too great an interval has elapsed since the time of injury, muscle function in the hand can be provided by tendon transfers. Paralysis in the hand and forearm from ischemic contracture can be overcome to a considerable degree, although never completely cured. In vasomotor disorders, surgery seldom need be weighed against prostheses.</p> <h4>Prostheses for Partial Hands</h4> <p>The literature on prostheses for the partial hand is meager, and therefore when a hand is damaged there is a distinct preference on the part of prosthetists to have a wrist disarticulation or a long below elbow amputation. In the event they are confronted with a partial hand amputation, many limbfitters prefer to enclose the wrist immobile (as in <b>Fig. 32</b>) rather than to construct a partial hand prosthesis. Even those who furnish cosmetic glove prostheses (as in <b>Fig. 33</b>) prefer to enclose the whole hand in the glove and to substitute, for the missing parts, foam filler reinforced with pliable wire. Although a long below elbow amputation offers the advantage that many more or less standard terminal devices may be applied (a split hook, a mechanical hand, perhaps some special tools), a partial hand, whatever can be saved, can often be fitted with considerably more success. If the thumb alone is spared, a casing over the palm and wrist can support a pad or other suitable device against which the remaining digit can work (<b>Fig. 34</b>). If only the palm, perhaps with a few remnants of phalanges, remains, a casing over the forearm can support a similar pad against which the palm can be pressed by wrist flexion (<b>Fig. 35</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. One form of prosthesis for partial hand amputation thumb free, wrist encased, split hook activated by shoulder harness as in the case of the wrist disarticulation. The disadvantages are numerous. The long cuff virtually eliminates any possibility of wrist motion. Except in the thumb remnant, residual tactile sense is obviated, and the device as a whole is much too long </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Cosmetic hand for partial amputation glovelike and zippered at the wrist. Fingers are filled out by foam filler and stiffened by armature flexible enough to hold any shape. Courtesy Prosthetic Services of San Francisco. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Simple prosthesis for loss of all digits except the thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Simple prosthesis for major losses of most of the digits. Wrist serves as motor, hand working against prosthesis. Residual tactile sensation is utilized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By the combined talents of engineers, physicists, prosthetists, orthopedists, and others, there have been in the last ten years many advances in hand and arm prostheses. Accordingly, there has been developed the policy of saving as much of any limb as is likely to be functional and, particularly, as much of the hand as possible. Any portion of skin with sensation should be preserved because of the possibility of placing it in a functional part. Digits with sensation can do light work and, if necessary, a prosthesis can be applied to do heavy work (as in <b>Fig. 36</b>, <b>Fig. 37A</b>, and <b>Fig. 37B</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Partial hand capable of prehension. Top and middle, digital motion for light work. Bottom, wrist motor for heavy work. From Bunnell, Surgery of the Hand, 3rd ed,, Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 37A. Case E. E. Top to bottom: Right hand pulled into hay chopper. Debridement and abdominal pedicle. Later a two digit hand was made with a tendon T operation for prehension and a spread of 1 1/2 in. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 37B. Case E. E. Top and middle: A prosthesis which enabled the hand to work against a hook. This was discarded because it was too unstable. Right, bottom: A prosthesis made by Robin Aids Manufacturing Company, Vallejo, Calif., that was very satisfactory. It preserved residual wrist motion and could be removed when fine digital motions were required. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the wrist disarticulation, below elbow, above elbow, and shoulder disarticulation prostheses, many new devices have been developed. They include the alternator elbow lock for the above elbow case,<a></a> the outside locking elbow hinge for elbow disarticulation,<a></a> the polycentric elbow joint for below elbow cases,<a></a> the variable ratio step up hinge for the very short below elbow case,<a></a> the flexible cable units to allow pronation and supination for the very long below elbow and wrist disarticulation cases,<a></a> and the elbow coupled shoulder joint for shoulder disarticulation amputees.<a></a> For the arm amputee, these devices help to carry the terminal device (hook or artificial hand) to a place of usefulness. The <i>Manual of Upper</i> <i>Extremity Prosthetics </i><a></a> gives a full account of these and other devices that comprise a full armamentarium for upper extremity amputees. But the case of the partial hand amputation is not included.</p> <h4>Prostheses For One Digit Hands</h4> <p>For most practical purposes, loss of one or more distal phalanges does not require application of a prosthesis. Nevertheless, there are exceptions. An accomplished violinist, losing the distal phalanx of even one string finger, for example, is incapable of managing the strings properly. This could mean an occupational change for such a person. A good prosthetic replacement may enable him to continue his occupation. The same occasionally occurs with an organist, a pianist, a typist, or other person in any occupation where finger dexterity means the difference between success and failure. A suitable prosthesis for such a case can be made using thin stainless steel for the socket and extension framework and then dipping the device in flexible vinyl plastic to form the tip cushion and finger build up. The socket portion may be split along one side to allow it to expand and contract, thus ensuring snugness of fit.</p> <p>For amputation of all of the fingers at the metacarpophalangeal joint, or approximately half an inch distal thereto such that the volar crease of the metacarpophalangeal joint remains, a 1/8 in. rod framework of stainless steel can simulate the socket while leaving a maximum amount of exposed palm for traction and sensation (<b>Fig. 38</b>). The distal portion of the framework is bent to simulate the finger tips, the little finger side being curved to form a hook for pulling or lifting and the index side shaped to appose the thumb as would the first two fingers in three jaw chuck prehension.<a></a> This arrangement provides for prehension between the simulated index finger and the remaining thumb. A similar appliance can be made for an amputation proximal to the metacarpophalangeal joint, but in such a case the remainder of the hand must be fitted with a plastic, metal, or leather socket for attachment to the formed rod (<b>Fig. 39</b>). The notable disadvantage is the coverage of surfaces otherwise capable of sensation. In both instances, the rod framework is dipped in flexible vinyl plastic to provide a surface with adequate traction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Prosthesis for loss of all the fingers at, or slightly distal to, the metacarpophalangeal joint line. Metal ring, covered with vinyl plastic, is so shaped as to furnish one large hook, representing the index finger, and one small one, representing the little finger. Thumb works against ring throughout the range of the carpometacarpal articulation. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Prosthesis for transmetacarpal amputation. Socket may be of leather, molded plastic, or hammered stainless steel. Metal ring, covered with vinyl plastic, is shaped to simulate fingers, as in Figure 38. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 40</b> shows a single stainless rod curved in hook fashion and mounted to a stainless steel plate, which in turn is attached to a molded hand and wrist socket. The hook is so positioned as to give apposition to the thumb, and the thumb is exposed to utilize its capability for sensation. This single hook, being small and smooth, allows easy entry into pockets and other tight places.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 40. Simple prosthesis for loss of most of the palm but with retention of the thumb. Wrist and hand stump are encased in a socket to which is attached a single stainless steel hook. The hook may be used by itself or as a member for apposing the thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the thumb is the most important single digit of the hand, it would seem a sound principle not to involve it as a motor for powering other mechanisms. A collar around the thumb would appear to diminish tactile surface, and any mechanical linkage would seem to lessen mobility and dexterity. In general, wrist flexion extension provides a far more desirable motor with less hindrance to function. But these principles have only general applicability and are not specific. For certain special needs, a thumb powered mechanism may be desirable. In any individual case, the selection of equipment must be left to the mutual judgment of the patient, the doctor, and the prosthetist. (<b>Fig. 41</b> and <b>Fig. 42</b>) illustrate the principles involved but show the distinct differences to be found in individual cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 41. Prosthesis for amputation of all fingers at the metacarpophalangeal joint line with retention of the thumb. Socket about wrist and hand stump supports split hook, which is powered by the thumb. Courtesy Navy Piosthelics Research Laboratory, U.S. Naval Hospital, Oakland, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 42. Prosthesis for loss of all digits but the thumb. Hinged at and powered by the wrist, this device provides for prehension by virtue of a thrust rod. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the arrangement shown in (<b>Fig. 43</b>), the hand, wrist, and forearm socket give versatility for the accomplishment of either light tasks or heavy duty work. For light tasks, the thumb stump is free to appose the remainder of the hand or to contact a small metal post or spoon attached to the hook. The forearm socket allows freedom of wrist motion but provides hook stability for heavy duty work. Since the thumb stump is also free to appose the hook activating lever, no shoulder harness is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Amputation of the fingers at the metacarpophalangeal joint line and of the thumb at the inter phalangeal joint; thumb phalangized for deeper cleft. Top to bottom: holding with thumb unassisted; use of hook (powered in this case by shoulder harness) as device to appose palm; holding with thumb, hook available for auxiliary function if needed; holding with hook, thumb as stabilizer. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For a hand retaining only the thumb, without fingers or even without their metacarpals, a special prosthesis designed by the United States Navy gives reciprocal motion and active prehension powered by the thumb (<b>Fig. 44</b>). To a simple hand cuff and wrist strap is attached a metal plate, which, on the radial side, supports a lever for the thumb to appose and, on the ulnar side, bears a metal finger pivoted on an axis near the base. Apposition of thumb and metal finger is effected by a linkage between the two lever systems.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Prosthesis for transmetacarpal amputation with retention of the thumb. Power supplied by the thumb activates metal finger, which is otherwise held in extension by a spring at its base. Courtesy Navy Prosthetics Research Laboratory, U.S. Naval Hospital, Oakland, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetic Thumbs</h4> <p><b>Fig. 45</b> and <b>Fig. 46</b> illustrate fixed prostheses for partial or complete loss of the thumb. Two features are essential. First, the prosthetic thumb must furnish proper apposition to the fingers, and its lip should be of such material as to provide adequate traction. Second, the thumb must provide a shaft and a crotch so as to make it possible to hold objects too large for the fingers themselves to encircle. A two position thumb, such as the thumb from an APRL hand,<a></a> can be used on a prosthesis for disarticulation of the thumb at the carpometacarpal joint. The result is that a larger selection of objects can be held in the hand.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Prostheses for partial or complete loss of the thumb. Fingers work in apposition to fixed member. Above, prosthesis for amputation of thumb at metacarpophalangeal joint, thumb web deepened surgically to provide cylindrical stump proximal to site of amputation. Below, variation suitable for amputation of thumb at carpometacarpal joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. One form of fixed prosthesis for total loss of the thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 47</b> depicts the application of a mobile artificial thumb, powered by the wrist, to a partial hand possessing only the little finger. Attached to a hand cuff, which in turn is hinged to a forearm cuff, the thumb pivots about an axis near its base. Linkage between thumb and wrist hinge is such that wrist flexion causes the thumb to approach the little finger. In the example shown, the small finger has been rotated surgically toward the radial side of the arm to give better placement for apposition.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Prosthesis for loss of all digits except the little finger. Laminated plastic socket, hinged to leather or plastic forearm cuff, supports plastic covered metal thumb, which is so linked to forearm piece as to be driven by wrist motion. Little finger has been rotated surgically to provide better apposition with respect to prosthetic thumb. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prostheses For Loss of All Digits</h4> <p>In the case of a hand too crippled or too paralyzed to be of much use in the direct operation of a prosthesis, a split hook may be attached to a forearm cuff and positioned in the palm. This arrangement (<b>Fig. 48</b>) allows the palm to work against the hook for some types of prehension and still provides for the hook to be operated by shoulder harness in the usual way. The stainless steel hand plate shown in <b>Fig. 49</b> provides a simple, light, and cool means of mounting a split hook to a hand stump that is too short to grasp objects without a prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Prosthesis for virtual loss of all digits. Palm can work against hook, or hook can be operated in conventional way by virtue of cable attached to shoulder harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Method of attaching a split hook to a short hand stump. Mobility of the wrist is maitained </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Still another way of accommodating for loss of all digits is to enclose the base of the hand in a leather cuff linked to a forearm cuff, a split hook being attached to the hand cuff (<b>Fig. 50</b>). The cuff and forearm members are connected by a rod working levers in such a way that, when the wrist is flexed, the split hook opens; extension of the wrist closes the hook.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Prosthesis for loss of all digits. Wrist supplies power and excursion for operation of split hook. No shoulder harness needed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>New Devices for Paralyzed Arms</h4> <p>For the paralyzed arm, many new devices have come forth in the past five years. They all have the same essential purpose that of carrying the useful, or partially useful, hand to a place where it can operate to advantage. But in these cases there is an additional hurdle to be jumped. Whereas an arm prosthesis can be built to almost any desired weight, in the case of a paralyzed arm the weight of that arm must be overcome before motion can be reacquired. Equipment such as the shoulder suspension hoop, the locking lever arm brace, the alternator elbow lock arm brace, suspension slings, and single, double, or triple rocker feeders or arm balancers can do this job <i>.</i><a></a> </p> <p>Once a paralyzed arm can be positioned in a place of usefulness, hand function must be restored, either by surgical or by prosthetic means. Some of the terminal devices intended for arm amputees can be utilized for patients with paralyzed or badly disabled hands. A good example of the management of the paralyzed hand is to be found in the application of the "Handy Hook" <a></a>. It constitutes a simple but effective means of positioning a split hook in the palm of the hand and fastening it there to a metal or plastic palmar plate, which is held in place by straps around the dorsum of the hand (<b>Fig. 51</b>). In the event the wrist also is flail, a simple brace on the forearm constitutes a suitable modification (<b>Fig. 52</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. The "Handy Hook" as applied to a flail hand. Positioned in the palm by means of a plate passing over the dorsum, it is powered by shoulder harness. Hand sensation is preserved. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. The "Handy Hook" as applied to a flail hand when the wrist also is flail. Courtesy Robin Aids Manufacturing, Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For a hand that is lacking in one or more features of normal motor power but which retains valuable sensation, there is still another assistive device, the "Handy Hand"<a></a>. <b>Fig. 53</b> and <b>Fig. 54</b> show two variations out of numerous possibilities, each designed to accommodate specific motor losses (flexion or extension of fingers, flexion or extension of wrist, and so on). In <b>Fig. 53</b>, finger opening may be brought about voluntarily (or, if necessary, by rubber bands), closure being effected by shoulder harness. In <b>Fig. 54</b>, active wrist extension effects finger closure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. The "Handy Hand" as applied to a flail hand when the wrist also is flail Extension of the fingers may be effected voluntarily or, if necessary, by rubber bands. Flexion of the fingers is brought about by means of shoulder harness Courtesy Robin Aids Manfacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. The "Handy Hand" as applied when extensors of wrist and fingers are active, finger flexors inactive. Extension of the wrist , Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Conclusion</h4> <p>So vast and so laden with potentialities is the subject of surgical reconstruction of the hand, and so also is that of partial hand prostheses, that a single article such as this can constitute only a very brief introduction to either. But even a brief review of some of the recent advances, both in reconstructive surgery and in prostheses for partial hands, may offer valuable guidance in selecting the best procedure for any given case. In the absence of a well developed literature, the whole field of work with partial hands is long apt to remain highly empirical and largely dependent upon the experience, judgment, and skill of individual surgeon and prosthetist. Since, unlike the more conventional amputation stump, the partial hand is invariably a special problem, the approach to its solution, whether surgical or prosthetic or both, also invariably calls for special departures. The most that can be said is that from long practice and much trial and error it is possible to extract certain principles generally applicable to the more common types of hand losses.</p> <p>In any event, it is apparent that the surgeon who would undertake reconstructive hand surgery ought first to be intimately familiar with the best that can be done with prostheses for partial hands. Similarly, the specialist in partial hand prostheses needs to be acquainted with what can be accomplished through surgery. Both, separately and together, must consider each case individually not only from the standpoint of the patient's life and work but also with a view toward his ability to afford the financial outlay incident to surgery and recuperation. Fortunately, insurance has in recent years played a large part in eliminating the economic considerations otherwise involved.</p> <p>The strongest argument that can be advanced for reconstructive hand surgery is that it preserves the highly desirable facility of tactile sensation. Among the disadvantages are the fact that the result does not always present the best cosmetic effect and the additional one that the reconstructed hand may not be able to perform heavy work as well as could a full prosthesis. The particular requirements of the individual therefore exercise a strong influence upon the choice between the partial hand and the wrist disarticulation. As has been seen, the most practical result is often best obtained through some combination of surgery and prosthetics, the two complementing each other in such a way as to provide a wide range of functional regain.</p> <p>Of course there will always be hands with too much wrong with them to justify attempts at reconstruction. Where such appears to be the case, amputation at the lowest possible level, followed by application of a good, functional prosthesis, obviously offers the best solution. But in the face of a rapidly growing technique in hand surgery including special manipulations with muscles, tendons, nerves, and vessels it would appear wise always to choose the most conservative course possible. That would mean reconstruction whenever the anticipated result is likely to serve satisfactorily the needs of the individual concerned. The possibilities outlined here are representative of what might reasonably be expected under a given set of circumstances.</p> <h4>Acknowledgment</h4> <p>For much valuable information on partial hand prostheses that have proved successful, the author is indebted to George B. Robinson, of the Robin Aids Manufacturing Company, Vallejo, Calif. The drawings accompanying this article are the work of George Rybczynski, free lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, September 1954</li> <li>Bunnell, Sterling, Surgery of the hand, 3rd ed., Lippincott, Philadelphia, 1956.</li> <li>Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</li> <li>Fletcher, Maurice J , and Fred Leonard, The principles of artificial hand design, Artificial Limbs, May 1955.</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</li> <li>Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Co., Inc., Hagerstown, Md., 1944.</li> <li>Navy Prosthetic Research Laboratory, U.S. Naval Hospital, Oakland, Calif., Cineplaslic above elbow prosthesis (congenital bilateral arm amputation), Interim Progress Report [on] Research Project NM 007 084.26, 1 November 1954.</li> <li>Pursley, Robert J., Harness patterns for upperextremity prostheses, Artificial Limbs, September 1955.</li> <li>Robin Aids Manufacturing Co, Vallejo, Calif.,Functional arm bracing and artificial arms, 1956.</li> <li>Schottstaedt, Edwin R., and George B. Robinson, Functional bracing of the arm, J. Bone and; Joint Surg., 38A(3):477;38A(4):841 (1956).</li> <li>University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</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>9.</b> </td><td class="clsTextSmall">Robin Aids Manufacturing Co, Vallejo, Calif.,Functional arm bracing and artificial arms, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Robin Aids Manufacturing Co, Vallejo, Calif.,Functional arm bracing and artificial arms, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schottstaedt, Edwin R., and George B. Robinson, Functional bracing of the arm, J. Bone and; Joint Surg., 38A(3):477;38A(4):841 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J , and Fred Leonard, The principles of artificial hand design, Artificial Limbs, May 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>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J , and Fred Leonard, The principles of artificial hand design, Artificial Limbs, May 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>11.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Navy Prosthetic Research Laboratory, U.S. Naval Hospital, Oakland, Calif., Cineplaslic above elbow prosthesis (congenital bilateral arm amputation), Interim Progress Report [on] Research Project NM 007 084.26, 1 November 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upperextremity prostheses, Artificial Limbs, September 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>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, September 1954</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, September 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">Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, September 1954</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, 3rd ed., Lippincott, Philadelphia, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Co., Inc., Hagerstown, Md., 1944.</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>Sterling Bunnell, M.D. </b></td></tr><tr><td class="clsTextSmall">516 Sutter Street, San Francisco 2, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-90.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-91.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-91b.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-92.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-93.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-94.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-95.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-96.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-98aa.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-98b.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-100.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-101.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-102.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-103.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-104.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-105.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-106.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-107.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-107b.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Management of the Nonfunctional Hand Reconstruction vs. Prosthesis Creator An entity primarily responsible for making the resource Sterling Bunnell, M.D. * 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/2dea17a3a5a3c752d1ee37559bbaa825.pdf 7a4435086ff3850c01c2ef893fa48eac https://staging.drfop.org/files/original/43d8a129940cb8511733726caf27bf79.jpg 5b81f8134177bd4ec394e1f9f2c7aa76 https://staging.drfop.org/files/original/39e08fec5517e38ce66dbeac92235181.jpg 69fe78cabce5d19c388bd5c6790f61fa https://staging.drfop.org/files/original/3a2aea30bf763bcff465c69a91b543c6.jpg 50d23a5eff289ab00376b2787b04b7a4 https://staging.drfop.org/files/original/a8157ca13387fd20c5b413875668ef69.jpg 0ae08cbaf0551506dc3f01cef5e2c987 https://staging.drfop.org/files/original/0b36336724f1ed95ee0fdecea4e24704.jpg 72776be8ad19dce1b202d29195559889 https://staging.drfop.org/files/original/9f72cc18e382ab675a87069c72e62cd2.jpg b62295fcb70277ba0a60bef4591a702f https://staging.drfop.org/files/original/58911f3f64dd71a25a20575b8272b859.jpg b996ee7ff9c38a927feb2bb4ca0678f1 https://staging.drfop.org/files/original/900709fd561acd10c0f47effcf1360ef.jpg b85e77771aac862aba66ec7c33585be5 https://staging.drfop.org/files/original/073bad9839c0df598f8e71002a2f42be.gif 4535091be1c2df849d6a024ab57da422 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_047.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 47 - 56 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_047.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Noticeability of the Cosmetic Glove</h2> <h5>Tamara Dembo, Ph.D. <a style="text-decoration:none;">*</a><br />Esther Tane Baskin, M.A. <a style="text-decoration:none;">*</a><br /></h5> <p>Ahand prosthesis can be useful in more than one way. It can be helpful in dealing with objects, and it can be helpful in interpersonal relations. The latter aspect is the one with which we are here concerned. The usefulness of a prosthesis in human relations is termed "social usefulness." To a wearer who considers his hand amputation a private matter, for example, and to one who does not wish to be recognized as an amputee, a prosthesis is socially useful if it cannot be recognized as an artificial device. Moreover, the amputee may be concerned that another person looking at the prosthesis should feel comfortable. In such a case, that prosthesis is most useful which does not repulse or embarrass another person but is "good to look at."<a style="text-decoration:none;">*</a></p> <p>In 1949 a cosmetic glove, produced at the Army Prosthetics Research Laboratory, was sent for testing to the Research Division of the College of Engineering, New York University. Investigation of the cosmetic glove led to formulation of the problem of the social usefulness of prosthetic devices in general. The methods developed during the study of the glove are, furthermore, generally applicable to the investigation of the social usefulness of other prostheses. This article deals only with the problem of the noticeability of the cosmetic glove. The question of its appearance, <i>i.e., </i>the desirable and undesirable characteristics of the sight of the cosmetic hand, is not discussed.</p> <h3>Experiments and Results</h3> <p>On cursory examination, the experimental prosthesis looked like a normal hand, but on closer scrutiny it could easily be recognized as a cosmetic device. Further, it did not match the normal hand of the particular wearer, although it was, at that time, the best match among several available cosmetic gloves (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, and <b>Fig. 4</b>). Moreover, the glove simply was filled with vinyl foam, and the hand was thus nonfunctional except insofar as the amputee might wedge light objects between the springy fingers.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Winthrop Sullivan wearing the cosmetic glove on his left (to the reader's right). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Mr. Sullivan's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Brennan C. Wood wearing the cosmetic glove on his right (to the reader's left). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Mr. Wood's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The problem was to determine whether such a glove is realistic enough not to be noticed as a prosthesis, or, rather, how frequently the wearer of such a glove goes unrecognized as an amputee. Four different experiments were conducted.</p> <h4>Experiment I</h4> <p>In the first experiment, 30 separate tests were performed. Each required a wearer,<a style="text-decoration:none;">*</a> an experimenter, an observer, and a stranger. The stranger was the "subject" because his reaction, <i>i.e., </i>whether he did or did not recognize the cosmetic hand as a prosthesis, was of prime importance. The wearer went, as a cus tomer, to various stores and shops in New York City and engaged salemen (subjects) in conversation. In each instance, he put his arms on the counter and, to make sure that the cosmetic glove was in sight of the salesman, gestured, pointed, scratched his hand or face, indicated size or shape of objects, held a newspaper, smoked, soiled the cosmetic hand and wiped it off, or supported objects <i>(e.g., </i>held a wallet against his body with the artificial hand), all the while acting in a leisurely manner in order to prolong the contact, usually for from five to twenty minutes. Experimenter and observer entered the store with the wearer but as a separate party. While the wearer talked to the subject, experimenter and observer stood aside as if engaged in conversation, the observer pretending to listen to the experimenter but actually taking notes on the behavior of the wearer and the salesman. The latter, of course, did not know that he was the "subject" of a psychological experiment.</p> <p>When the wearer left the store, the experimenter approached the salesman and asked some questions about the man who had just left. The observer continued to stand aside and recorded the discussion (interview) between the experimenter and the subject. An example of an interview follows:</p> <blockquote><p><i>Experimenter: </i>Did you notice anythingabout the man who was just in here? <br /> <i>Salesman: </i>In what respect? <i>Experimenter: </i>Well, did you notice anything unusualabout him? <br /> <i>Salesman: </i>About his hand. <br /> <i>Experimenter: </i>What was there about it you noticed?<br /> <i>Salesman: </i>There was no action in it. <br /> <i>Experimenter: </i>When did you notice it? <br /> <i>Salesman: </i>When he had his hand at his side. When helighted a cigarette. He held his hand like this[shows stiff position].<br /> <i>Experimenter: </i>Do you think it could have been an artificial hand? <br /> <i>Salesman: </i>No, it was not an artificial hand. It was his hand. He held it close to his side. Maybe he had no action in the shoulder. He did not use that hand. Used one hand at mirror. Held it. Just turned it.</p> </blockquote> <p>After being informed that the hand was a prosthesis, the salesman said he had not recognized it as such.</p> <h4>Experiment II</h4> <p>In the second experiment, three or four people (college students and their friends) were asked to take part as subjects of a psychological group experiment on "impressions of personality." On their arrival, the subjects found the wearer, who was introduced as one of the group members. Everyone was asked to sit around a table and to wait for another group member supposedly delayed and, in the meantime, to get acquainted with each other. The wearer, holding his hands in plain view on the table, conversed with the group members. After about 10 minutes he left the room, ostensibly to make a phone call. Then each member of the group was asked to accompany an experimenter to another room, where the participant was asked to give his impression about the person who went to make the phone call. If, during the interview, it became clear to the experimenter that the subject had not noticed the hand, the subject was given another opportunity to observe the wearer, and then a second interview took place. Sometimes the procedure was repeated a third time. In all, 29 subjects were used.</p> <p>An example of an interview performed in Experiment II follows:</p> <blockquote><p><i>Experimenter: </i>As you know, we are studying quick impressions of personality. Mr. X is part of the experiment. Could you give your first impressions of him? What struck you about him, mainly?<br /> <i>Subject: </i>He seemed intelligent, friendly, sociable. It seemed as though he could talk on other than his major field of interest.<br /> <i>Experimenter: </i>How would you describe him physically?<br /> <i>Subject: </i>Physical impressions are a pretty personal matter, I think. Would say he was more positive than negative, from the point of view of attractiveness. Genial.<br /> <i>Experimenter: </i>Could you give the outstanding characteristics of his face?<br /> <i>Subject: </i>He had a fairly easy smile, seemingly accompanying a sense of humor and a desire to please.<br /> <i>Experimenter: </i>Could you describe his hands?<br /> <i>Subject: </i>Yes, I noticed his hands. I usually do notice hands.<br /> <i>Experimenter: </i>Could I interrupt to ask why you always notice hands?<br /> <i>Subject: </i>I just always have. It dates from the fact that when I was young I thought I couldn't be beautiful, but I could have nice hands and fingernails, so I always notice other people's. I guess I can visualize the hands of every friend I have ever had. I think his were in between, no particular character.<br /> <i>Experimenter: </i>Anything else?<br /> <i>Subject: </i>He had nice hair, a little wavy. A kind of flushed face, more healthy than not.<br /> <i>Experimenter: </i>Were there any gestures on Mr. X's part that you remember?<br /> <i>Subject: </i>No. He had his hands out on the table most of the time, but I don't remember his gestures particularly.</p> </blockquote> <p>The subject who stated that she usually notices hands did not notice the cosmetic hand or any signs of difference about the hand. The experimenter and the subject returned to the group. After about ten minutes more the wearer left, and the second interview took place:</p> <blockquote><p> <i>Experimenter: </i>Now can you give some further impressions of Mr. X?<br /> <i>Subject: </i>I noticed his eyes more this time, a little different than most people's but difficult to describe, noticeable. I noticed his nose tips up a little, like Sonja Henie's. I noticed his hands more because you called them to my attention, but I don't think these physical impressions mean too much.<br /> <i>Experimenter: </i>Was there anything outstanding about his hands?<br /> <i>Subject: </i>His nails were not particularly graceful, they were a little short, but clean looking. I confirmed the fact that his hair was curly and his face ruddy. He seemed very well balanced, not neurotic, in that he seemed willing to go along on other people's fun. He certainly didn't show any compulsion to take the spotlight or to resent it when somebody else took it.<br /> <i>Experimenter: </i>We'll all go back together again, and then<br /> there will be a third interview. I want you to notice his hands again particularly, and in detail. Notice the movement or lack of it. The subject was interviewed again after she saw the wearer for the third time:<br /> <i>Subject: </i>I did notice his hands, the shape, and the rather short fingernails. They looked clean and healthy, but I like tapering fingernails.</p> </blockquote> <p>Even during the third period of contact with the wearer, the subject did not notice any difference between the wearer's two hands, although she was able to describe them. The results of Experiments I and II are given in (<b>Table 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of 30 subjects in Experiment I, 24 (80%) did not recognize the cosmetic hand as a prosthesis. In fact, they did not even notice any difference between the two hands of the wearer.<a style="text-decoration:none;">*</a> The remaining 6 subjects (20%) commented that the arm or hand was in some way injured, but they too did not notice that the hand was artificial.<a style="text-decoration:none;">*</a> Thus, in an everyday situation of a salesman dealing with a customer, <i>not one </i>salesman in Experiment I noticed the cosmetic glove <i>as a prosthesis.</i></p> <p>The question arises as to why the prosthesis was not noticed by the salesmen. One could ask whether the unnoticeability may not be accounted for by the "fact" that the busy New York salesman does not have enough time to pay attention to the appearance of his customers. This, however, was not borne out by the data. When asked to describe the customer (the wearer), the salesman was well able to describe how the wearer looked, what he did, and what he said. Yet the saleman had not noticed the cosmetic glove.</p> <p>In Experiment II, 29 subjects took part.<a style="text-decoration:none;">*</a>Within the framework of "description of personality," 23 (80%) did not notice any difference between the two hands, 3 (10%) noticed that one hand looked different from the other but did not recognize it to be an artificial hand, and 3 (10%) noticed that it was a prosthesis.</p> <p>That the cosmetic hand was not recognized by any of the salesmen as a prosthesis and rarely as such by the students and their friends, one may argue, is due to the "fact" that people do not pay attention to the properties of another person's hands. To test this "hypothesis," Experiment III was carried out.</p> <h4>Experiment III</h4> <p>In Experiment III, with a setup essentially the same as in Experiment II, the wearer used a hook instead of the cosmetic hand. Here, 11 out of 12 people (92%) noticed that the amputee was wearing a prosthesis. It appears, then, that the cosmetic hand goes unnoticed not because people are negligent in their observations but rather because it does not deviate sufficiently from the appearance of the natural hand. The hook, however, which deviates radically in appearance the normal is noticed readily (<b>Table 2</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Experiment IV</h4> <p>In the first three experiments, untrained observers were used. The question arose as to whether different results would be obtained in experiments with people especially trained to notice bodily characteristics. One could expect that art students, for example, would be especially apt to notice the cosmetic hand. Accordingly, in Experiment IV, six art students participated as subjects, all members of a drawing class for which the wearer served as a model. Six to eight feet separated the wearer from the students. They were told that, after having made the drawing, they would be asked how the model impressed them as a person.</p> <p>During the first part of the experiment, the wearer posed with his cosmetic left hand supporting his chin (<b>Fig. 5</b>). Ten minutes were allotted for the drawing. Then the wearer left, and the art students were questioned individually, the interviews being conducted in terms of what impression the art student had of the model's personality. Results showed that not one of the six art students was aware that he had been drawing an artificial hand, although some reference was made to the difference between the two hands, or it was felt that the hand somehow did not fit the person.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mr. Sullivan as sketched by an art student. The hand held to the face is the cosmetic one. While drawing this picture, the art student did not notice a difference between the two hands (Experiment IV, Part 1). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The second part of the experiment offered even greater opportunity for direct comparison of the two hands. Here, the subjects were told that the model (wearer) would return for a second pose and that later the subjects would be asked "how his <i>hands </i>expressed personality." During the second drawing period, the wearer sat with his two hands covering his face (<b>Fig. 6</b>). But even under these conditions, only two of the six subjects noticed that one of the hands was artificial. The remaining four did not realize that they were drawing a cosmetic hand.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Second drawing of Mr. Sullivan by the same art student who drew the picture shown in Figure 5. The notation listing the differences between the two hands is that made by the student at the time of the drawing (Experiment IV, Part 2). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To illustrate how, in spite of differences noticed between the two hands in Experiment IV, it did not occur to the subjects that one hand was artificial, excerpts from two interviews conducted after the second drawing (<b>Fig. 7</b>) follow:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Drawing made by an art student during Experiment IV, Part 2. The left hand (on the reader's right) is the cosmetic one. The student saw the hands as different owing to the occupation he ascribed to the wearer. He thought the wearer was a violinist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p><i>Experimenter: </i>What gives now?<br /> <i>Subject: </i>Interesting things, real interesting. Makes a difference when you know you're supposed to look at hands. About his hands, there is a basic difference in his two hands. The right hand is more used, I would say [left hand is the cosmetic one]. There are several interesting things about them. First of all, the fingernails were fairly short. Gives me an idea that he may play a stringed instrument. The button of his cuff was open, couldn't tell if broken off. I thought of a violinist who would open his cuff so he could handle it. I think he is right handed because that would be the bow hand, and all the movement would have opened the cuff. I don't think this particularly jibes with the feeling that the hand that would do the fingering would be the most wrinkled, worn hand. For this was not the case. Yet had the feeling that he does do something special that involves t h specialized use of one of his hands.<br /> <i>Experimenter: </i>Why do you think this?<br /> <i>Subject: </i>Well, there is a basic difference in structure. 1 couldn't see the right hand before when he was posing [subject refers to <b>Fig. 5</b>], I drew the right hand first. It was thinner. I felt there was more structure visible, it was more wrinkled, I could think of some special occupation. Another interesting thing, the watch was worn inside the wrist on the right hand, which made me think it indicates a little about the personality.</p> </blockquote> <p>Another interview in Experiment IV went as follows:</p> <blockquote><p><i>Experimenter: </i>And what did the hands express?<br /> <i>Subject: </i>Well, it looked to me as if [the hands express] the character of a person in very serious thought.Some trouble, wrestling with some problem, rather unhappy.<br /> <i>Experimenter: </i>Was this because of the hands, or the pose, or both? <i>Subject: </i>Both together. The hands were very tense and tight, not relaxed. Indicated that there was a conflict. <br /> <i>Experimenter: </i>This was the physical appearance?<br /> <i>Subject: </i>Yes, the tense position of the hand and fingers, the fingers close together and tight, not relaxed and easy. They show what's inside the person. He unconsciously clenched his fist and you noticed something.</p> </blockquote> <h3>Discussion</h3> <p>In the first experiment in which the cosmetic glove was worn, not once was the cosmetic hand recognized as a prosthesis. In Experiment II, the glove was seen as a prosthesis by only three (10%) of the subjects. In both experiments, a difference between the two hands was noticed only rarely. In Experiment III, the hook was recognized as a prosthesis in all cases save one. If one wishes to "explain" the unnoticeability of the cosmetic hand during relatively short contacts, one may say that the appearance of the cosmetic hand is similar enough to that of the normal to remain unnoticed. We know, however, that the differences between the glove and the normal hand are pronounced enough to be seen by almost anyone. What, then, are the conditions under which the <i>similarity, </i>rather than the <i>dissimilarity, </i>is decisive? To understand what is involved requires a brief discussion of a few general problems of visual perception.</p> <p>It is a well known fact that objects on which we focus are seen much more clearly than are those seen within the area of our peripheral vision. Distinguished from these two areas in the visual field should be two others, namely, "area of concern" and "area of mere presence." An object is in the "area of concern" if we inspect it, that is, if we concern ourselves with it. If, however, we perceive an object "as just being there," if it is not being examined by us and we do not concern ourselves with it, it is in the "area of mere presence."</p> <p>The area of presence and the area of concern of a visual field do not necessarily coincide with the central (focal) and peripheral parts of the field of vision. Each of the areas, that of concern or that of mere presence, can be either central or peripheral. We can, for example, stare at an object, focus on it, and yet not be concerned with it but with something going on elsewhere in our field of vision. Such is the case, for example, when one is looking at an object but wishes to watch another person unobtrusively. Here, the object focused upon is central and at the same time is in the area of mere presence. The person being watched is in the peripheral field of vision but at the same time is in the area of concern. Centrality and peripherality thus are distinguished by whether we do or do not look at an object directly, areas of presence or concern by whether or not we attend to (examine) the object.<a style="text-decoration:none;">*</a></p> <p>Often there is a tendency on the part of an observer to make the area of concern coincide with the center of his field of vision, while objects that do not concern him are shifted to the periphery. The separation of the field of vision into central and peripheral areas is, however, essentially different from the separation into areas of concern and of mere presence. With regard to the noticeability of the cosmetic hand, the most important fact is that objects in the area of concern differ in appearance from those in the area of presence. Some differences in details perceived when two objects are in the area of concern are not perceived when two objects are in the area of mere presence. Thus, two objects in the area of concern may look different, whereas the same two objects may look alike when in the area of mere presence.</p> <p>In meeting people, we usually do not concern ourselves with their hands, <i>i.e., </i>hands are in the area of mere presence. Because the observer perceives fewer details in this area, hands which on examination look different can appear alike to the stranger and thus may not provoke attention during casual contacts. This would account for the infrequency with which the cosmetic hand was recognized in Experiments I and II. Since looking directly at or focusing on an object does not necessarily mean that the object is examined, glancing and looking at the hands directly, as did some of our subjects, failed to result in observation of significant differences.</p> <p>When something unusual happens, the hands shift from the area of mere presence to that of concern or, to put it in another way, the observer changes the position of the hand from the area of mere presence to that of concern. If, for instance, the subject expects the wearer to use a given hand, and if this hand is not used as expected, or if the action is interrupted (Experiment I), the observer becomes concerned with the hand, examines it, and becomes aware of its deviation from an ordinary hand. Again, if examination of the hands is suggested to a subject, the area in which they are seen becomes one of concern. Moreover, if the subject is told that the hand is artificial, an incentive is provided to examine it. In this case, too, the hand is perceived in the area of concern.</p> <p>The physical properties of the cosmetic hand are such that, on examination, they are seen not to match those of an ordinary hand. Yet the handlike prosthesis is sufficiently similar to a normal hand that, in the area of mere presence, it may be seen as an ordinary hand. A hook, however, differs to such an extent in physical properties that, even in the area of mere presence, it can hardly be mistaken for a hand. This accounts for the results of Experiment III, in which the hook was noticed by all but one subject.</p> <p>In comparatively few instances (Experiments I and II), the cosmetic hand was seen as "different" from the other hand but was not recognized as artificial. The existence of cases in which differences are recognized, but in which the hand is not recognized as a prosthesis, may be due to the fact that, as a rule, people are not aware that a realistic hand prosthesis exists. Were that fact commonly known, the 20 percent who noticed the hand as "injured" in the first experiment, and the 10 percent who noticed it as "different" in the second experiment, might have seen it as a prosthesis. But knowledge of the existence of such a prosthesis would not affect the proportion of those who saw <i>no </i>difference (80 percent in both the first and second experiments). Since they did not notice any difference, these subjects would not even begin to concern themselves with the hand. As long as the hands match in the area of presence, knowledge that artificial hands exist would not in itself lead to an examination of hands.</p> <h3>Future Work</h3> <p>Briefly stated, the results show that strangers in everyday contacts with the wearer rarely notice a difference between the two hands. Yet noticeability is only one aspect of the larger problem of social usefulness of the cosmetic hand. Recognition of the cosmetic hand as a prosthesis is bound to occur in repeated contacts with the wearer. Furthermore, friends and relatives know that a wearer is an amputee. When the hand is recognized as artificial, a new problem arises. The appearance of the hand in the area of concern becomes important. Preliminary investigations indicate that, when the cosmetic glove is recognized as such, its appearance evokes in some people very unpleasant feelings. The study of the appearance of the cosmetic glove thus is necessary in order to determine the emotional impact relative to that of other prostheses and to ascertain which properties of the hand provoke negative feelings.</p> <p>Some people perceive a cosmetic hand as having a yellowish greenish shade. This circumstance might evoke toward the prosthesis feelings as toward a dead hand. Such feelings might be alleviated if the color of the cosmetic hand approached more closely that of an ordinary hand (page 57). It might even be shown that, to appear as real as possible, the cosmetic hand should have a definitely less yellowish tinge than does an ordinary hand. For such determinations, the subjects chosen should have strong negative feelings toward the hand available now, and observations should be made when the hand is worn.</p> <p>In conclusion, it should be stressed again that the problem of noticeability is only one aspect of the larger problem of the social usefulness of prostheses. Further studies are required to uncover those psychological properties of the observer which have to be taken into account in order to develop not only "functionally" but also "socially" (or rather "socio psychologically") useful prostheses.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-34.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-35.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-36.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-37.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_047/table01.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_047/table02.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-40.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-41.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-42.gif Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Noticeability of the Cosmetic Glove Creator An entity primarily responsible for making the resource Tamara Dembo, Ph.D. * Esther Tane Baskin, M.A. * https://staging.drfop.org/files/original/181a62dbeea14fc8cb1883736bd6f417.pdf 090f8bf2b70b72c4c5b835bebc2ed0d7 https://staging.drfop.org/files/original/63ac87e98d222a1677b6e3631411fbe9.jpg 99dbf6e84f6a51a868181896f9e1847e https://staging.drfop.org/files/original/f51d49a6caadcd9ae0527929c1b793b2.jpg a5661d7829f929030e7b25e4be6e54ab https://staging.drfop.org/files/original/a9262bba31c61cb78e9c241a50d1da89.jpg 1bb3115c8ee83f1deee20edaf6dd73aa DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_02_004.pdf 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/1956_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Adjustment to Misfortune-A Problem of Social-Psychological Rehabilitation</h2> <h5>Tamara Dembo, Ph.D., <a style="text-decoration:none;">*</a><br />Gloria Ladieu Leviton, Ph.D., <a style="text-decoration:none;">*</a><br />Beatrice A. Wright, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <blockquote><p><b>Dedicated to the memory of Kurt Lewin</b></p> </blockquote> <p>At particular times in the history of science, particular problems become ripe for investigation. A precipitating event brings them to the attention of a single person and sometimes to that of several at the same time. It is therefore understandable that during World War II the need was felt to investigate the problems of social psychological rehabilitation of the physically handicapped and that someone should look for a place and the means to set up a research project that would try to solve some of these problems. In pursuit of such a goal a research group was established at Stanford University on February 1, 1945. Conducted partially under a contract between Stanford University and the wartime Office of Scientific Research and Development (recommended by the Committee on Medical Research), partially under a contract between the University and the Army Medical Research and Development Board of the Office of the Surgeon General, War Department, the work continued until April 1, 1948. </p> <p> To investigate the personal and social problems of the physically handicapped, two groups of subjects were needed—people who were considered handicapped and people around them. Therefore, as subjects of the research both visibly injured and noninjured people were used. Interviews were employed as the primary method of investigation, the great majority of the 177 injured persons interviewed being servicemen or veterans of World War II. More than half the subjects had suffered amputations and almost one fourth facial disfigurements. The injured man was asked questions designed to elicit his expectations, experiences, and feelings in his dealings with people around him. Sixty five noninjured people also were interviewed in regard to their feelings toward the injured man. </p> <p> A first task in the research project was to determine the meaning of the relationship between the injured and the noninjured. Was it primarily that of the helper and the helped, of the curious onlooker and the one who is looked upon, of the independent and dependent person, the one who rejects and the one who is rejected, the person who pities and the one who is pitied? All these relationships exist between the injured and the noninjured. Some of them were described during the first period of the research program.<a></a> As the research proceeded, it was seen that one particular relationship between the injured and the noninjured was more "basic" than others—basic in the sense that it underlies and determines the character of other relationships. This underlying relationship is the one which exists when a person who regards himself as fortunate regards another as unfortunate. We learned that to understand this relationship one has to see "being unfortunate" as a value loss and, furthermore, that the adjustment of this relationship involves the problem of acceptance of loss—a case of value change. </p> <p> In current psychology, the problem of acceptance of loss is hardly investigated. Loss is usually seen as an end point of unsuccessful, goal directed behavior (failure) or else it is investigated in terms of the effect of failure on further goal directed behavior (such as on setting the next "level of aspiration"). But it is important to know what loss means to the person himself, how it affects the opinions and behavior of others toward him, and what acceptance of loss implies. Too often life is seen as a series of goal directed acts, whereas the <i>consumption of gains </i>and the <i>acceptance </i>(or nonacceptance) of losses which result from those acts are disregarded. </p> <p> Almost all people are at some time faced with the necessity of adjusting to loss. In investigating the problems of injured people, therefore, we are dealing not only with special problems of a special group but with problems important to all. If we state that the injured need psychological rehabilitation or adjustment, this in no way implies that they are not "normal." The impact of loss which they experience produces suffering and difficulties. The overcoming of psychological suffering, whether or not it threatens mental illness, is a problem of adjustment. </p> <p> This monograph is written as a scientific paper and no attempts at popularization are made. Popularization of our findings is a special task—a task which, if skillfully done, would indeed be useful for the information and education of the general public. Those who are not specially concerned with methodological and theoretical considerations may still find the less technical chapters (Chapters V through VII) of interest. The first four chapters and the last one will be of greater interest to the theoretical psychologist. </p> <p> Part I introduces the general field of social emotional relationships. It deals with our approach and viewpoints regarding problems, data, theory, and measurement. We tried to examine the appropriateness of scientific beliefs and attitudes for the new area investigated. Part II deals with the investigation of the visibly injured, a group which, in our culture, is frequently considered unfortunate. Chapter IV presents the procedures used and their rationale. Chapter V discusses devaluation, by the noninjured, of the injured as people who have experienced a misfortune a value loss. Chapter VI is concerned with the reactions of the noninjured to the suffering aspect of misfortune rather than to its value loss aspect. The structure or nature of the genuine, positive feelings of sympathy is outlined. Chapter VII deals with the problem of overcoming suffering through acceptance of loss. In Chapter VIII we attempt to point out the direction which future research may take. The appendices include sample interviews with injured and noninjured subjects and a brief summary of methods other than interviews that were tried out in our study.<a style="text-decoration:none;">*</a> </p> <p> Three years in a new and relatively unexplored field has to be considered a pilot period. After exploration the field is seen to be fruitful, both for the growth of ideas on the specific topics and also for the development of more general theoretical problems in psychology. But only a beginning has been made, and the material here presented is therefore properly viewed only in the light of its pioneer character. </p> <p> Many of our findings may from the theoretical standpoint be seen as more precise statements of problems awaiting further investigation. From the practical standpoint, the study may be useful to those who critically examine the findings, not with the orientation of translating them into rules of behavior but so that their understanding of the problems involved in loss may be broadened. The injured, we hope, will find this type of investigation promising in its attempts to lead people to feel that it is not the AMPUTATED LIMB and John Doe but John Doe, the person, who really exists. </p> <h3>Part I: Methodological and Theoretical Considerations Concerning Social Emotional Relationships </h3> <h4> Chapter I: Some Characteristics of Social Emotional Relationships </h4> <p> We shall present a list of pairs of words designating social emotional relationships. We ask you, the reader, to think about the feelings connoted. Specific points to consider may be seen in the first example, the idea of "abandonment." How does the abandoner feel? How does the abandoned feel? How do they feel toward each other? How do you, as a person not involved in the interaction, evaluate abandonment? As you proceed down the list, you should ask yourself these and any other questions you think of which bring out the emotional meanings of the interaction concerned. We ask you to work hard because in so doing we think that you will see the problems of the psychology of emotions in a very different way from the orientation given them traditionally. You will see this field not only as unexplored but also as full of psychological resources available to those who are ready to dig. Here is the list: </p> <ul> <li>To abandon — to be abandoned. </li> <li>To abhor — to be abhorred. </li> <li>To feel that someone is able — to feel that another considers you able.</li> <li>To consider someone abnormal — to be considered abnormal. </li> <li>To be abrupt — to be exposed to abruptness</li> <li>To consider someone absurd — to be considered absurd. </li> <li>To abuse — to be abused</li> <li>To accept another person — to be accepted. </li> <li>To feel in accord with someone — to feel that another person is in accord with you.</li> <li>To accuse — to be accused. </li> <li>To become accustomed to someone — to have someone become accustomed to you.</li> <li>To consider someone as an acquaintance — to be considered an acquaintance. </li> <li>To acquit someone — to be acquitted. </li> <li>To act in a given way, without actually feeling that way — to feel that someone is just acting. </li> <li>To adapt yourself to someone — to feel that another person is adapting himself to you. </li> <li>To help someone become adjusted — to have someone try to adjust you. </li> <li> To admire — to be admired. </li> <li> To admit to someone — to get an admission. </li> <li> To adopt — to be adopted. </li> <li> To adore — to be adored. </li> <li> To advise — to be advised. </li> <li> To feel affable — to feel that another person is affable. </li> <li> To give affection — to get affection. </li> <li> To affront — to be affronted. </li> <li> To be against someone — to feel that another person is against you. </li> <li> To aggravate someone — to be aggravated by someone. </li> <li> To be aggressive toward someone — to feel that another person is aggressive toward you. </li> <li> To agree with someone — to feel that another person agrees with you. </li> <li> To aid someone — to be aided. </li> <li> To alarm someone — to be alarmed by someone. </li> <li> To give an alibi — to get an alibi. </li> <li> To consider someone an alien — to be considered an alien. </li> <li> To allow someone — to do something to be allowed. </li> </ul> <p> Only a few of the diverse emotions or feelings are mentioned above. They were selected from the first 20 pages of <i>The Pocket Oxford Dictionary </i>(New York, 1927), which has 1010 pages. The list might have impressed you with the tremendous number of unexplored problems in the area of emotions. You might have wanted to take stock of the actual concern shown them in textbooks and courses and in current research in the field of emotions. The psychological structure and the functions of the majority of emotional relationships are unknown. Yet these problems practically do not exist as topics of systematic investigation. At the 1947 meeting of the American Psychological Association, only four of some 200 papers fell under the program headed <i>Emotions. </i>The program on <i>Emotions </i>was sponsored by the Division of Physiological and Comparative Psychology. </p> <p> We do not wish to imply that emotional problems are completely disregarded by psychologists. The psychology of personality, social psychology, and abnormal psychology <i>do </i>take them into account, but within these divisions other problems, particularly problems of needs and goal directed behavior, have been in the center of attention. </p> <h4>Evaluation by the Outsider </h4> <p> When you were asked to evaluate the emotional relationships given in the list, you may have felt uncomfortable because of a vague feeling indoctrinated into all of us that in science one should be nonevaluative. Whether a psychologist should or can be nonevaluative is not our present topic. Rather, we are concerned with emotional relationships which are considered by people at large, with or without the permission of the scientist, as desirable or undesirable, good or bad. It is simply an undeniable psychological phenomenon that evaluations are made, and as phenomena they cannot be disregarded. In fact, these evaluations, as shall be seen, are important for the understanding of the dynamics of emotional interpersonal relationships and the problem of adjustment of these relationships. </p> <p> If one considers the relationships in the list, it is noticed that, even though no specification is given of the conditions under which they exist, some of them connote undesirable feelings and states, others more desirable ones. Examples which fall into the negatively evaluated group are "to abuse," "to abhor," "to accuse," "to affront." Examples which fall into the positively evaluated group are "to accommodate," "to admire," "to allow." There are others which seem less definitely to belong to the negative or positive group. For example, "to get accustomed," "to admit." Such abstract evaluations are not made specifically in terms of the meaning of the relationship to either of the partners. They are given by a person who psychologically takes the position of an outsider. </p> <p> Evaluations of outsiders very often show a high level of agreement, as is easily demonstrated by a simple experiment. The list of words can be presented rapidly to a group of subjects who are asked to evaluate the relationship as positive or negative from the standpoint of an outsider to the relationship. In only a few instances will there be disagreement, and these disagreements will be due largely to what amounts to a violation of the instructions: for instance, the subject may "take sides" with one of the partners, or the subject may base his reply on the circumstances of particular situations. </p> <p> Evaluations of outsiders might be considered standards of cultural judgment. It may be the high agreement in the evaluations of outsiders which make them appear to have the role of common cultural standards. It might be interesting to investigate whether some of them are not, in fact, intercultural. The common cultural standards play a not unimportant role in the life of human beings. For example, they strongly determine reputations and the jury's verdict of life or death. </p> <h4>Evaluations by Donor and Recipient </h4> <p> In any relationship, the person who bestows the emotion may be called the "donor," and the person upon whom the emotion is bestowed may be called the "recipient." The difference in the meaning of the relationship for the donor and the recipient is frequently very great. To give an appreciation of this difference, the list was arranged in pairs. You were asked to feel the way the donor in the relationship might feel and the way the recipient might feel. "To abuse or to be abused, to accept or to be accepted" are emotionally far apart. Sometimes both donor and recipient will evaluate a given relationship in the same way. But since the meaning which the relationship has for one partner is not the same as that given to it by the other, their evaluations often differ, and this difference may produce difficulties in the relationship. Help, for example, is almost always seen as positive for the recipient as judged by the donor, but as judged by the recipient it often has both positive and negative aspects. It is important for adjustment of relationships to know the conditions under which the donor and the recipient give the same evaluations and, when they do not, to find ways of producing a change which will lead to agreement in evaluation. </p> <p> The donor and recipient not infrequently attempt to overcome the difficulties resulting from their different evaluations by urging each other to "be objective." But objectivity, in the sense of assuming the position of an outsider and giving abstract evaluations, is not what is really desired. What each <i>really </i>wants is that the partner should "understand" him, <i>i.e., </i>should understand the meanings the relationship has for him. He wants the other to take his (the first's) position and from this standpoint to think, evaluate, and act. </p> <h4>Scope of Meanings and Structure of Relationship </h4> <p> It is seen from the list that a great variety of social emotional relationships exist and that each is characterized not merely by pleasantness or unpleasantness but by a diversity of qualitative connotations. It might be agreed, for example, that one feels lost and hurt when abandoned or that one may feel free and at the same time guilty when abandoning someone. It may also be agreed that one will feel aversion for, and a desire to escape from, one abhorred and that one would feel rejected and resentful if a person abhorred him. Each connotation will be referred to as a "meaning" of an emotional relationship. The diverse, sometimes apparently contradictory meanings which an emotional relationship can have for different people under different circumstances build the "scope of meanings of a social emotional relationship." </p> <p> As an illustration, we present some of the meanings which "being helped" has for the injured: it means that a goal is made accessible; it means that another person is courteous and polite; it means that the injured person is in a position of lower status; it means dependence, burden, etc.<a></a>. We assume that these meanings are not merely a congeries of separate entities attached to the same word. Instead, we believe analysis will show that many of them hang together, that they may be integrated within one or more coherent structures.<a style="text-decoration:none;">*</a> When the structure of a relationship has been determined, it is sometimes found that some of the meanings which subjects give to the word do not belong to the relationship in question but to a different one. For instance, in the case of the sympathy relationship, the structure of which is described in Chapter VI (page 27), some of the subjects gave meanings which belong to the relationship of "pity," a relationship which has a different structure. </p> <p> The determination of the scope of meanings seems to us an essential problem because it is the first step toward determining structures of relationships. The structure is a better description of the social emotional relationship than is the scope of meanings. Even before the development of the structure of a relationship, however, the determination of the scope of meanings has practical value. It permits realization of possibly disturbing connotations and encourages precautions and safeguards against them. </p> <h4> Chapter II: Qualitative versus Quantitative Approaches in a New Field </h4> <p> In a new field, the formulation of meaningful problems is a task in itself—a task which often takes much time and effort. It is easy within an hour or two to state a hundred questions, in a few days to state many more. Yet only a few of these will prove to be fruitful. The selection of problems which are scientifically promising is an extensive qualitative research job. </p> <p> Essential questions are those which promise to become an integral part of an interrelated group of problems and to lead to the development of corresponding systems of concepts. In a new field neither the problems nor the systems are known. They have to be discovered by giving a "qualifying examination" to the problems and preconcepts which occur to us, since these include both promising and unpromising ones.<a style="text-decoration:none;">*</a> The qualifying examination consists of a test which shows whether a particular problem and preconcept with other "candidates" promise to form an interdependent team. When they not only develop but also add to the development of the emerging system, they acquire the position of fruitful essential problems and preconcepts. </p> <p> Consider an example of a problem which does not seem promising, in the sense that it is likely to remain an isolated problem. It is noted that some of the items in the list connote what may more frequently be called feelings <i>(e.g., </i>"to abhor," "admire," "adore"). Others have the character of emotional acts <i>(e.g., </i>"to accuse," "advise," "acquiesce," "admit"). Still others reflect social distance <i>(e.g., </i>"to consider someone an acquaintance or an alien"). These categorizations seem, however, not to lead to further understanding. They simply fix the different relationships into more or less neat cubbyholes, which are, as far as we can see at the present time, blind alleys. In this example, categories rather than preconcepts are relied upon to "order" the facts. Only an orderly catalog instead of a system of interrelated dynamic concepts can be built up in such a way. </p> <p> An example of a problem which we consider promising is the determination of value structures held by those people who are undergoing difficulties and by those who have overcome these difficulties. This, we believe, is one of the first steps in conceptualizing adjustive change (Chapters V, VII, VIII). </p> <p> Another example of what might be considered promising for future investigation relates to the "mutual" relationship. When discussing the relationships in the previous chapter, all of our examples were of "onesided relationships." Each involved one donor and one recipient. But partners may abuse each other, accept each other, or admire each other. Each may be in the position of donor and recipient at the same time. Mutual and one sided relationships are not merely convenient methods of classification. They bring into focus a number of questions important dynamically. </p> <p> It frequently happens that when a one sided relationship is unpleasant for the recipient, he will try to change it to a mutual one. For example, if he is being abused he may begin to abuse the other. What effect does this change produce? The question will be sharpened if we consider the following hypothetical statement: </p> <p> <i>R_p^rd </i>= <i>R_p^r </i>+ <i>R_P^d,</i> </p> <p> where <i>R_p </i>indicates the person <i>p</i>'s relationships, and <i>d </i>and <i>r </i>indicate the donor and recipient positions, respectively. In this statement, <i>p's </i>mutual relationship is a simple summation of his relationships as donor and recipient. Can this actually be the case? Are the <i>meanings </i>for <i>p </i>in the mutual relationships <i>(R_p^rd) </i>equal to the sum of meanings which the one sided relationship has for him when he is only a recipient <i>(R_p^r) </i>plus the meanings it has for him when he is a donor <i>(R_p^d)? </i>This question is important, for if the addition of the new meanings of the donor relationship does not change the old meanings of the recipient relationship, then the addition will not diminish the previously existing conflicts or difficulties.<a style="text-decoration:none;">*</a>Actually, the "adding" of new meanings may not be an addition at all but rather a re structurization of the first one sided relationship <i>(i.e., </i>a change in some of the meanings which the relationship originally had for the person). In the latter case we would have to study the type of change produced by the restructurization and the circumstances under which the change is adjustive. </p> <p> At different stages of research, the "candidate problems" must be subjected to further test. For a time they might drop out from the "team," and then later their participation may again become fruitful. Within this process they may change their character and gain a new role. </p> <p> The "candidate problems" are thoughts of the investigator, fed by qualitative observations and checked by them. For this type of work, an armchair and a pencil are more appropriate than a straight chair and a calculating machine. It might require self control on the part of the investigator to go on with conceptualization and qualitative analysis of data when he is constantly lured by more easily quantifiable, nonsystematic, isolated problems. </p> <h4>The Position of Measurement in Psychological Research </h4> <p> The attitude, "Investigate what you can measure," is not infrequently found in psychological research practice. But there is such a thing as primitive quantification. Quantification of data on systematically unimportant questions is primitive. And there is also such a thing as premature quantification. That quantification which is done before the laborious task of qualitative description of problems and concepts is sufficiently advanced is premature.<a style="text-decoration:none;">*</a></p> <p>The determination of statistically significant differences between two sets of data does not ensure that these data are important either practically or for further theoretical advance. Instead of regarding the statistical fact as an observation which needs anchoring in an explanatory system before its import can be judged, all too frequently such observations, by sheer virtue of their statistical nature, are held up as contributions in themselves. We do not declare that measurement should not be done without a well developed theoretical framework. But we do assert that such measurement often produces statistically significant differences on inessential details. And we further assert that where problems well grounded in theory have not as yet been formulated, data analyzed qualitatively may contribute far more to the understanding of important problems. </p> <p>Where there is a well defined theoretical system, however, measurement has a very important and different position. Measurement in this case, as we see it, means measurement of conceptually defined constructs and the determination of interrelationships among those constructs. Preliminary to such measurements, one has to determine whether the constructs used permit metrization or whether nonmetrical mathematical (topological) statements should be made. The particular problems involved in this type of mathematical determination in psychology were first realized by Kurt Lewin<a></a> in regard to problems of goal directed behavior. Such mathematical determination will have to be made in the field of emotions as in any other field, though it may take years before it is possible. In the meantime, sound investigation, systematic in nature, will have to be primarily qualitative.</p> <p>There also may be considerable practical value in qualitative investigation before quantification is possible. The knowledge of <i>what </i>affects a given social emotional relationship, even if we are unable to indicate the strength of that factor, is of value. For example, we may not be able to state the extent to which sympathy reminds an injured person of the negative implications of his injury. The fact that sympathy <i>may </i>remind, however, immediately calls for caution in conveying compassion to the injured.</p> <h4>Concerning Frequency Counts </h4> <p>At any stage in theoretical development, one may tally the number of times a given observation occurs in the sample studied. But the meaning of such frequencies needs to be examined. The sheer number of occurrences does not indicate the relative importance of the event. We do not consider more important the fact that a person dealt honestly with us ten times than that he once cheated us. Nor can we say, without further proof, that there is a one to one relation between the strength of a factor and the frequency of its occurrence. </p> <p> One function of frequency counts is to permit a more accurate prediction of the number of occurrences of like events in like populations. This function, however, is often limited by failure to define the research population in terms of systematically important factors. </p> <h4>Some Problems of Sampling </h4> <p> To "select" a population for research in a new field which lacks systematization is harmless but also meaningless and therefore to be rejected as impractical. The traditional parameters of age, IQ, socioeconomic status, and geographic location should not be thought of as automatic principles of selection. Their usefulness for the particular research has to be determined in each case. It may be, for example, that in research on the injured it would be more appropriate to define the sample in terms of preinjury attitudes toward the handicapped, relative evaluation of beauty and physical prowess as compared with other personality characteristics, and sensitivity to status position. A group which is homogeneous with regard to some arbitrarily selected factors will actually be heterogeneous with regard to those factors which prove to be of systematic importance. </p> <p> Heterogeneity is, however, not a disadvantage. In an unstructured, new field, where the first task is to determine fruitful problems and the concepts to be used in their solution, the danger lies in overlooking diversities which should be taken into account. Heterogeneous groups which yield a wide range of differences in behavior are therefore welcomed. To narrow down the range of subjects is permissible only for a good reason. This reason has to be specified. In the beginning stages of our research on the social emotional relationships between visibly injured and noninjured persons, it was legitimate to include a variety of subjects. To have limited the investigation to, say, leg amputation cases, for the sole reason that in the interests of homogeneity the type of disability should be uniform, would have been groundless. </p> <p> In later stages of research, the original sample might legitimately be narrowed down or enlarged, depending on the particular problem being pursued. For example, we have indications that a person's status values affect his attitudes toward such social emotional interactions as sympathy, help, curiosity, and so on. This suggested systematic relationship could be tested by narrowing down the sample so that but two groups would be included, one strongly status minded and the other not, according to certain criteria. Whether the expected differences are to be found could then be determined. As an example where an even more heterogeneous sample than the original one is indicated, we can present again an instance from our research. The understanding of problems of loss became clearer to us when the concept of misfortune was introduced. In light of this theoretical orientation, it undoubtedly would be fruitful for further research to enlarge the sample to include, in addition to the injured, other persons regarded as being in an unfortunate situation. In short, throughout research, the sample taken for study should be determined by the requirements of the problem being studied and not by applying sampling procedures which are either extraneous to the purpose of the research or else actually interfere with it. </p> <h4> Chapter III: The Interview as a Tool for Investigating Emotional Contents </h4> <p> The interview as an experimental tool is in disrepute with many present day investigators. Some investigators will go as far as to withdraw the honorable title of "real scientific endeavor" from a study which uses "just interviews" because interviews do not deal with how the person "actually behaves." In this chapter we shall examine the validity of this argument. </p> <h4>Reflection Units and Interaction Units </h4> <p> Consider this example: A young girl gets an invitation to a ball. She is full of anticipation perhaps she will be the belle. Perhaps a certain young man will dance often with her. She decides what gown she will wear and how to arrange her hair. She plans imaginary conversations with gallant partners. But she is anxious too. Maybe she will be a wallflower; maybe the young man will not even notice her. Finally, after a succession of alternating moods, the ball arrives. The social interaction which has occasioned so much thought and feeling actually takes place. </p> <p> If, in the investigation of social emotional relationships, only interaction units were studied, a large part of the course of events would be neglected. Periods of reflection which include planning, expectations, evaluations, struggle with one's feelings and moods, would be excluded from study. Similarly, if in the investigation of personal emotional events only action units were studied, periods of reflection would be overlooked. The interactions or actions themselves might not be fully understood without the consideration of reflection units. </p> <p> The high status position of interaction data as compared with the data of reflection units seems in part to be based upon a vague feeling that only interactions are "real facts." But the types of reflection units enumerated above are all <i>real in the sense that they exist as psychological phenomena. </i>Even if reflection units had a segregated existence and did not influence interaction units, they would still have to be studied as real psychological phenomena within the life of the person. The reflections themselves may produce pain and consequently require adjustment; for instance, a man with a scarred face believed that "no woman in her right mind could possibly accept me now." </p> <p> Is it meaningful to ask whether interaction units are <i>scientifically more real </i>than reflection units? The frequently stated criterion of scientific reality, "What is real is what has effects," concerns not observable facts but the reality of descriptive, explanatory concepts. The reality of the effects is not under discussion in the criterion; nothing is implied about them but their virtue of being available for observation. Scientifically, reflection units and interaction units are both legitimate observable facts. It is true that in the case of reflection units the content must be communicated to the interviewer. But this mediation should be no more disturbing than that of other instruments. The criterion cited does not specify that the observable facts must be observed directly.<a style="text-decoration:none;">*</a> </p> <p> What conclusions can be drawn as to the relative merits of the two types of units for study? Both interactions and reflections are real phenomena and legitimate observable facts; psychological difficulties requiring adjustment may exist in either case. They differ in that interactions can be observed directly, whereas the content of reflections must be communicated to the investigator by the subject. For an investigator, the difference between them is simply one of kind and not of value. </p> <h4> Interviews Versus Behavior Observations </h4> <p> We submit that the richness of emotional life can be more fully realized through the use of the interview than through observation of behavior. It is true that we can infer something about underlying emotions from behavioral observations, but the understanding gained in this way is usually more limited. If we could have observed the girl smiling over the invitation, taking from her wardrobe first one gown and then another, being absent minded about her everyday tasks, and so on, we might have been able to infer something about her feelings. But the complexity of her feelings, the content of her hopes and fears, remains largely unappreciated. On the other hand, for particular problems observation of behavior would be required, for example in order to study the effects of reflections on behavior, such as how fear of failure affects performance, or whether verbal attitudes correspond to behavior.<a style="text-decoration:none;">*</a> Only when a particular problem is specified may one method be judged better or worse than another. </p> <h4> Validity of Interviews Versus Validity of Behavior Observations </h4> <p> It is frequently stated that the subject willfully or otherwise does not tell the interviewer what he actually feels. But one cannot claim superiority for behavioral observations on these grounds. Hiding emotional contents is not limited to interviews. One can cover up one's real feelings with actions just as easily as with words. One can smile when he is sad just as easily as he can say he is well when he feels bad. Friendly acts may be due to bad intentions. They may be performed to cover up the real feelings behind them. One covers up if there is a <i>need </i>for it. </p> <p> The need to hide during an interview, it might be argued, may frequently be less strong than in interaction units. It might be considered whether hiding of feelings from a person with whom they are connected is not frequently more necessary than when discussing or reflecting about these feelings with a third person. It is likely that feelings of guilt or shame will be less strong in regard to statements than to acts. Especially if the third person takes a nonjudgmental position or the position of an ally will the true feelings as far as they are recognized by the subject be expressed more openly than in interaction units. Of course the need to hide particular emotions will exist during interviews, but the interaction units cannot be turned to as the better ones in this respect. </p> <h4> Knowledge of the Subject About His Own Emotions </h4> <p> Interviews are sometimes held in disrepute on grounds that people do not know their own feelings. Has not depth psychology taught that people fool themselves? Does not the subject need first to be analyzed and to be an experienced psychiatrist or to have special training in psychological matters in order to be able to make pertinent statements? Fortunately, people do not learn to cognize feelings in college only. Much of what one feels when someone nags him, for example, or helps him, or when he is jealous, can be perceived without special psychological training.<a style="text-decoration:none;">*</a> If the objection is raised that the conscious meanings which feelings have for the subject are less important and more superficial than those of which he is not aware, we would say that such a statement is premature. Explicit criteria of importance have first to be given. </p> <p> If important feelings are those which affect a person's behavior, we say that those consciously given share the same honors as the hidden. And if it is asserted that unconscious feelings are more important because they explain <i>more </i>of a person's behavior, one is called upon to compare counts. This has never been done, nor does it make sense to do so. For immediately the question arises as to what weights to assign to the individual behavior units. Are they more important because they are resisted? Then what is the rationale for considering the resisted more important? We suspect that all too often the hidden is identified with the important by sheer virtue of the fact of its covertness. Clearly missing is a link which must be supplied before such an evaluation can have scientific merit. </p> <p> As far as we can see, it is scientifically meaningless to argue about the importance or superficiality of perceived meanings of feelings before the criteria of such judgments are made clear. One criterion does exist. If important problems are those which are essential in the sense discussed on page 8, <i>i.e., </i>problems which attempt to relate observable facts to systems of concepts, then there is nothing which leads us to exclude feelings as perceived by the subject as "candidates." Criticisms regarding essentiality of problems are applicable to overt and covert meanings alike. </p> <h4> Feeling Level Versus Intellectual Level of Discussion </h4> <p> Emotional topics can be discussed with almost anyone who is willing to participate in an interview. The discussion, however, may take place on an intellectual level or on a feeling level. One can "just talk about" feelings, in an abstract, impersonal way (intellectual level), or one can analyze one's feelings in terms of the particular intimate meanings they have for the individual (feeling level). Psychotherapy, whether directive or non directive, strives for such a feeling analysis by the patient. It has been commonly recognized that, in order for feeling analysis to take place, the person must have a need to examine his feelings, and he must expect the interviewer to be tactful, understanding, trustworthy, etc. In the study of the meanings which social emotional relations have for the donor and for the recipient, however, a further important condition must be realized. To approach such meanings on the feeling level, the subject must <i>actually feel </i>the position of a partner in the relationship. He must feel something of the hurt involved in being stared at, for example; or in the case of the donor position, something of the curiosity. It is more advantageous to select subjects who in actual life are donors or recipients in the relationship investigated. Otherwise the subject tends to discuss on the intellectual level or evaluate as an outsider, and in neither case can he convey the emotional impact which the relationship has for a partner. </p> <h4>Analysis of Data in the Area of Emotions </h4> <p> The principles which guided us in choosing methods of collecting data apply no less to its handling after it has been gathered. The whole flavor of the emotional meanings which one was at such pains to obtain can be lost if the approach to the data is unwisely rigid. The investigator is forced to perceive and to feel emotional relationships from the point of view of the donor and recipient before he can understand the meanings and evaluations ascribed to them. Not being involved in the particular relationship, the investigator has to find equivalent relationships in his own experience. Frequently in our research we had to feel through relationships from our own personal histories in order to be able emotionally to understand the subject's comments. Though the occasion at which sympathy, for instance, was given to us differed from the occasion leading to sympathy relationships in our subjects, the tool of self analysis was useful. There is an obvious danger of analyzing superficially similar relationships instead of equivalent ones. Self analysis, therefore, should be used for the purpose of getting "hunches" which can be applied to the data obtained from the subjects. Such an approach leads to aspects of data which an investigator, viewing the data as an outsider, will overlook or misinterpret. </p> <p> There is nothing unscientific about being a subject and an investigator at the same time. In perception psychology, for example, the investigator frequently takes this double role. He can perceive and then cognize what he is perceiving. In the area of emotional problems, the investigator should try to feel the emotional situations being studied and then to examine what he is feeling. Physical, physiological, and psychological laws which hold for the object of the investigation hold for the investigator also. In investigating emotional relationships, to feel is at least as essential as to think. </p> <p> If we state that one has to do not only a thorough job of thinking but also of feeling we make a realistic statement concerning the method of studying emotional relationships. Our view on the necessity of emotional understanding is not as radical as it may seem. Frequently in psychology statements are made that we have to investigate contents as they "exist for the subject," "what it means to the subject," "to see with the eyes of the subject." The need for feeling "like the subject feels" was long felt by therapists. The requirement of psychoanalysis that they themselves be analyzed is partially for the purpose of facilitating emotional understanding. </p> <p> In attempting to find aspects under which the data may be fruitfully seen, complete freedom should be given to the investigator. He cannot be free enough and "wild" enough in looking for interpretations and possible implications of the raw data which might lead to hunches, hypotheses, and conceptual formulations. Hunches are freedom loving birds which do not hatch in supervised, restricted areas. This does not mean that the data will be distorted or that the results will be "only speculation" and not "facts." The test is whether, when a category has been well defined, independent observers will agree that given items of the raw data fit the category. If they do agree, then this aspect is indeed "an observable fact." If we are too "wild" in our interpretations, then we shall be caught by another observer. But if we are unwisely rigid we shall not be able to make a step in the direction of theoretical progress. </p> <h3><b>Part II: Study on the Visibly Injured</b> - A Group Considered Unfortunate</h3> <h4>Chapter IV: Research Procedures </h4> <p> Our approach to the problems of the social emotional relationships of the visibly injured was based on the theoretical and methodological considerations discussed in Part I. Because the task was that of determining essential problems in the new field of social emotional relationships, qualitative methods were chosen as the appropriate ones. Measurements at this time would have been premature. Frequencies of observations and statistical analysis are therefore not presented, since they would only be misleading. </p> <h4> Subjects </h4> <p> Heterogeneity of subjects, as has been seen, is an asset for such a study. The subjects (177 visibly injured and 65 noninjured persons) varied as to age, race, intelligence, socioeconomic background, occupational interests, marital status, and so on. The injuries varied. The relationship of the noninjured to the injured persons varied. To have narrowed the groups for the sole reason that they should be homogeneous would have given us a more limited picture of the emotional meanings of the relationships existing between the injured and the noninjured. </p> <p> If, at the beginning of our investigation rather than at the end of it, we had known that the relationship of misfortune was especially important to the understanding of the problems studied, we would have considered it profitable to have included persons who experienced misfortunes other than injuries. But our research was an outgrowth of interest in the problems of the injured, and thus misfortunes other than visible injuries were not studied. Orthopedic cases and cases involving plastic surgery were chosen because the visibility of the injury is important in relationships with noninjured who are not close to the injured. Blind and deaf persons were excluded as subjects since it was felt at the time that the specific additional problem of communication between them and the noninjured would have in the beginning of the research unnecessarily complicated the data. </p> <p> The ages of the injured subjects ranged from 19 to 58 years, the duration of their disabilities from two months to <i>33 </i>years. Of the 177 injured subjects, 121 were hospitalized servicemen of World War II and four were women. (<b>Table 1</b>) presents the distribution of the subjects according to type of disability; (<b>Table 2</b>) gives the distribution of the non injured according to relationship with injured persons. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Interview Procedures </h4> <p> After having tried out several techniques of investigation, a summary of which is given in Appendix I, we found that the scope of meanings of social emotional relationships could most adequately be determined by interviews. Prior to the interview much work was done on the selection and formulation of questions, the purpose being not to set up a questionnaire for the interviewer to follow rigidly but rather to prepare him for the interview. We wish first to point out why we think it unnecessary and often disadvantageous to follow a rigid order and formulation of questions; then we would like to explain what we mean by "preparing the interviewer for the interview." </p> <p> It was observed that, for at least three reasons, the actual course of events in an interview might require deviations from a prearranged interview. In the first place, identity of questions and order does not ensure that the psychological situation will be the same for different subjects. In many instances, a question will have the same meaning for each subject only when it is put in a different form. Thus, in our study, as well as in many investigations where comparisons among the subjects are made, rigid interview procedure is con traindicated. That we deny the necessity of maintaining a rigid formulation and order of questions does not imply that we disregard the influence of preceding events upon a given question. Rather, we assert that this kind of influence can be validly determined only when the analysis of data is made. A rigid order gives an "appearance" of the same conditions and illegitimately relieves the experimenter from investigating the effects of the actual psychological conditions upon the responses of the subject. </p> <p> Secondly, a rigid interview leads in many cases to a more superficial intellectual discussion than is the case when the interviewer follows the natural course of the discussion. If a subject is developing a topic in a given direction and the interviewer goes on to the next question on the list, the interruption might be emotionally disturbing. Such interruptions promote the feeling that the interviewer is not really interested in what the subject is saying but just has to complete the task of getting answers to "twenty questions." </p> <p> Finally, in a nonrigid interview the subject may introduce new topics which, in the exploratory stage of research, are often worthy of consideration. </p> <p> To "prepare" or train the interviewer, the design and redesign of questions that might be asked in the interview is of extreme value. First, the process of developing questions sharpens the sensitivity of the interviewer to the scope of meanings which may be implied in a question and in possible answers to it. It prepares him to listen for the shades of meanings which the subject may bring out. Secondly, the interviewer, when later analyzing the interviews, will also be more sensitive to the shades of meanings implied in the subjects' statements. Third, the attention given in the training to the problem of the logic of transitions from one question to another and to the possible negative effects implied in some transitions is also important. The interviewer is then better able, when the subject waits for him to take the lead, to introduce a new topic without disrupting the relationship. And finally, the training on design of questions makes the interviewer realize what questions may be seriously disturbing to the subjects, a matter especially important with the injured subjects and their sharers for whom the injury is a vital problem not limited to the interview situation. </p> <p> The design of questions to be used as guides for interviews in a new area is a serious and laborious task. During the research, changes in the original questions were made; some were dropped, others added. In successive interviews, the improved interview form served to suggest the areas to be brought up for discussion, but when and how they were to be introduced was left to the judgment of the trained interviewer. We present below one of the prearranged lists of questions which was developed during the training period and used as a guide in some interviews with injured subjects: </p> <ol> <li>How do people act? <ul> <li>How should they treat you?</li> </ul> </li><li>How about their asking questions? </li><li>How about help?</li><li>Do you think that noninjured people are uncomfortable when they are with you for instance are they at a loss for words? <ul> <li>Do you think they are afraid of hurting your feelings?</li> <li>Do you try to put them at ease? </li> </ul> </li><li>Do you think it wise for the uninjured to make light of the injury? <ul> <li>Do you think a person who is not injured should kid the man about the injury?</li> <li>Is it good for them to tell an injured man about all the things that another injured man can do? </li> <li>Is it good for them to tell a man that his injury is not noticeable? </li> </ul> </li><li>Do you like to hear it said that the injured man is courageous? </li><li>What do you think comes into a person's mind when he sees someone with an amputation? <ul> <li>Do you think many people would feel sorry for him?</li> <li>Would many people feel respect for him?</li> <li>Is the opposite ever true? Would anybody look down on him? </li> </ul> </li><li>Do other people react any differently from what you expected at first? </li><li>What percentage of people do you think act very well and really badly? How many in between? </li><li>How would you check whether a person has the right feeling toward injured people? Do you do anything like that? </li><li>Did you ever know anybody who was injured, before you were hurt? 11a. How did you feel about him? <ul> <li>Do you feel differently about them now? </li> </ul> </li><li>What would you be careful of now when you're with another injured person? </li><li>Do you ever feel sorry for anyone around here? </li><li>Is there a bad kind of sympathy and a good kind? <ul> <li>Is there a kind you can't help? </li> </ul> </li><li>Is pity different from feeling sorry? </li><li>Quite a number of things may be important for other people who are injured to know about the stages one goes through. It would help them to know they are not the only ones who have these feelings in the beginning. How was it at the beginning? What are the stages one has to go through and the things you have to get used to? </li><li>Do you think a person should try not to think about his injury? </li><li>Is it better if he thinks and talks about his injury in a matter of fact way, whenever there is any reason to think or talk about it? </li><li>What would you do if you saw a fellow patient who was feeling sorry for himself? </li><li>What kind of person will let his injury lick him, or get him down? </li><li>Do you think you would have been able to take it if it had been worse? </li><li>Does it help to know that another person was injured worse than you? <ul> <li>Is it because the other person is in a worse condition, or because even though he is in a worse condition he can still take it? </li> </ul> </li><li>What things have you learned to do since you were wounded? <ul> <li>What things do you still have to learn? </li> </ul> </li><li>Which is more important, the looks, or the things you can't do? <ul> <li>Does it matter much how it looks, either to other people, or to you? Do you have to get used to it? </li> </ul> </li><li>Is an injury easier to take for a woman or a man? 25a. Would you object to marrying an injured woman? </li><li>Do the men feel that their injuries will make a difference in their getting married? <ul> <li>Let's say that about 70 out of 100 men are married in the general population. What would you expect about wounded people, would there be more of them married, or less, or about the same? </li> </ul> </li><li>Are you satisfied with your stump? <ul> <li>Some people say that they get mad at the stump and try to hurt it. What do you think the reason might be? </li> <li>Have you ever felt that way? </li> </ul> </li><li>Are there some words you object to? <ul> <li>How about the word, stump? </li> </ul> </li><li>Do you think that after an injury a man gets more interested in new things that didn't interest him before that he looks on life differently or that things that were important before don't seem important now while new things do? <ul> <li>Do you have any new plans for a job? </li> <li>Do the same kind of people interest you? </li> </ul> </li><li>There are a good many things we haven't talked about that might be very important, and we'd be glad to have your suggestions. Is there anything else that occurs to you that would be good for us to talk about? <ul> <li>Anything you think the wounded man ought to know? </li> <li>Anything the public ought to know? </li> </ul> </li></ol> <p> The interview usually lasted about an hour and a half. In a few instances, there were repeated interviews with the same subject. About half of the interviews were recorded by the interviewer himself as verbatim as possible, the others by a stenographer or a trained recorder. A sample interview with a noninjured subject is given in Appendix II. Sample interviews with three injured subjects are given in Appendix III. </p> <p> The cooperation of the injured subjects was obtained by telling them that the purpose of the study was to determine difficulties existing in the relationships between injured and noninjured people and how these difficulties could be overcome. The subjects were asked to help in finding out "how people act" and "how they should act." The injured considered the endeavor a worthy one. Many of them challenged the usefulness of current magazine articles, and some felt that correct information might improve matters. The social emotional relationships discussed had a high potency for them. Many of the subjects were recently injured, but all of them had had contacts with the noninjured—contacts in which they were the recipients of help, of curiosity, of sympathy, of being considered an unfortunate person. For them, such relationships were real and vital. Because they mattered to them they discussed problems not only intellectually but also on the feeling level. </p> <p> In the interview the injured subjects were first asked "how the noninjured behave and how they should behave." This confirmed the feeling which we had attempted to convey when we first approached them that we valued their opinions and knowledge as they "are the ones who really know." This openended question was also a precaution against feelings in the subject of intrusion into his privacy. Later in the interview, when the subjects became involved and felt secure and free with the experimenter, they frequently shifted to their own personal feelings and were even willing to discuss private matters brought up by the interviewer. </p> <p>Since particularly during the war the feeling that something should be done to help the injured was strong, cooperation was also readily secured with the noninjured subjects when the purpose of the study was explained to them. At the beginning of the interview, however, it was a difficult task to achieve real emotional involvement on the part of those noninjured who were not close to injured persons. Noninjured persons who are in the position of sharers, wives and mothers of the injured for example, do feel that relationships between the injured and noninjured really concern them. But for other noninjured, the area of problems is not a vital one. Some time was therefore spent with subjects of this group at the beginning of the interview in discussion of injured persons they knew and how they felt about them in an attempt to bring the discussion to a more basic feeling level. In order to keep the subject on the feeling level, the interviewer also attempted to bring out the conflict in the noninjured between ethical demands and emotional feelings. Because it is considered "good" by the noninjured to believe that the injury does not matter to them, they may try to convince the interviewer and themselves that they do not have any "special feelings toward an injured person." When the interviewer responded to the underlying emotional feelings rather than to the overt ideological statements, the noninjured not infrequently became aware that the relationships involved important meanings for them and not merely intellectual or ideological ones. Discussion on the feeling level could then take place. </p> <h4>Analysis of Data</h4> <p> The analysis of data in a new field, where the aim is to discover essential problems, requires a great flexibility on the part of the investigator. Because the search is for "hunches" and connections among them and not for frequencies of occurrences, an attitude of a single subject in its ramifications requires much thought and understanding. For those who will work further in this field, we wish to mention some points which are well to keep in mind when analyzing interview material. </p> <p> The understanding of the emotional meanings implied in the statements of the subject requires taking into account the context of the discussion. It is important to consider the interplay between the responses of the subject and those of the interviewer. Sometimes contradictory statements made by the subject in different portions of the interview lead to understanding of basic feelings. Always it is necessary to try to put oneself in the position of the subject and to feel with him. Often, in order to appreciate the subject's subtle feelings, it helps to examine one's own feelings in situations similar to those evaluated by the subject. Frequently the impact of the subject's own feelings is further enhanced if the investigator assumes the position of the other partner in the relationship he was talking about. In our work this was especially true in analyzing the noninjured records. The covert meanings appeared most clearly if we tried to see the implications which a superficially innocuous statement might have if an injured person were to read it. </p> <p> A rigid scheme of analysis of interview material may lead to superficial conclusions; since in such a case one is obliged to cover the material in a technical, automatic way, the many meaningfulness of the single answer of the subjects is apt to be overlooked. Thus, for our purpose, the interview material was more fruitfully analyzed by developing categories as the analysis proceeded rather than by following a predetermined scheme. This meant categorizing, recategorizing, and again re categorizing. When a new category was added it sometimes required a re examination of parts of interviews in the light of the new insight gained. Not all of our theoretical statements, however, are based on category analysis of all the interviews. Sometimes the attitudes expressed in single cases gave us hunches which led to the development of hypotheses and theoretical understanding. In these ways we tried to determine the scopes of meanings and structures of social emotional relationships. </p> <h3> Chapter V: Misfortune </h3> <p>Many kinds of social-emotional relationships exist between injured and noninjured people. Which should be investigated as more essential? We began with those which were frequently pointed out by the injured themselves, namely, "to help—to be helped," "to question—to be questioned," "to stare—to be stared at," "to sympathize—to be sympathized with," "to accept—to be accepted."<a style="text-decoration:none;">*</a> During the analysis of data, a different relationship emerged as more basic for understanding the social psychological problems of the injured the relationship "to consider someone unfortunate to be considered unfortunate." This relationship enables us to tie together many of the phenomena observed and indicates the direction which further research should take. The finding and description of this essential relationship is a <i>result </i>rather than the historical beginning of our investigation. </p> <h4> An Experiment for the Reader </h4> <p> The line below represents a scale. The letter <i>F </i>designates the position of the most fortunate person and <i>U </i>the position of the most <i>un</i>fortunate. The sign in the middle of the scale designates the average position. Before reading the text further, quickly and going simply by feeling rather than on the basis of intellectual consideration indicate your own position on the line. (<b>Fig. 1</b>) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Figure 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> This experiment was performed with a group of 30 students at Stanford University but not in the context of a discussion about the injured. Only one of the group placed himself in the average position, none below this point. In a variation of the experiment with 10 other subjects, the instructions were changed so that the middle of the scale represented the average position for members of the subject's own social group. The "fortune phenomenon" still held in this case.<a style="text-decoration:none;">*</a> </p> <p> We expect that you too will have put yourself somewhere above the average position. It would seem that there must be a "terrible misfortune," and even this may not suffice, to lead one to put himself below the average. One feels also that should somebody judge him to be unfortunate and place him low on the scale he would resist accepting such a judgment. Yet very easily does the noninjured make such a judgment regarding the injured. </p> <p> It is our task to specify further the feelings of the person who considers himself fortunate toward the one whom he considers unfortunate and also the feelings of the person who is considered unfortunate when he knows that he is so considered. Though the relationship as it concerns the injured is in the focus of our attention, the discussion has implications for anyone who is judged unfortunate. </p> <h4> Misfortune As An Event </h4> <p> A painful event which does not have far reaching consequences may be called "a mishap." If the event produces prolonged and more inclusive suffering, if it affects a large part of the life space of the person, it is called "a misfortune." Other people will tend to shift the position of the sufferer downward on the fortune scale. The circumstances surrounding the event may themselves be important. They may affect the feelings of the person himself and the relationship between him and others. But this is a special problem, and fruitful investigation of it presupposes knowledge of the nature of the misfortune relationship. We shall, therefore, in this first study of misfortune, disregard such differences as whether an arm was lost in a car accident or because of shrapnel wounds. </p> <p> For an investigation of the effect of the circumstances surrounding the event upon the feelings of the person himself, simple grouping into war and accident casualties, for example, would be too superficial. The groupings have rather to be made in terms of the intimate psychological meanings which the circumstances have for the person. For example, in the case of the war wounded: I volunteered and therefore I caused my injury; I was not careful enough I handled explosives too automatically; I got shot when I went out to help my friend it just came; I wanted to be wounded in order to return to the mainland. Moreover, one would have to know whether after his injury the person believes that his loss was for a worthy cause, or whether he became disillusioned, and so on. Similarly, psychologically meaningful subgroups would have to be distinguished for the investigation of the effect of the circumstances upon the evaluation of the donor. We shall emphasize not the nature of the event which produced the change in position on the fortune scale but the consequences of the persisting difference in position between those who are considered fortunate and those who are considered unfortunate. </p> <h4> Misfortune and Suffering </h4> <p> That an unfortunate person suffers is the fact which is outstanding from the point of view of common sense observation. It is also the suffering aspect of misfortune to which people who are close to the sufferer and who share his difficulties predominantly react. We can then ask, "Is the judgment that a person is in an unfortunate position only a statement that he suffers and nothing more?" Are "unfortunate" and "suffering" equivalent? We shall see that there are instances in which the judgment of unfortunate is made in spite of the fact that the person does not suffer, at least not directly from the event itself, and that there are other instances in which suffering occurs and yet the judgment of unfortunate is withheld. </p> <p> Let us first consider the fact that when suffering is not perceived the person may still be considered unfortunate. This is true, for instance, in the case of a person having a facial disfigurement. It may be objected that, even if the suffering is not perceived, people "realize" that he suffers, and this may have something to do with considering him unfortunate. But, we ask in a provoking way, may it not be this "realization," the opinion of others that he is unfortunate, which makes him suffer, rather than anything independent of these opinions? </p> <p> It is also puzzling that not all people who experience suffering are considered unfortunate. Boxers, pioneers, members of an arctic expedition are not considered unfortunate. The argument that in such cases the suffering is of short duration does not always hold; the hardships of the pioneers lasted a lifetime. Nor does it help to point out that these sufferings are self imposed and are therefore not misfortunes. It is not strictly true that they are self imposed, especially when they are necessary to gain a livelihood. Moreover, someone who imposes an injury upon himself in attempting to commit suicide is still judged by many to be an unfortunate person. </p> <p> It should be clear from the foregoing that the statement, "One considers somebody unfortunate when one perceives that he suffers," is unprecise. We shall see in a subsequent section (p. 21) that a statement which is almost the reverse will, paradoxical as it seems, lead us further: "When one considers somebody unfortunate, one will not only expect him to suffer but may even feel that he <i>ought </i>to suffer!" </p> <h4> Misfortune As a Value Loss </h4> <p> In order to understand many of the social emotional relationships arising between the fortunate and the unfortunate we must make explicit one important aspect of misfortune: a misfortune involves, in the eyes of the judge, a loss or absence of something valuable. But the word "misfortune" is sometimes used when the person has experienced no unfortunate event, for example when the injury is congenital. In this case, the absence of a value may be felt psychologically as a loss. </p> <p> The judgment of misfortune is an expression of personal and social values which the donor holds high. In our culture, most persons do not consider an amputation, a facial scar, or other injuries simply neutral variations, like color of eyes or length of hair. Instead, these variations of "body whole," "body competent," and "body beautiful" are <i>considered </i>disfigurements and handicaps. That is, they are judged to be misfortunes value losses. </p> <h4> The Requirement of Mourning </h4> <p>Since a misfortune is, in the eyes of the judge, a loss of something valuable, the person who experiences a misfortune is generally expected to suffer and mourn his loss. An injured man described the expectations of his visitors in the hospital as follows: "They expected to see me in a worse mental state. I was pretty cheerful and cheered <i>them </i>up." Sometimes these expectations may even have the character of a judgment as to what is proper: it is <i>natural </i>and <i>normal </i>to mourn one's loss when struck by misfortune. It may therefore be disturbing and uncanny to the noninjured to find an injured person who is not distressed, who does not feel and act like an unfortunate person. The noninjured will tend to suspect that the injured person is putting on a good act, or they may conclude that he does not yet realize what has happened to him but "will in time." </p> <p> We venture to say that these feelings of the donor do not arise solely from the possible intellectual consideration that emotional acceptance of a loss is inconceivable. It is likely that they stem also from the need on the part of the fortunate to keep high those personal and social values which he possesses or cherishes. He therefore objects to the apparent disrespect shown these values as implied in the nonacceptance of the unfortunate position by the person who is deprived of them. When the recipient does not show that he feels unfortunate, the implication is that the loss is not so great, and therefore the donor requires that the recipient mourn. We are now ready to state the following hypothesis: When the fortunate person has a need to safeguard his values, he will either <i>(a) </i>insist that the person he considers unfortunate is suffering (even when he seems not to be suffering) and that he ought to suffer or <i>(b) </i>devaluate the unfortunate person because he ought to suffer and does not. </p> <p> We expect that the noninjured will resist the implications of this hypothesis. It implies that they <i>want </i>the unfortunate to suffer, which is in direct conflict with prevailing ethical codes. An analysis of several examples will, however, make the hypothesis more convincing. </p> <p> Consider a woman to whom "position is everything in life." She must consider as unfortunate those who are omitted from the social register. If she does not it would mean that her position is not so valuable after all. If they do not accept the fact that they are unfortunate, she must consider them either too stupid to know better, or insensitive, or shamming; otherwise her own position is threatened. </p> <p> Or take the attitude of a married woman toward her spinster sister. Perhaps the duties of a wife and mother make up her whole life. If these are not important, then what is she? Nothing. It would be an intolerable state. She must consider single women unfortunate and require that they recognize this position. Otherwise how can she escape insecurity, anxieties, conflicts, and the necessity for revaluation which might increase the importance of other value scales on which she has a low position? </p> <p> To one who is proud of her beauty, whose sole stock in trade it is, the ugly duckling who flirts and seems happy would be disturbing. The beauty may laugh at the plain one and comment on her appearance so that she will "know her place." If she accepts this place, then she supports and does not challenge the values of the beauty. </p> <p> For like reasons, it is considered scandalous if a widower remarries too soon. He should have observed a "decent" period of mourning. He is heartless and disrespectful. He threatens the value of strong interpersonal ties. He undermines the value of dependence upon each other in close relationships. </p> <p> The feelings of the judge which are implicit in the requirement of mourning will tend to be expressed, however, only in covert ways because of the conflict between these feelings and ethical demands. Thus in the following example, though the demand for suffering is not overt, the noninjured subject makes it clear that an injury is devaluating and that the injured should be ashamed of and hide the injury: </p> <blockquote><p> The last place I worked there was a girl there who had been born without an arm. It was about to here [indicates above elbow). And she had fingers on it. She didn't care. She used it to hold bobbie pins, etc. ... I didn't think it was very nice. Right in front of the other girls she would uncover it. Would you think that was all right? [Interviewer: What did you feel about it?] It was repulsive. If it had been an amputation it would have seemed cleaner. I thought at the time that I would have gone into the dressing room and do that and not be where so many people could see it. </p> </blockquote> <h4>Misfortune and Devaluation </h4> <p>It has been seen that if a person does not mourn his loss when the donor believes that he ought to he will be devaluated. Mourning his loss does not, however, insure the unfortunate against devaluation. He may be devaluated whether he mourns or not. There remains then the task of determining other conditions under which a person who experienced a misfortune is devaluated. </p> <p>Devaluation of a person implies comparison. The comparison may be made between two persons in respect to particular characteristics, or between the current state and a previously existing or predicted future state of the same person, or a person may be compared with some abstract norm. The standard of comparison has a position which is evaluated positively and below which any position is negative. Thus, when there is devaluation, the comparisons are not made in neutral terms indicating likeness or difference. Instead, there is always a judgment of better or worse. The position of the person being judged and the standard against which he is compared may be represented on a value scale. </p> <p> Summarizing, we may say that devaluation presupposes comparison on a value scale on which a person is judged to be in position <i>x, </i>the standard occupying position <i>y, </i>which is higher on the scale. Close consideration of this statement, which sounds so self evident, will show the problems actually involved. Several terms used require further specification. These specifications will help in the task of determining the conditions which lead to devaluation. The terms are "value," "person," "position of the person," and "standard." </p> <h4> <i>Value</i> </h4> <p> We raise the question: Does devaluation occur when a person has lost or lacks <i>any </i>value, or does it occur only when particular values are involved? It would seem that even when something is evaluated highly, the nonpossessor is not necessarily devaluated. Two kinds of values which preclude devaluation can be distinguished—possession values and asset values. </p> <p> <i>Possession Values. </i>If a value is seen only as a possession of a person and not as a personal characteristic, devaluation of the person cannot take place. Thus beautiful pictures may be evaluated highly, yet those whose homes do not boast of even one old master are not devaluated. Though this seems clear, the terms "personal characteristic" and "possession" are in themselves problematic. Psychologists are uncomfortable when they have to draw a boundary between the person and the environment. Whether something is seen as a part or characteristic of a person or as a possession seems to depend upon the judge. The person who has lost someone dear to him may feel that he has lost part of himself. Clothes may be thought of as a material possession and "being well dressed" as a personal characteristic. Where some judges would perceive a "man who owns a house," others would perceive a "home owner," a substantial and responsible member of the community. Even a part of the body may be thought of simply as a possession rather than as a characteristic of the person, as the following statement of an injured man would seem to imply: </p> <blockquote> <p>In other words, I kind of think now that the hands and legs are just merely tools. Where if you haven't got the right tool there are some jobs you cannot do. It is not the handicap that holds a man down. It is his head. In the beginning one does not see it— that they are tools. </p> </blockquote> <p> The general problem will have to be solved: What are the conditions under which a value will be seen as a personal characteristic or simply as a possession? </p> <p> <i>Asset Values. </i>Even when a value is seen as a personal characteristic, the nonpossessor is not devaluated if the value is regarded as an asset value. When asset values are involved, the person does not base his evaluation upon comparison with any standard. He may, for example, simply enjoy the musical performance of his acquaintance without comparing it with the performance of anyone else. Should the judge not be talented in this regard, he is not disturbed because he is inferior to another. Musical ability in others and himself is seen as an asset value. More generally, the existing state of a person may be felt to be satisfying (or disturbing) without comparing it with a standard. A woman, for example, who is forced because of family and children to give up a vocation which until then had made up a large part of her life will not feel inferior if a vocation represents to her an asset value which is a "fine thing to have" if circumstances permit. </p> <p> From the above, it is clear that it is not inherent in a value to be considered an asset value. Among other things, the needs of the judge will determine whether or not he is in a comparison frame of reference. Thus, though musical ability may be an asset value under certain circumstances, when the judge is in a comparison frame of reference because he has to select members of an orchestra it is not. In the latter case, we may speak of musical ability as a comparative value, a value used in making comparisons for the purpose of evaluating the person. </p> <p> We wish to make a sharp distinction between comparative values and the possibility of making comparisons when asset values are in question. In the latter case, comparisons which might be made are intellectual ones which do not affect the evaluation of the person. In the former case, the comparison is the main aspect; whether or not the person is meeting the standard with all its consequences is most important. </p> <h4><i>Person</i> </h4> <p>We have to distinguish between what we call "total person" and "characteristics of a person." By "total person" we mean all the characteristics which are taken into account by the judge at a given time whether they are clearly or only vaguely perceived. Devaluation can exist in regard to single characteristics and not in regard to others. If the characteristics on which the person is devaluated are "decisive" for the judgment of the total person, total devaluation will take place. But if these characteristics are seen as unimportant, then the person is not devaluated as a total person though he is devaluated on single scales. Moreover, when the single characteristics on which the person is devaluated are the only ones that enter the evaluation of the judge, then "total person" is equivalent to these characteristics and total devaluation takes place. </p> <p> Consider the example of the noninjured girl who said: </p> <blockquote> <p>He's correct in not proposing if he couldn't earn a living because of his handicap. </p> </blockquote> <p> This subject evaluated the injured person as a husband in terms of a single characteristic or scale on which she feels he has an inferior position. Because other characteristics of a good husband are not taken into account, he is necessarily devaluated as a husband. If other characteristics which are felt to be the decisive ones are considered, such as affection and understanding, he may be judged equal to whatever is taken as the standard. He will be devaluated only if the girl feels that earning a living is of primary importance. </p> <p> Examine similarly the self devaluation of an amputee who says: </p> <blockquote> <p>You feel like a heel lots of times when kids are playing on the street with their sleds. Other fathers can play with their kids.</p> </blockquote> <p>The subject devaluates himself because other characteristics which may be considered more important for a good father than those on which he falls short are not considered at the moment. </p> <p> Devaluation of the injured is not limited to bodily values only. When the injured person is devaluated because of physical performance, appearance, or aptitude for particular roles, a jump is not infrequently made so that he is also devaluated in regard to assumed mental characteristics. Some people directly indicate that abnormality of the body means abnormality of the psychological make up. Thus we have the following statements made by noninjured subjects: </p> <blockquote><p>You'd be very conscious of your own deformity; it would hurt you psychologically.</p> <p> Some have a disposition to arrogance. "You are going to accept me whether you like it or not" like a midget, you know, inferiority complex. Some overdo the matter of being congenial. [Note that even positive traits are seen as negative]</p> <p>After she [girl with short bowed legs] had been with us for a short while, we accepted her as normal, except for that handicap. [This implies that at first they didn't accept her as normal.] </p> </blockquote> <p> We should like also to point out that devaluation of the total person does not always occur by way of single characteristics. Sometimes there seems to be a direct, all inclusive judgment of devaluation of the total person. It seems that the broader the meaning of the word "person" the less clearly does the judge perceive how the single scales determine his evaluation of the person. He has a vague feeling, for example, that a "cripple" is somehow "an inferior person." </p> <p> In speaking about devaluation of a person, then, we must ask two questions. Is his devaluation limited to particular characteristics or is he devaluated as a total person? Is he devaluated because only those scales on which he has a low position are taken into account or because these scales are given considerable weight when the scope of values is enlarged to include other characteristics of the person. </p> <h4> <i>Position of the Person</i> </h4> <p> To a judge, the permanence of a person's position with respect to the standard is important in his evaluation of the person. We may expect that devaluation will be less severe if, when taking the "time perspective" into account, the position of the person is seen to shift in the direction of the standard.<a style="text-decoration:none;">*</a> The judge may expect the shift for different reasons. In some cases, he may feel that the loss can be replaced in whole or in part. Thus, even a person who considers "home owner" as a characteristic of the person, and a minimum requirement for the role of a responsible community member, may not devaluate someone who suffers the misfortune of having his house destroyed. The judge may expect that he will again be able to establish a home and thereby to regain his former position. The loss is only temporary. </p> <p> In other cases, the person may be expected to adjust to his loss even though the lost value cannot be regained. The position of the person, then, is felt to shift so that he can meet the standards in regard to such values as, for example, adequate personality, social usefulness, and the like. For problems of injuries, the shift due to perception of adjustability is of particular importance. Even in those instances in which physical improvement can be limited only, the recognition that one can adjust to the injured state will minimize de valuative feelings. A noninjured woman says: </p> <blockquote><p>When I thought of the courage it took to ignore those handicaps, I felt humble. I felt that anyone who overcomes a handicap like that wins an added amount of respect from everyone.</p> </blockquote> <p> For this subject, the fact that the injured men were able to adjust to their handicaps led her to evaluate them not as inferior but, on the contrary, as persons meriting respect. </p> <p> We believe further that the judgment of adjustability will depend upon the adjustment of the judge. A person who feels in essence "What a terrible misfortune to be injured, I could never stand it. I would rather die," we consider maladjusted with respect to injuries. The following comments were made by noninjured people: </p> <blockquote><p> It wouldn't be worth while to live. I'd develop a complex and go off in my little hole. I'd go into hiding and not show my face for the rest of my life.</p> </blockquote> <p>To such people it will seem impossible that one can adjust to injuries. </p> <h4> <i>Standard</i> </h4> <p> In connection with the term "standard," we have previously noted that the standard may be another person, the same person at a different time, or some abstract norm. Frequently the abstract norm has the character of the minimum requirement for a certain role. If the person does not meet the minimum requirement, he will be judged as an unacceptable candidate for whatever role is in question (for example, that of husband, employee, team member, etc.) or he will be devaluated as unfit to continue in the role. This is illustrated by the noninjured girl who said: </p> <blockquote><p> He's correct in not proposing if he couldn't earn a living because of his handicap. </p> </blockquote> <p> In the extreme case of devaluation of the total person, the person will be thought of as an outcast. He does not meet the minimum requirements on a value scale which, in the opinion of the judge, everyone "ought to possess" in order to be a normal human being. Though such extreme devaluation is not often directly expressed, we do find, in the records of the noninjured, statements such as the following when severe handicaps are being discussed: </p> <blockquote><p> If you have no limbs you are not a person really. With both arms and legs gone the person isn't of any use, a detriment to society. </p> </blockquote> <p> When a person is above the level of minimum requirements or "ought standard" (either for a particular role or for a "normal" human being), he may still be devaluated as inferior, for example in comparison with some other person, but the devaluation will not be as severe. </p> <p> There are individual differences in regard to where the ought standard is set. For some it is simply undeniable that a man ought to be able to support his family entirely by his own efforts. If he is disabled so that his wife must work, or if state assistance is required, he will be seen to fall short of this minimum requirement and will be judged unworthy to have a family. Some people may not see this as an ought standard at all; others may apply it to themselves and yet not require anyone else to meet it. </p> <p> We can now state that the most severe type of devaluation (devaluation as unworthy or unacceptable) will occur when the person, in the eyes of the judge, falls below the ought standard on a value scale. </p> <h4> <i>Conclusion</i> </h4> <p> It is obvious by now that the value structure of the judge is of utmost importance. Devaluation will depend upon whether the judge regards the values in question as possessions or as personal characteristics. It will depend upon whether the judge considers the values as comparative values or as asset values. It will depend upon whether the judge regards the person only in terms of single value scales on which he has a low position; whether the judge regards these values as decisive in the context of other characteristics of the person, that is, when the scope of values is enlarged; or whether in this context they are felt to be nonessential. It will depend upon whether or not the judge regards the state of the person as an unadjustable one. It is up to the judge how high the standards will be set, whether he considers a particular standard an ought standard for <i>his </i>concept of the role of husband, father, etc., or of a "normal" person, and whether the standards are flexible or rigid. It is not the objective loss but the values of the judge which determine devaluation. A remedy, therefore, is a change in the value system of the judge. The judge may be another person, or the person himself who experiences the loss. In the first case we speak of the devaluation of someone else, in the second case of self devaluation. </p> <h4> Conflict in the Noninjured </h4> <p> Devaluation of the injured, like the requirement of mourning, conflicts with ethical prescripts as well as with spontaneous, positive feelings toward the injured. The noninjured person does not want to hurt the injured. He tries to be tactful. He will not address the injured with an emotionally loaded word like "cripple." He will be reluctant to say that the injured man is inferior, to be pitied, etc. He will not point to the injured part of the body. He will hesitate to mention handicaps in the presence of the handicapped person. He might sometimes dare to mention handicapped people who "get along amazingly well" (almost as good as a noninjured person) or who, like Roosevelt, are as good as the best noninjured. He might dare to say that he "would never have noticed it" or that someone else has not noticed it. He might feel a strong positive tie with the injured person and feel genuinely sympathetic toward him. </p> <p> Because negative, devaluating attitudes conflict with positive feelings toward the injured which are ethically prompted or which are spontaneous and genuine, we can expect that devaluation will seldom be manifested simply and directly but will tend, instead, to be covered up. For example, a noninjured subject who showed concern and warmth toward the injured could not admit his attitude that a handicapped person is less acceptable. But this status discriminatory attitude is covertly expressed when he says: </p> <blockquote><p>I can readily understand how they [people with less severe handicaps] might resent being classed with those who are totally handicapped.</p> </blockquote> <p>Another subject is able to express his de valuative feelings when speaking about himself if he were injured: </p> <blockquote><p>Without doubt I would be tremendously depressed [if I had an arm or a leg off] at the thought that your usefulness is over now and that you will be nothing but a burden from now on. </p> </blockquote> <p> But he is unable to leave the discussion on this negative level. He hastens to right the situation, to pay deference to the other side of the conflict, and adds:</p> <blockquote><p>But I presume that that would pass and with a little bit of expert help one could return to a normal life.</p> </blockquote> <p> It is also often difficult to disentangle just when the favorable, verbalized attitudes correspond to the underlying feelings and when they do not. When our subjects speak of the courage of the injured, their cheerfulness, perseverance, etc., they are expressing attitudes which overtly are favorable. Sometimes these attitudes seem to be prompted by ethical demands and sometimes they seem to reflect genuine feelings. One suspects that the positive feelings expressed by the following subject are glib and superficial: </p> <blockquote><p> I have met one woman in particular with both legs gone and she had artificial limbs and she got along beautifully. She lost her legs about a year before I met her. And she was very happy. I have more sympathy, and I thought she was very brave.</p> </blockquote> <p>On the other hand, in the following account a noninjured subject reveals a feeling of warmth and respect for the injured: </p> <blockquote><p> I went to a dinner party the other night for the wounded Japanese soldiers at —— Hospital. There were about a dozen of them one completely blind, two with partial sight, another with a leg off, another without an arm. When I first arrived I thought, "I can't bear this. I have never been able to look at suffering." I wanted to go away. I stayed. I got acquainted with these boys. They not only had the physical handicap. They had the racial handicap which is a serious one in this country. I stayed until midnight. I felt each one could have been a friend of my son. They were so courageous, so gay, so sympathetic and generous with the blind boy. They helped him so unobtrusively. I felt I had learned a great deal. I felt there was nothing we could do for them. They were doing for us ... . The way I felt about those boys I felt inferior. </p> </blockquote> <p> The conflict in the noninjured may be evaded or diminished in different ways. We should like to mention two phenomena which might be less obvious than simple avoidance of the injured as a means of escaping the conflict. These phenomena are aversion and spread emotional reactions which make it easier for the noninjured to avoid the injured Aversions have the useful quality of enabling the non injured person to feel that he does not voluntarily avoid the injured but that he does so for reasons beyond his control.<a style="text-decoration:none;">*</a> Spread, or the exaggeration of negative effects of an injury, may provide the noninjured with an excellent reason for excluding the injured from participation in activities which might, for example, be somewhat strenuous. And if one exaggerates the injured person's sensitiveness and withdrawing tendencies, ethical demands will not be obviously violated, since one can assert that the injured person would feel uncomfortable in the group or decline the invitation anyway. </p> <p> In the following chapter we discuss in detail one type of genuine and spontaneous positive feeling toward the injured—that of sympathy. </p> <h3> Chapter VI: Sympathy </h3> <p> Sympathy is brought about in the donor by the suffering aspect of misfortune rather than by the value loss aspect. As stated on page 8, our approach to the study of the sympathy relationship was to consider the total scope of meanings assigned to the word "sympathy" and then to extract those which were tied together by a coherent underlying structure. Pity and other devaluative meanings which the subjects sometimes give to the word "sympathy" do not belong to the same structure. </p> <h4> Primacy of Needs and Emotions </h4> <p> In the older treatises, sympathy was considered an instinctive, or at least an immediate, response to the perception of emotion in another; the perception of pain would bring about discomfort in the observer, the perception of joy would give him satisfaction. We would have no great objection to such a "theory" as far as it goes, but there are difficulties in its incompleteness. For example, we would be reluctant to term "sympathetic" one who, because of his discomfort on perceiving the distress of another, tries to escape the situation. </p> <p> It is essential for the sympathy relationship that the donor set aside his own needs and feelings in favor of those of the suffering member. The recipient will then feel that his needs and emotions are given primacy, and only then will he feel that the donor is sympathetic. The conditions leading to the existence of primacy of needs and emotions of the other are not known to us and require further study. Most frequently it arises in what we call "we groups." The partners in a we group feel bound together by strong ties of friendship, family, etc. They like each other, enjoy being together, need each other. But relative contributions are not measured; comparison of values possessed is not in order; what is important is "we" rather than "you as compared with me." The group is characterized by the sharing of the feelings of one member by the other. The partner is pleased with the joy of the recipient; he is made sorry by the recipient's sorrow. As an injured man says: </p> <blockquote><p> Love for a certain person, that is why you feel sorry. I know my mother feels awfully sorry that I lost my arm. Every time something happened to me my father too felt awfully sorry for me. It was just that he loved me. You just can't get away from it I guess. </p> </blockquote> <p> Instead of putting one's own needs always first, primacy is given to those of the other when they are felt to be more urgent. Exceptional stress and exceptional happiness of the other take precedence over the everyday level of feelings of the donor. He sets them aside and participates in the intense joys and sorrows of the partner. </p> <p> Primacy of needs and emotions, however, does not arise in we groups only. It may exist between people who have no lasting relationship with each other, whose relationships are as tenuous as being fellow Americans in a foreign country or even passers by. What the forces are which keep the donor in the negative distress situation in these instances are not known. </p> <p> What primacy of needs and emotions implies in the sympathy relationship may be described under the headings <i>Congruence, Understanding, </i>and <i>Readiness to Help.</i><a style="text-decoration:none;">*</a> </p> <h4> <i>Congruence</i> </h4> <p> The injured sometimes slate that no one can ever really know what it is like to be injured unless he is himself injured. Those who would urge this against the possibility of real sympathy would probably subscribe to the "identity theory" of sympathy. This as usually stated is "seeing and feeling the distress as the other person sees and feels it." An injured person who rejects sympathy gave this as a reason: </p> <blockquote><p> It's very easy for a person to sympathize who hasn't had the experience himself. It would be a very shallow thing. It wouldn't mean anything to me ... . How can you sympathize with me if you haven't lost your father and I have? You wouldn't know what it is like. How can a fellow sympathize with you if he hasn't lost the leg or the arm? I don't think he could do it. </p> </blockquote> <p> It should be clear that primacy of needs and emotions does not imply identity of feeling. We doubt that the feelings of the donor and recipient can be identical. Nor would identity have advantages. The donor cannot <i>see </i>the situation as the recipient sees it. He cannot know all the emotional ramifications of being injured. And even if he were to understand much of what it means to be injured, he would not feel the suffering in the same way as the injured person does. He does not suffer the actual social deprivation nor the self devaluative feelings of the recipient. The recipient is distressed over the loss itself, the donor because the recipient suffers. The <i>content </i>of their distress is therefore different. Even in the case of a sharer (e.g., a wife or mother) who may himself experience loss, the content is still different. </p> <p> The donor need not approach the <i>mood </i>of the recipient in intensity, nor is it necessary that his mood be the same qualitatively, as long as it is not incongruous. If someone is depressed, a sympathizer need not also become depressed. There are other manifestations of concern sufficiently in harmony with the mood of the recipient to be considered sympathy. On the other hand, gay attempts to divert him will seem incongruous and may be considered an indication that the donor does not give primacy to the needs and emotions of the recipient. </p> <p> Moreover, were the donor to feel precisely the same way as the recipient, it is questionable whether any <i>action </i>he could take would be effective in diminishing the distress. The anxiety and fearfulness of the recipient, for example, would prevent him from realistically evaluating his situation. A similar anxiety and fearfulness in the donor would also act as a barrier to adjustive effort. </p> <p> Thus the donor and the recipient <i>perceive </i>differently, <i>feel </i>differently, and <i>act </i>differently. Congruence rather than identity is required in each of these instances. What makes for congruence is an important problem meriting special investigation. </p> <h4> <i>Understanding</i> </h4> <p> In a distress situation there are in the recipient two conflicting needs that must be taken into account by the donor. On the one hand the recipient wishes to remain in the area of preoccupation with his loss because of attachment to the object of loss, desire for clarification, etc. On the other hand, he wishes to leave the area because of the negative character of the situation (the unpleasantness of the state of depression, a feeling of unproductiveness, etc.). A clear example of both tendencies is found in a bereavement situation in which, in spite of the negative characteristics of grief, one wishes to continue to mourn as an expression of devotion to the person he loves. The first thing the donor must understand, then, is this conflict in the recipient. He must not only be concerned about the emotional state of the recipient in the sense of wishing to help him leave the negative area; he must also give sufficient weight or respect to the reasons which produced the distress and which keep the recipient in the area of preoccupation with the loss. When either of these attitudes is felt to be lacking, the recipient feels that he is not understood. For example, a mother may be genuinely concerned over the unhappiness of her adolescent daughter, but if she tries to soothe her by saying, "It's only puppy love. You'll soon forget all about him," the daughter, even when recognizing her mother's concern, will feel that she doesn't understand and thus that she is not really sympathetic. Similarly, if someone tries to "cheer up" an injured friend by saying, "Oh, you'll soon get a new leg," he may be felt to take lightly the feeling of loss which the injured man experiences. It is equivalent to saying to someone bereaved, "You'll soon get a new wife"! In the following instance an injured man defines sympathy entirely in terms of giving sufficient weight to the reasons for distress: </p> <blockquote><p> Sympathy is appreciating the difficulties you might have.</p> </blockquote> <p>The wish for respect to the cause of distress is seen in the following statements made by injured subjects:</p> <blockquote><p>[People say] "Now before long you'll be as good as new." That's a bunch of posies all for naught .... They don't know what they're talking about .... Though people say, "Oh you'll forget it in a few years," they're always the people who aren't injured. </p> <p> People would come in and tell me how lucky I was. It was just that they were trying to put a whole new set of values on my misfortune. If there is anything you feel about it, it is that it was not lucky. </p> </blockquote> <p>The sympathizer cannot take lightly any features of the situation which are of great moment to the injured even though, in his efforts to bring about emotional relief, he may try to emphasize certain positive aspects. </p> <p> It is important to point out that the word "understanding" is misleading when it is taken to imply only a conscious intellectual appreciation of the diverse meanings which the loss has for the injured. When the injured speak of a person who understands, they sometimes speak in these terms: </p> <blockquote><p> Probably that girl could not answer your questions but she just knew. Some people are like that. . . . There is a person that just has an instinctive good taste and quality in her.</p> </blockquote> <p>It seems as though there is such a thing as emotional understanding that is, grasping the emotions of the other person directly on the emotional level without the intermediate step of intellectual realization of these emotions. The distinction between intellectual and emotional understanding is clearly brought out in the following statement of a noninjured woman: </p> <blockquote><p> Every mother thinks about the possibility of her son coming back wounded or disabled. ... I don't know just how I would react. . . . You would have to feel your way along and learn every day. But if you really love and understand them, you would learn very quickly, by experimentation, and I think you would have to give it a great deal of deep thought, and you would have to have a lot of wisdom, but wisdom comes in an emergency of that sort. [Interviewer: When you said wisdom, that implied intellectual knowledge.] Not necessarily. I would say more a wisdom of the heart. </p> </blockquote> <p> There is nothing mystical in the fact that one may react before having time to understand intellectually. We spontaneously catch a ball suddenly thrown to us without intellectually deciding on a course of action. Similarly, in the case of emotional relationships we frequently react in an appropriate way which is called "intuitive." It seems necessary to assume that the speed of emotional processes is greater than the speed of intellectual ones and that, in communication, emotional grasping of the feelings of another person is faster than intellectual grasping.<a style="text-decoration:none;">*</a> Intellectual understanding may, however, enhance the relationship in which emotional understanding already exists. It may increase the effectiveness of the help offered because intellectual understanding may lead to useful suggestions which the recipient may be ready to accept. </p> <h4> <i>Readiness to Help</i> </h4> <p> It is not by chance that expressions of sympathy are usually followed by some such statement as, "If there is anything I can do, let me know." Such readiness to help should be considered as much a part of the structure of sympathy as congruence of feelings and understanding. This is demonstrated when the injured inveigh against the "so called sympathy which is nothing but words." For example: </p> <blockquote><p> The good kind you try to do what you can for them to help them out. The bad kind they just say they feel sorry and let it go at that. </p> <p>Oh, absolutely [there is a good and bad kind of sympathy]. But it can be expressed through actions rather than through words fidelity, sticking by you through thick and thin. </p> </blockquote> <p> The kind of physical help which is acceptable is elaborated elsewhere<a></a>. In the sympathy relationship, we are especially concerned with emotional help in overcoming feelings of distress. Whether or not this type of help will be acceptable will depend upon whether the donor continues to be guided by the recipient's wishes and also upon his knowlesdge of the relative strength of the momentary tendencies toward and away from the distress area. The donor should be passive or active depending on these wishes and tendencies. </p> <p> When the tendency to stay in the area of concern with loss is very strong, the recipient may want nothing more than assurance of concern, an understanding listener, or the comfort of bodily contact with a person with whom strong ties exist. The word "passive" should be taken very seriously. Expressions of concern which are uncontrolled and immoderate may be very disturbing. A few subjects give hints as to why demonstrative manifestations of sympathy are disturbing: </p> <ol> <li>The injured person may be so keyed up emotionally in regard to the whole injury situation that additional emotionality is difficult to bear: <em>Sympathy is disagreeable to the man because of the state of emotion he is already in.</em> </li><li>Any strong emotional expression may make the man feel that his situation is even more unfortunate than he thought it to be. It can easily lead to a feeling of futility of his attempts to adjust: <em>I don't want them to cry. It makes me feel sick I can do anything anybody else can but when they do that I would have to feel that I would have to give up trying to do things.</em> </li><li>The man does not know how to act when strong emotionality is shown. The situation tends to become unstructured. Embarrassment results: <em>Sometimes a motherly old gal embarrasses you with how sorry she feels for you.</em> </li><li>Strong emotionality may arouse feelings of guilt in the man at having caused so much distress: <em>I don't want anybody to feel sorry for me Sorrow isn't a thing to share.</em> </li></ol> <p> Further, there are other important reasons why the injured objects to excessive emotionality. The injured may doubt the sincerity of the feeling, and any demonstration may convey to the injured that the donor is trying to make sure that his "goodness" is appreciated by the injured (page 31). We wish especially to stress the fact that excessive emotionality has also the danger of making the donor imperceptive to the shifts in feelings and changes in needs of the sufferer. It is important to note that in the opinion of the injured a deep positive feeling on the part of the sympathizer can be conveyed to them without any emotional display. They object to shallow sympathy, but shallow sympathy is not, of course, equivalent to sympathy that is manifested simply and without elaboration. <i>Active </i>help requires that the donor be alert in watching for an occasion when he can strengthen the forces in the recipient in the direction of leaving the distress area without provoking resistance from the recipient. One injured subject identifies this as encouragement rather than sympathy, but the idea is essentially the same: </p> <blockquote><p> You can always take encouragement. More than sympathy, it is the cheerful look, not a sorrowful look a feeling of raring to go that kind of infects you not the idea that the world has gone wrong. </p> </blockquote> <p> Yet sudden or too strong or persistent urgings in the direction of leaving the area reflects on the genuineness of the donor's appreciation of the cause of distress. At the first sign that he has proceeded beyond the ability of the recipient to follow him, the donor must be ready to abandon any benevolent attempts. Because the emotions of the donor are not identical with those of the recipient, because he is not so depressed, he is already a step ahead in the struggle to overcome the distress. It is this discrepancy in feeling which gives the donor the possibility of shifting the recipient in positive directions. But the emotional change required of the recipient cannot be too great. Only small steps can be taken, the size of the allowable step being not infrequently smaller than the donor wishes would be possible. </p> <p> The meaning of size of step may be grasped more fully if we consider the parallel case in the intellectual realm. A teacher may explain too quickly or may omit necessary intermediate points. The student is then unable to follow because the size of the steps taken by the teacher has been too great. In the emotional realm, we may take the case of a noninjured person who, wishing to overcome the brooding of his injured friend, suggests a joyful interlude. Though the injured friend <i>also </i>wishes to overcome his brooding, merrymaking requires too great an emotional change for him. It is interesting that when someone is deeply distressed a sympathetic person may suggest a cup of tea. This may represent not only concern for needs which the sufferer himself might neglect; it is also a shift from preoccupation with loss to an activity which is neutral enough not to seem incongruous. It will also not be seen as too great an emotional step if the donor gradually aligns himself with and strengthens those positive aspects which the recipient might express, for example that he has the fortitude or stamina required, or the hope of an eventually successful outcome. </p> <h4> Spontaneous and Ethically Dictated Sympathy Sincerity </h4> <p> In the absence of spontaneous sympathetic feeling, there may still be strong social pressure to play the appropriate role. Thus, besides sympathy based on genuine primacy of need of another person there is simulated sympathy— sympathy for the purpose of adhering to the ethical ideal that one <i>ought </i>to be a good person, which sometimes implies self aggrandizement. Most people will be able to recall being at one time or another donors of both kinds of sympathy—that which is "ought inspired" and that which is prompted by genuine concern In some instances the former will be difficult to admit to oneself. </p> <p> It is important that the dynamics of interrelationship between the donor and recipient is different in the two cases. If the sympathy is ought inspired, the donor will do as much for the recipient as is required by the donor's need to be "good." We cannot help but suspect that he will be guided much more by what <i>he considers </i>good for the other than by the needs and wishes of the person he is sympathizing with. The recipient distinguishes between spontaneous and ought inspired feelings of sympathy in the donor and speaks of them as "sincere" or "insincere." This does not mean that he always correctly detects them. But when the underlying feelings are seen as spontaneous and genuine they will be evaluated as positive, even though the recipient may not for other reasons welcome the overt expression of sympathy <i>(e.g., </i>because of lack of knowledge or sensitivity in the donor or because of some conflict in himself; see page 32). Positive evaluations of the genuine feelings are expressed in these terms: </p> <blockquote><p> I don't mind [if old friends say they are sorry]. Being a friend I felt that his word was sincere, coming from the heart. <br /> Sincerity means a lot.</p> <p>Yes [there is a good kind of sympathy and a bad kind]. You can always tell the person who does actually have a feeling for you and is sincere. </p> </blockquote> <p> Ought inspired sympathy can be evaluated as proper when seen as a formal expression of politeness. The donor thereby conveys only a recognition of the seriousness of the event and his intention not to intrude further into the privacy of the recipient. A limited interaction of this sort is accepted, but it must be brief and does not bear repetition. The injured say: </p> <blockquote><p> I think it is all right [for someone to say he is sorry on first meeting]. I think I would say the same thing. If he would let it go with saying he was sorry and not rave on about it. </p> <p>I don't mind anybody saying that. It's just like a person saying, "I'm sorry you are sick." Not if he just said it once. It's the same if you have lost a wife or relative or something; people offer their condolences. That is the same thing. It is all right if you don't overdo it. That is just common politeness. </p> </blockquote> <p> While this type of sympathy is less valuable to the recipient than is genuine sympathy, it bears no great dangers. Perhaps the only additional caution required is that overt expression of this sort of feeling should emphasize the event and not the man. To say, "I'm sorry it happened," conveys what is needed. "I'm sorry for you," may connote devaluation: </p> <blockquote><p> A person can say he is sorry it happened, but I don't want him to say he's sorry for me. . . . It's in the time element. Sorry it happened refers to the past and it doesn't mean he keeps right on feeling sorry . . . and pity and being sorry <i>for </i>a person suggests looking down. </p> </blockquote> <p> Though interactions of this kind are accepted, they are by no means considered necessary by the injured. But the injured know also that their acquaintances may feel embarrassed if they make no comment on first meeting the man after the injury. Hence, in addition to the evaluation of "proper," the same behavior may be regarded as <i>neutral or unimportant:</i> </p> <blockquote><p> They don't really need to say it, but it's all right. If they say [casually], "It was hard luck," it's all right. I'd just as soon they wouldn't say it. If it's a friend of yours, you know anyway. </p> </blockquote> <p>The evaluations become negative when the basis for the expression of sympathy is felt entirely to be a matter of obligation:</p> <blockquote> <p>Some people who are not so close to you feel they <i>should </i>give sympathy and say they're sorry you lost your leg. </p> <p>This sentimental stuff. It seems to be partly an act. Old people seem to think they are obligated. </p> </blockquote> <p>The simulated sympathy which is feigned for self aggrandizement or to satisfy some other need of the donor is rejected: </p> <blockquote><p>Well, there's the crocodile type [of sympathizer]. . . . Cries, you know, like the crocodile. Then . . . the he man type. He comes up and claps you on the back. All the time patting himself on the back. </p> </blockquote> <p> Ought inspired sympathy, when mistaken by the recipient for genuine feelings, provokes positive feelings toward the donor in return. When the recipient does reciprocate and later finds no real concern for his needs, he feels cheated or fooled first because he was under false pretenses drawn into serving as a means of satisfaction of the needs of the other; second because he was ready to accept emotionally this person whom he now rejects as unworthy; and third because, believing himself secure with this person, he permitted himself to expose his private and sensitive feelings. Insincerity in such a case is therefore threatening; it is rejected and avoided. </p> <h4> Desire To Be Noninjured </h4> <p> Sympathy may be unwelcome not only because of some failing of the donor but because of the recipient's own attitude toward his injury. To welcome sympathy means that the injured man must admit that the injury has made a difference to him, even if it is only in particular and confined ways. He must not only see himself in the sympathetic situation as an injured person but must also be willing to have the sympathizer see him as such. This is not easy to do if the man has negative emotional feelings toward being considered an injured man. The resistance against being regarded as an injured person may be seen in the man's resentment of sympathy when he says: </p> <blockquote><p> Servicemen don't want their family to feel sorry for them. . . . Some people feel sorry but not around Utah. They see a lot of it. They treat you just as if you were another man. </p> </blockquote> <p> The persistent demand by the injured to be treated like anyone else may be indicative of healthy attitudes when it reflects their resistance to being devaluated. But when it is a sign that the injured person doesn't want to share injury connected matters because he is ashamed of them, that he wishes above all else to be considered a noninjured person, then he must of necessity remain troubled. When he reaches the point where he can face the fact of his injury, then he becomes able to receive the comfort which sympathy may bring. </p> <h4> Sympathy and Adjustment </h4> <p> The desire of the sympathizer is to help the sufferer to reach a happier state, to help him to adjust. The recipient, too, may wish sympathy not only because of the immediate comfort that it may give him but also because he hopes that the other will help him overcome emotional difficulties. But is there anything in the nature of the sympathy relationship as such which will assure better adjustment? Does it imply that the sympathizer will be better able to recognize intellectually or emotionally what leads to adjustment? Just as the recipient himself, the donor may err as to what is adjustive. He may lead in nonadjustive directions. One can say only that the sympathy relationship provides a favorable atmosphere for influencing the recipient, whether for better or for worse. </p> <p> There is, however, another point to be considered, namely, whether sympathy, as an expression of we group feelings, does not always have some adjustive value. Sympathy, as an expression of we group feelings, gives assurance that one is of worth to another person. We shall see that adjustment may imply the overcoming of the feeling of worthlessness of oneself and meaninglessness of the world around. </p> <h3> Chapter VII: Acceptance of Loss </h3> <p> In the preceding two chapters we spoke about the meaning which misfortune has for the noninjured and about his feelings toward the injured. We indicated that these feelings lead to difficulties <i>(Misfortune, </i>Chapter V) and to attempts on the part of the noninjured to lessen the suffering of the injured <i>(Sympathy, </i>Chapter VI). In his social relationship with the noninjured, the injured has to find a manner of living most satisfactory for him. He has also to overcome certain individual difficulties in addition to those produced by social relationships. He has to accept both personal loss and social loss. </p> <p> The content of personal loss as felt by the injured may be conveyed by the following statement ascribed by us to a leg amputee: </p> <blockquote><p> The leg which was a part of me and like the other is now detached from me. With it I felt free to move, to jump, to run, to play. I could move it, move with it; it moved me. I will be hampered. I will not be able to climb a mountain (even though I never climbed one before). I won't be able to dance or fight as well as before. I won't be able to take a job that requires standing for hours. The prosthesis can fail. I can slip and fall. I have to take care of the stump. When I look in a mirror I won't see a whole man; I will have to get used to seeing myself this way. I can't bound out of bed in an emergency. When I move I will think, "Is it worth the inconvenience and effort of getting up?" So much that I will do would have been so much easier; in a shorter time I could have done so much more. I will always be less able than I would have been. I was a better man when I had my leg and amounted to much more than now. I will never be what I wish I were, and ought to be had I the leg. </p> </blockquote> <p> In suffering from social loss, the individual suffers as a member of a group. He feels that he is not accepted as equally worthy. Other values which the group can offer, such as companionship, are made inaccessible. </p> <p> The content of social loss as felt by the injured may be conveyed by the following statement ascribed by us to a leg amputee: </p> <blockquote><p> I will be considered inferior by others. They feel that I can't contribute my fair share. I will be regarded as a burden. They won't want to associate with me. They might stand my presence but not accept me as they would a noninjured man. Girls won't want to go out with me. People will be repulsed by the sight of me. </p> </blockquote> <p> One could consider each of these difficulties and see how each in turn could be overcome. This obviously is an endless task, for one could continue to enumerate specific sufferings involved in personal and social loss. Instead, it is more meaningful to try to see whether there are not some conditions common to diverse difficulties. Understanding of these conditions is actually a first step toward solving problems of adjustment, for only when they are clearly specified can we tell what it is that must be changed, and only then are we able to get some insight regarding the state to which it would be desirable to change and how to produce the change. </p> <p> The desired state which we call "acceptance of loss" does not mean becoming reconciled to one's unfortunate situation. Instead, acceptance of loss is a process of value change. Before discussing value changes, however, we wish to describe those attempts at adjustment which seem promising to the injured, yet not only fail basically to overcome the difficulties but even create new ones. </p> <h4> Maintaining the Noninjured Standard </h4> <p> The way in which the injured person tries to overcome difficulties is determined by the fact that his values are those of a noninjured person. A blow which damages a part of his body does not at the same time lead to changes within his value system.<a style="text-decoration:none;">*</a> He may continue to maintain the noninjured position as <i>the </i>standard of comparison and direct his efforts toward reaching it. He may cling to the belief that the way to overcome his difficulties is to be, in his own eyes and in the eyes of others, a noninjured person. To achieve the end of being considered noninjured, he uses all means available, both realistic and unrealistic ones. </p> <h4> <i>Realistic Attempts to Achieve the Noninjured Standard</i> </h4> <p> The realistic means used by the injured to be like the noninjured are strenuous efforts to perform certain tasks independently and to equal or surpass the success of the noninjured in certain roles. These attempts can be considered realistic because in certain limited ways they are successful. The injured can equal or surpass the noninjured performance on particular scales or in particular roles. But <i>if the sheer fact of being an injured person is a difference which makes a difference to the injured man, that is, if the noninjured remains the wished for ideal, no matter how often he does as well or better than the noninjured he will still devaluate himself as an imperfect noninjured person.</i> </p> <p> In their efforts to be noninjured, the injured impose upon themselves unnecessary strain, Whereas the noninjured person often readily accepts help when it is more convenient to do so than to perform a task alone, the injured person tends to be reluctant to accept help if the help is not absolutely necessary<a></a>. Thus an injured man says: </p> <blockquote><p> I wouldn't accept help except where absolutely necessary. Offers of help get me down unless I were in a real jam. [Interviewer: What do you mean by absolutely necessary?] Oh, something like an earthquake out here where I couldn't get my hands on my crutches in time. </p> </blockquote> <p> <b>And another says: </b></p> <blockquote><p> You'd like to be a lot more independent than you were before. If somebody opened the door before, you never paid attention to it, but they do it now and you notice it. </p> </blockquote> <p> In order to explain why the injured, in striving to be and behave like a noninjured person, is led to impose greater hardships upon himself, we must take into account that "help is necessary" has a double connotation. It means "Without help I will not reach a desired goal," and "I am not able." The latter implies comparison of one's own ability with that of another. "You cannot do it, but I can," is, in our ability minded society, a most unwelcome comparison. For the injured person who wishes to be noninjured, the ability comparison aspect of help has a greater weight than for the noninjured, and he wishes to deny that he <i>needs </i>to be helped. The necessity of the goal, therefore, has to be greater for the injured in order to overcome the resistance against being helped. This, we suspect, could be shown by a simple experiment. </p> <p> A scale of the necessity of help is constructed. One end indicates "help is a pure matter of convenience" <i>{i.e., </i>no great effort needed to perform the activity alone, but someone willing to share the effort), the other "help is absolutely necessary" <i>{i.e., </i>an important goal completely inaccessible without the assistance of another). We can then determine the points at which help will be welcomed by injured and noninjured persons. Judging from the data we have, we would expect that the point of acceptance of help by those of the injured who wish to be as much like the non injured as possible will not in general coincide with that chosen by the average of the non injured subjects but will be nearer to the point of "help is absolutely necessary." Thus, when the injured person in speaking about help says, "Treat me like anyone else," he may not mean "Give me as much help as you would a non injured person for whom a task is inconvenient." Instead, he may mean "Do not help me; a noninjured person would not require help in this situation." </p> <h4> <i>Unrealistic Attempts to Achieve the Noninjured Standard</i> </h4> <p> The unrealistic means toward being considered noninjured are the attempts to deny that an injury makes any difference whatsoever, either to the person himself or to anyone else. The injured man should forget and others should forget; if both would forget there would be no difficulties: </p> <blockquote><p> [Interviewer: How should a person go about adjusting?] <br /> I think he should forget about it. People should just forget what happened. If he doesn't think of it, it won't bother him. </p> </blockquote> <p> Two reasons seem to support the belief in this literal kind of forgetting. First of all, in the highly emotional striving for adjustment, the aim and the means are not sharply distinguished. "I wish my injury would be forgotten," and "It can be done by actual forgetting," merge together in an emotional state which leads to primitivization in thinking. </p> <p> Secondly, the injured man does many things without feeling like an injured person. When he is in a bar, reading the comics, discussing political affairs, and so on, the thought that he is an injured person may not enter. In such situations he escapes the painful devaluative feelings associated with his loss. Temporary forgetting which the injured man does experience may make him believe that he can forget the injury most of the time. </p> <p> Temporary forgetting may not be altogether valueless in the process of adjustment. It may provide much needed emotional relief before one can again become involved with the problems brought about by other adjustment attempts. Consideration of problems connected with the injury goes on at the emotional level with such intensity that temporary escape may be welcomed as a psychological rest from too much strain on the organism.<a style="text-decoration:none;">*</a>But the injured person realizes in time that it is not only hard to forget what exists but that also so much happens which may "remind." Thus an injured man who said, "You can forget you are hurt if everybody ignores it," a few sentences later complained, "If you go out you can hardly go through a day without people asking you about it." And reminding is not due only to the incorrigibility of the non injured. A person who wears a prosthesis, for example, has to put it on and take it off. The injured often has to enter situations in which other people are handicapped, and again he is reminded. Thus even if one could willfully forget, one would constantly be reminded by new occurrences. The wish and the impossibility of forgetting are brought out clearly in this statement: </p> <blockquote><p> More or less forget about it is the best thing, but how are you going to forget when everybody keeps reminding you of it? I guess in time to come they won't be half as curious and will accept it. ... I don't think about it unless someone speaks about it, or if I think about something I want to do and then I think, "Hell, I can't do that." You shouldn't worry about it, but you can't forget that one moment when you got hit. But it's about the future that you think. </p> </blockquote> <p> The belief in the possibility of literal forgetting gives way, therefore, to the feeling that the injured and noninjured should behave toward each other <i>as if </i>the injury did not exist: </p> <blockquote> <p>I'd just act normal, as if nothing had happened. <br /> The happy and perfect thing is to have it ignored completely. <br /> [Forgetting?] That's hardly possible but we can all make believe. </p> </blockquote> <p> It is evident that such behavior does not really mean that the man will be considered noninjured. On the contrary, it is implicit in acting "as if" that he actually is not noninjured. </p> <p> As in the case of temporary forgetting, which has some positive aspects, so also "as if" behavior has its assets, though they be limited. The injury may be considered a personal matter, and "as if" behavior serves the purpose of keeping others from intrusion into privacy. Thus, under certain circumstances, "as if" behavior may be appropriate, especially where strangers are involved. But "as if" behavior, again as in the case of the attempt to forget, brings about difficulties in the relationships between the injured and the noninjured. When the participants in a relationship are closely associated, persistent role play has negative effects. First, if each feels that he can never relax his guard there will be a constant strain. But worse than that. It is characteristic of close relationships for the partners to share their feelings. If the formal surface behavior which is appropriate to stranger relationships persists, they will begin to feel like strangers to each other. Closeness, which is built upon easy communication, sharing of feelings, the warmth of sympathetic interactions, gives way to estrangement. Basic understanding between the persons cannot be reached. The injured person will continue to feel that he is not understood and cannot be understood.<a></a> Again, as in the case of help (page 34), the injured deviates from the actual behavior of the noninjured, for the noninjured does not ordinarily impose such restraint upon himself and does not in time of stress deprive himself of the comfort of sympathy. </p> <h4>Some Value Changes Involved in Acceptance of Loss </h4> <p> Denial that a difference exists, as we have seen, not only does not overcome difficulties; it may actually create new ones. But above all it hinders basic adjustment, for admission that a difference exists is a prerequisite for the further step of accepting the difference as non devaluating. Most important for the process which we have called "acceptance of loss" is a process of revaluation. Although this process is too complicated to permit us at present to make more than a few statements regarding either observed changes or possible ones, we can present, as an incentive to further study, the advances we have thus far made in understanding it. </p> <p> The first problem is why revaluation should be so difficult for the injured. Why, in the face of persistent difficulties, do they cling so strongly to those evaluations which hurt them? Two reasons may be mentioned. First, the injured seem to feel that, since abnormality of the body connotes psychological deviation or even mental abnormality to some people, they will only strengthen this impression should they maintain values which differ from the noninjured's viewpoints and ideals. Second, and most important, is the fact that to produce value changes on the emotional level is at least as difficult as to change the needs of the person. Though one may easily convince a person intellectually of the advantage of adhering to different values, their actual integration within the value system of the person is bound to meet resistance. This is understandable if we consider that single values are not independent from other values of the person, so that one change in the value system necessitates making changes in other values or giving them up. </p> <p> Some of the value changes which we believe would do much to overcome suffering from loss may be examined in the light of certain considerations brought out in the discussion of devaluating misfortune. First, devaluation will be diminished to the extent that the values lost are felt to be nonessential for the evaluation of the person when the scope of values is enlarged to include other personal characteristics. Second, devaluation will be overcome when the values lost are regarded as asset values rather than as comparative values. A third possibility, viewing the value lost as a possession value rather than as a personal characteristic (page 22), doubtless has ad justive significance, but this will not be further elaborated here. </p> <h4> <i>Enlargement of Scope of Values</i> </h4> <p> We may describe two examples in which enlargement of scope of values takes place.</p> <p><i>The State of All-Inclusive Suffering. </i></p> <p>For the injured person to see the lost values in a larger setting of other values is of special importance in the case where he feels he has nothing more for which to live. The problem then is to bring about the emotional realization of the existence of other values. Some injured subjects have admitted that in the initial stages their suffering was so acute, the experience of loss (of both personal and social values) so overpowering, that the idea of suicide presented itself. In such a state the loss seems to pervade all areas of the person's life. Whatever he thinks about, whatever he does, he is troubled, pained, and distressed. There is no differentiation between areas of the person which are and are not injury connected. All that matters are the values affected by the injury, and they are lost. No other values in life are important or even exist. </p> <p> There are two characteristics of such a state which make the thought of suicide likely. First, the perception of only a single area which is characterized by suffering means complete devaluation of one's life. Moreover, the suffering seems to be boundless, not only in extent but also in time. If no other area is seen, then there is nothing to which one can hope to change. The only hope of escaping suffering is to leave life altogether.<a style="text-decoration:none;">*</a> </p> <p> Fortunately, such black depression and despair does not persist in most of the injured who experience it. There is a gap in our knowledge as to just how it is overcome, but what is necessary is the perception of something besides suffering in life. It may be that, when the decision to commit suicide is made and when only execution of the plan remains, the injured may look back at what will be given up: suffering <i>and life. </i>When fighting against living further is no longer necessary, as it is before the decision is reached, life itself may be seen as a value. At such a moment this sudden experience of something else than suffering may be sufficient to give the first hold and with it the feeling of hope and strength which we have called the "stamina experience," so distinctive and easy to recognize when encountered, although difficult to convey, that it was named long before its place in problems of value change was seen. </p> <p> Those who have had the stamina experience know that life is worth living again. They feel that'' they have been all the way down to the last door and come back," that no other enemy will ever be so formidable. The realization that the essential value of life is regained means that the unbearability of the situation has been overcome. It means that the person is able to attend to what life holds for him, to begin to appreciate the fullness of meaning of having what he does have. As one very severely injured man put it: </p> <blockquote><p> You gradually see that there is more to life than you thought possible. . . . They all think at the beginning that they are no good. Why there was a fellow here the other night who had a couple of fingers missing, and you would think there was nothing worse under the sun. And I said to him, "Well, son, you still have a pair of arms, a good pair of legs, a good pair of eyes. Why just think of it! I would be glad to have a good pair of anything." </p> </blockquote> <p> Another injured man stated: </p> <blockquote><p> I have a sharper appreciation of things I valued before health, happiness, comfort, friendship. I am a hedonist. I feel lucky for just being here.</p> </blockquote> <p>And still another calls it a "conversion to life": </p> <blockquote><p> Before, when I would try to analyze myself, I would come against a blank wall. F'or seven months I don't think half the time I knew what was going on. . . . Some things have become more important that before seemed so unimportant, and consequently less important the other things that seemed so important before. ... I never had a clear conception of what it meant to live. In other words, I have come to the conclusion that most people go through life and never accomplish anything. They just live. They eat and sleep. . . .Cows I call them . . .They just grow and disintegrate. ... I feel that if I don't make a contribution what's the use of having come back alive. I don't want to waste my life now. . . . [Interviewer: It's almost a religious experience.] Well, it's a complete change. . . a conversion to life. Religion is another thing. . . . You have got to dance, to laugh, and have your fun, but also you can put your aims on a higher plane. </p> </blockquote> <p> The injured frequently maintain that "It is up to the man himself," to overcome the depression in the acute suffering stage. In other words, perception by an outsider that something other than suffering exists is felt to be unconvincing to one who is within the area which seems all pervading. Some injured therefore state that the depressed one should be left alone. Others, however, try to overcome what they call "self pity" in a friend by scolding and ridicule: </p> <blockquote><p> That's all within the man himself. I have seen them when they haven't anything to live for after the injury. [One guy] wasn't eating, feeling so sorry for himself. I called him everything but a gentleman. I called him everything I could think of. After that he started eating. </p> </blockquote> <p> The fact that the friend is hurt and feels these insults to his manliness means that he discovers at least pride as a remaining value. As different as the overcoming of depression by oneself or with this sort of "help" may be, they have in common the finding of a value at a time when every value is lost. </p> <p> The method of hurting the injured man during depression should not be given as a recommendation to the noninjured. Such behavior on the part of the noninjured would simply intensify the feeling of being devaluated. When the injured use this method it means "He is not devaluating me for being injured but for being unmanly." At the same time, the injured friend is there as an example that one can be injured without feeling that everything has been shattered. </p> <p> What the conditions are which give the values of manliness, of pride, the power to restructure the meaning of the lost values so that they no longer dominate the person's life needs further investigation. Though the lost values may retain their importance, the stamina experience brings with it the strength and hope which make the injured person feel that he is ready to live further <i>in spile </i>of difficulties. An important condition toward overcoming devaluation is thereby realized. The injured state is no longer regarded as an unadjustable one. At least in the sense of being able to make a go of it in spite of difficulties, the person feels he can adjust (page 24). But though the worst consequences of loss may be avoided through enlargement of scope of values, it does not mean that all suffering is overcome. It does mean, however, that the person has been faced with the necessity for revaluation. He has had to see the place of the lost values in his whole value system. In this way he is a step ahead, for adjustment, when the person is not in a depressed state, also entails value changes. </p> <p> <i>The Problem of Appearance. </i>A person may be bothered by his appearance because he feels that it discounts his attractiveness to others. The injured person may believe, for example, that when someone looks at him his scar is seen and nothing else matters. We propose that devaluation due to damaged appearance will be diminished to the extent that surface appearance is felt to be nonessential for the evaluation of the person when the scope of values is enlarged so that surface appearance is included within personality appearance. Actually, the perception of the appearance itself may then change so that it is seen in light of the personality. Thus, whatever the objective condition of the surface appearance may be, when one reacts positively to the person the appearance may be felt to be attractive. Of appearance, a man who was undergoing plastic surgery had this to say: </p> <blockquote><p> Some people who you can look at their picture and say that they are extremely homely and yet the people who know them will swear that they are good looking. I heard that people used to think that Lincoln was very handsome. A man could not grow an awful lot homelier than Lincoln. . . . There are certain things in a man's face that are an indication of his character, and if those things are what you like they make him good looking despite the fact that his features are a little irregular. </p> </blockquote> <p> In this case the attractiveness of a person is determined not primarily by a smooth, unblemished surface appearance but more decisively by his personality, from which scars may not detract. </p> <p> Many people quite naturally judge a person's attractiveness in terms of his personality. Under certain circumstances it seems that the influence of personality recedes to the background while that of surface appearance becomes the focus of attention. In the case of the injured, primacy of surface appearance leads to devaluation, so that the integration of surface appearance within the context of personality should diminish suffering. The conditions which determine the primacy of personality or surface appearance is a problem requiring special investigation. </p> <p> We present below an excerpt from an interview with a person who has a severe facial injury. During the interview, the evaluation of the appearance or attractiveness of a person is seen to change from surface appearance to personality appearance: </p> <blockquote><p> <i>Subject: </i>Undoubtedly at first it is a great shock to a person's family their loved ones when they see him with his features changed from what he was before. It is a great shock at first. They have to be around him for a while before they realize that fundamentally he is not changed. <br /> <i>Interviewer: </i>Do you think, actually, it is a big shock? I don't think so. I am speaking from my own experience, I am asking you, what do <i>you </i>see in a person you meet a new person what do <i>you </i>see? <br /> <i>Subject: </i>The first thing you see is his appearance. <br /> <i>Interviewer: </i>Why do you say that? The first person you saw here was John Hall. When he came in, what did you see? <br /> <i>Subject: </i>A fine looking young man a gentleman. <br /> <i>Interviewer: </i>Now, has gentleman anything to do with a scar? <br /> <i>Subject: </i>No. <br /> <i>Interviewer: </i>Now let us say there is a new doctor on the ward. He comes in. What do you see? <br /> <i>Subject: </i>It is hard to say. If he has a strong personality, the first thing you see is his personality. Is he capable? How he approaches you. <br /> <i>Interviewer: </i>That is it. Myself, I think is it a nice person? Do you see? It is the kind of person. What kind of a nose? Do you remember the kind of nose John Hall has? What kind of mouth he has? <br /> <i>Subject: </i>Not distinctly. But if there had been something outstanding, for instance a bad scar, you would remember, wouldn't you? <br /> <i>Interviewer: </i>Now, for instance, when you look at the patients in the hospital, what do you notice about them? <br /> <i>Subject: </i>The boys, when you first see them, you notice first their scars. <br /> <i>Interviewer: </i>The first moment? <br /> <i>Subject: </i>The first moment. That is the hard part. <br /> <i>Interviewer: </i>How long? <br /> <i>Subject: </i>Until he says something. Then you start getting an idea about his personality, and once you start thinking of him as he really is, you don't think of his scars. You don't remember them. <br /> <i>Interviewer: </i>You can see the nose of a person, but when you speak to a person you don't notice the nose. You notice the personality, because you see you looked at John Hall, and you only saw the personality. <br /> <i>Subject: </i>The way I was impressed that is the way I was impressed. That is new. I hadn't thought of that before. </p> </blockquote> <p> In the above example, the attractiveness of a person is seen primarily in terms of the more inclusive personality appearance rather than in terms of surface appearance. If this is a lasting change, then we can expect that for this subject devaluation of the injured due to damaged surface appearance will be diminished. </p> <h4> <i>Change from Comparative Values to Asset Values</i> </h4> <p> Two situations involving a change from comparative to asset values may be described. </p> <p> <i>The Problem of Mourning. </i>A person may mourn his loss because the personal satisfactions which the object of loss gave him in the past are now denied him. For example, the injured man may feel, "With the old leg I was free to move, to jump, to run, to play. I could move it, move with it; it moved me." Overcoming of mourning does not require a lowering of the level of aspiration (being satisfied with less), nor does it require depreciating the object of loss. What seems to be necessary to overcome mourning is a change in relationship to the object of loss. </p> <p> In the case of loss of a person, the one bereaved must recognize that, although further <i>interactions </i>with the person are impossible, a <i>relationship </i>nevertheless can still persist. Some of the values which they had formerly shared, and which, in his first grief, he may have seen as dependent upon the presence of the lost one, can be kept. He can do what the loved one would have done and wanted him to do. He can bring up his children to observe the traditions which his wife had begun. Then he can look back upon the past with tenderness rather than rejecting any painful reminders of it. </p> <p> Some similarities may be found in the change of relationship to the lost object which is necessary in the case of the injured. An amputee, for example, has to feel that the most essential functions which the limb had formerly enabled him to perform can be carried on by the stump and the prosthesis. He has to feel that he is still an intact organism, a whole man. A change of feeling has to take place from that expressed by one subject: </p> <blockquote><p>What does she see when she comes in? Half a man lying on the bed. . . .</p> </blockquote> <p>to that expressed by another:</p> <blockquote><p>I am a long way from worthless. I am still a good man without the leg.</p> </blockquote> <p> Such a viewpoint implies that one turns to the satisfactions existing in the present and does not derive essential satisfactions or dissatisfactions from comparison with the noninjured state in the past. It means that a leg as a value has changed from a comparative value (without which one is inferior) to an asset value (a good thing when it is present). If such a change takes place on the emotional level, the past can be remembered without pain but with tenderness with that tenderness which old people not infrequently feel toward the reminiscences of their youth. The two states of the person before and after the change can be described as, first, "I am nothing but an incomplete noninjured person who has always to mourn his loss," and, second, "I am as I am, and though I don't have all the possible values which can be <i>imagined, </i>my life is full." </p> <p> <i>The Problem of Disability. </i>The change from comparative to asset values is indicated not only when the person suffers because of personal loss as described above but also when he suffers because of loss which is socially evaluated. As an example, we shall consider the disability aspect of the injury. </p> <p> To call someone disabled implies that <i>performance </i>determines the evaluation of the person. In our society, people are frequently compared with each other on the basis of their achievements. Schools, for example, are predominantly influenced by the achievement or product ideology. High grades are given not to the one who worked hardest but to the one who performed best. Under certain circumstances, of two who reached the same performance level, the one who did so with greater ease is considered the better. He is seen as potentially a better producer than the one who had to work harder. Thus, effort is not always considered as a positive value but, paradoxically, sometimes as a liability. </p> <p> If one would follow the maxim which also exists in our society to the effect that, "All that is expected of you is that you do your best," it would mean that the person would not be compared with others in regard to ability; it would mean that his own state matters and thus that it does not matter whether he lost or lacks ability. Actually, one wishes to say, a person does not lack ability; he can only <i>have </i>it. In everyday life we do evaluate as equally good citizens those who pay taxes according to their financial state. The injured who applies himself with effort contributes the most that he can as a <i>person. </i>Though the unsatisfactory physical tools of his body may have limited his production, his personal contributions are at the maximum. As a <i>person </i>he is not different from the noninjured. </p> <p> Effort as a basis for evaluation is observed in the injured. A bilateral amputee stated: </p> <blockquote><p> Sorry is for someone who does his damnedest but still he is physically unable to accomplish what he does in the best way. Pity is for someone you feel like he isn't putting everything into it. Not up to standard, up to what you judge by. Maybe I am wrong but that's the way I think of it. </p> </blockquote> <p> This man expresses the thought that, in addition to the scale of achievement ("accomplishing what one does in the best way"), there is another scale, that of effort ("doing one's damnedest," "putting everything into it"), and that devaluation ("pity") should be reserved for those who are lower on the effort scale. Only those who do not put forth sufficient effort should be judged as "not up to standard." </p> <p> Why bring up the change from one comparative value (the product achievement value) to what appears to be just another comparative value (effort) when we are discussing the change of comparative values to asset values? It is true that effort, in this case, is seen as a comparative value, but when effort becomes the yardstick by which a person judges himself, then the <i>values lost </i>are changed from comparative to asset values. Greater ability or achievement becomes a good thing when it exists, but not a loss, or a lack, or a disturbance when it is absent. Such a change is but one among others that are required for the person to perceive his existing state as valuable rather than as a crippled, noninjured state. </p> <p> These differing evaluations of one's existing state have important consequences. The particular problem which we should like to discuss as an example is the effect of the two evaluations on the readiness of the person to improve wherever realistic improvements are possible and on his persistence in bettering his state. </p> <p> It would seem at first glance that maintaining the noninjured state as the standard would have the advantage of leading the injured to increase his efforts, for example in dealing with the physical environment. The injured would desire the best prosthesis, try to improve in using it, and learn as many skills as he could in order to be able to perform the physical tasks which the noninjured can perform. But the desire to be able to handle the physical world does not stem only from the wish to be as much like the noninjured as possible. We even doubt that the desire to be as good as the noninjured is helpful. The injured person who emotionally desires to be noninjured will see even objective improvement over previous performance as still falling short of the goal and hence failure. The same objective improvement can be seen as success (in comparison with recent performance) or failure (in comparison with the noninjured). The following two examples illustrate the different feelings resulting from the different evaluations of one's present state. In the first, "always wondering whether I could have done better" indicates feeling of failure, in the second, "enjoying learning over again" a feeling of success: </p> <blockquote><p> We'll be satisfied with less but there'll always be a little bit of doubt as to whether we could have done a little bit better without it. Maybe I'll be able again to play a good game of golf, but I'll always wonder whether I could have done better. ... In some part of your mind you just have to check off the fact that vou're missing something extremely valuable. </p> <p> The more you learn to use it the less it bothers you. If it's just hanging it will. . . . The more I learned the better off I was. ... I figured it was gone so I might as well see what to do about it. ... I enjoy learning to do things over again. It offers a challenge to you. I think, "What's the best way?" before I start fooling around. </p> </blockquote> <p> It seems reasonable to expect that, if a subject feels he is improving, he will hopefully continue. If he is constantly frustrated by unsuccessful attempts, forces away from the unreachable goal and disruptive emotional effects will appear.<a></a> </p> <p> Our discussion is of value for an important practical problem of the amputee. In trying out a new, technically improved prosthesis, some of the injured feel that it is an improvement and others do not. Besides the question of the physical fitness of the prosthesis for the individual, psychological conditions leading to the different reactions are important. It would be promising to study whether those injured who are dominated by the noninjured standard are more easily dissatisfied with the new prosthesis than are those who consider their postinjury state as valuable. We predict that the former group will more easily be disappointed because, in comparison with the noninjured standard, the results obtained with the prosthesis can be seen only as a failure. The latter group, however, will recognize any actual improvement and consequently will be encouraged to continue using the prosthesis. Those who maintain the noninjured as their standard require psychological adjustment before they will be able to accept an objective improvement as such rather than as a new indication of the unreachability of the noninjured state. We venture to say that only if the postinjury state is taken by the subject as a basis for comparison can he make valid judgments as to the advantages of the technically improved prosthesis.<a style="text-decoration:none;">*</a> </p> <h4> <i>Conclusion</i> </h4> <p> Acceptance of loss is seen as involving changes in the value structure of the person. We have pointed out only some of the changes which may lead to acceptance of loss. Clearly there are others. Our statements have to be taken as suggestions for further research rather than at their face value. We discussed four kinds of situations: <i>a, </i>overcoming all inclusive suffering; <i>b, </i>overcoming mourning; <i>c, </i>overcoming devaluation produced by damage to appearance; and <i>d, </i>overcoming devaluation produced by physical disability. </p> <p> The kinds of value changes that may alleviate the suffering in these situations are closely connected with those value preconstructs discussed under <i>Misfortune and Devaluation </i>(page 22). The value change involved in <i>a </i>and <i>c </i>can be seen as one in which enlargement of the scope of values takes place. In the case of all inclusive suffering, enlargement of the scope of values is the first step toward the possibility of acceptance of loss, since the main problem here is to regain, psychologically, values other than those lost. In the case of devaluating appearance, enlargement as such is not in itself an advantage unless with the enlarged scope of values the values lost are seen as relatively nonessential. In both cases, the person will maintain the noninjured standard and regard the values lost as comparative values. Thus, the person may still devaluate himself, for instance when a particular situation arises in which enlargement is made difficult. </p> <p> The value change involved in <i>b </i>and <i>d </i>can be seen as one in which the values lost are regarded as asset values rather than comparative values. In this case, the person feels that his own state is a worthy one. When, instead of selecting unreachable states as a standard, he turns to what he has and can reach, life can be seen to offer more than he can possibly avail himself of. He frees himself from devaluating comparisons with a ghost ideal of a different but actually not better person, the noninjured. Thus, acceptance of loss seems to be more fully realized through the second type of value change. </p> <h4> Acceptance of Personal Loss and Reaction to Social Loss </h4> <p> The injured person who has accepted his personal loss will feel one way about the discriminatory attitudes of the noninjured. He who has not accepted his loss feels another. The social loss of the injured person his feelings of nonacceptance as a group member has a basis in reality. Whether or not the person has adjusted to his loss, therefore, he will experience difficulties in his relationships with noninjured people. But the reaction in the two cases will be quite different. </p> <p> Where the person devaluates himself because of his loss, he will feel that his nonacceptance by others is largely justified. He will agree with the other group members that a noninjured person is more valuable, more likeable, more worthy. He will suffer keenly that he happens to be on the short end of this relationship, but he will see it as an unavoidable and natural fact, to be supported as morally valid. He will feel that no one can change this state of affairs that one can perhaps try to behave "as if" he were non injured but that emotional devaluation of him must prevail. </p> <p> If, however, the injured person has accepted his loss, he will not devaluate himself. He will consider himself an equally worthy member of the group and thus feel that he should be fully accepted by the group and have access to the values which the group can offer. He will see that it is the maladjustment of the noninjured toward injuries which leads them to devaluate and reject him, a fact which hinders him from having access to the values of the group. He will see that the locus of the difficulties is not in the injured who adjusted to his personal loss, not in the natural, lawfulness of devaluation of the injured, but in the noninjured. </p> <p> A considerable part of the suffering due to nonacceptance by others is thereby removed. Because the negative evaluations of others are seen as unwarranted, because the injured person does not blame himself, they hurt less. Instead, the person who holds them may in turn be devaluated and seen as ignorant or prejudiced. This counterdevaluation also may serve to diminish suffering from social loss.<a style="text-decoration:none;">*</a> </p> <p> Whereas the maladjusted injured person wishes to be accepted by the noninjured though he feels he ought not be accepted, the adjusted injured person will care less to associate with those whose values he does not share or respect. The adjusted injured person gains a considerable degree of emotional independence and freedom from the noninjured. This does not mean that the injured person does not and need not care about how the noninjured receive him. Even though he may not care to associate with a given person, he does wish to maintain close relationships with others. Moreover, in a world dominated by the noninjured, it is often the noninjured who determine whether the injured person can have access to important values such as jobs and group memberships of many kinds. Thus it is of vital interest to the injured that the noninjured become adjusted to injuries. </p> <h4> Acceptance of Loss By the Noninjured</h4> <p> Acceptance of loss is of great importance not only to the injured. Persons close to the injured (that is, those who are in the position of sharers), as well as the large number of non injured who have little to do with injured people, have much to gain from healthy attitudes toward injuries. The sharer suffers not only because the injured person suffers (sympathy) but also because he too experiences a loss (personal and social loss). A wife may feel the loss of her husband's leg just as personally, just as deeply, as the husband himself. The sharer has, therefore, to accept the loss just as does the injured person before suffering may be overcome. It is of extraordinary practical importance for an injured man to realize that his closest sharers his wife, mother, and so on cannot be expected to accept the loss immediately. Just as he has to go through the struggle to accept the loss, so does the sharer. </p> <p> For the nonsharer, adjusted attitudes toward injuries do much to free him from anxieties regarding bodily harm. He still will continue to regard body whole as a value, but as an asset value and not as a comparative value. The loss, then, is regarded as an adjustable state and not as a catastrophe. Consequently, in threatening situations, he would not become careless about his safety, but the anxiety would be reduced to realistic fear. </p> <p> Since acceptance of loss has adjustive significance for all persons, the question arises as to how the noninjured may be brought to face it as a problem. The need to attempt to accept the loss exists in noninjured sharers, for they also experience a loss. But what about nonsharers? In general, they do not feel the necessity of imposing upon themselves the problem of adjusting to injuries. They may feel uncomfortable in the presence of an injured person, they may devaluate the injured or wish to diminish his suffering, but they do not see the suffering as <i>their </i>problem. Not only do they feel that real acceptance of this kind of loss is extremely difficult; what is more important, they do not feel that they should try to accept it. The general attitude may be described as, "Problems of visible injuries are special problems. They do not actually concern me." </p> <p> At least two groups of people not in the position of sharing a loss with an injured person may consider more closely their feelings toward injuries. First, there are people who are bothered by social justice. When considering injured people, they may question their own attitudes, since negative feelings toward a suffering part of humanity are regarded as unjust and intolerable. As they puzzle, they may discover their own basic nonacceptance of injuries and struggle to see the loss as an adjustable and acceptable state. The second group consists of those people who have a general need for self adjustment in whatever area anxiety is felt. Just as a person who is frightened when climbing a mountain may wish to ascend again in order to overcome the fear, so may a person who feels uneasy about body welfare wish to meet the problem of non acceptance of loss. </p> <h3> Chapter VIII: Direction of Further Research </h3> <p> The study of adjustment of any kind, including acceptance of loss, requires the investigation of, first, the conditions C₁ and C₂underlying the nonadjusted and adjusted states, respectively, and, second, the conditions leading to change of condition C₁ to condition C₂, expressed as ch(C₁ --&gt; C₂). That is, two distinct tasks are involved: first, there must be determined <i>what </i>has to be changed to <i>what </i>and, second, <i>how </i>the change takes place. The study reported here deals only with the first task, that is, with the determination of conditions of nonacceptance (C₁) and acceptance (C₂) of loss. </p> <p> For the determination of what has to be changed to what, manifestations of the two conditions C₁ and C₂ have to be observed. These manifestations, or events, which in our case were the statements by injured persons concerning nonacceptance and acceptance of loss, were the raw data on the basis of which the underlying conditions C₁ and C₂ were specified. Conditions C₁ and C₂ are always specified in terms of constructs and their interrelationships; the underlying conditions in our case are value statements on the conceptual level. </p> <p> Once C₁ and C₂ have been determined, further research should take the direction of systematic search for and examination of the manifestations of ch(C₁ --&gt; C₂). As the result of our study, we know that conditions C₁ and C₂involve different value structures. The conditions of value change could then be studied by designing experiments which would promote value change and permit the observation of its manifestations. </p> <p> We will now suggest two examples of situations in which value change may be brought about. Both are designed to have the subject himself try to bring about the change. </p> <p> First example: The injured man is asked to try for one day to accept the role he usually resists taking, namely, the injured role. The injured role does not mean one of overde pendence and self pity. Rather, it means that the person does not go out of his way to appear noninjured. He is encouraged, for example, to take advantage of offers of special consideration by others which will make things easier for him. He may also be asked to discuss a personal matter related to his injury with someone to whom he feels close; this should be a matter which in the past he has refrained from bringing up. For that day he has to abandon the noninjured role as the ideal and accept the injured role as the one to strive for. He may succeed in changing, and report these changes, or he may fail and report the difficulties. In either case, a gateway is opened for analysis of the conditions of change. </p> <p> Second example: An injured man is asked to note events, situations, and interpersonal relationships occurring during the day which are and are not injury connected <i>(i.e., </i>whether the event included any aspect of the injury). He is asked to consider further whether the injury entered in a positive, negative, or neutral way. Finally, he is to examine, for alternative interpretations which give them a more positive character, those events which he characterized as negative. For example, the events noted may have included a lift on the way to work (injury connected, positive), staring by someone in the elevator (injury connected, negative), or dictating letters (not injury connected). Crucial for the study is the instruction given to the subject to search for a change in the character of the injury connected negative events. In the elevator example, the subject may come up with the statement that not all staring needs to be staring at an amputation; someone might stare when he is in deep thought about his own personal concerns. In searching for a substitute for the negative character of the event, the injured person thus restricts the all inclusive ness of the devaluating injury so that other values become available. As in the preceding hypothetical experiment, analysis of these attempts at changing values should lead us to the specifications of the general conditions of value change. </p> <p> In returning to our study here reported, we want to mention a number of value constructs related in pairs to C₁ and C₂. These are: comparative values <i>vs. </i>asset values, personal properties <i>vs. </i>posessions, and all inclusive value loss <i>vs. </i>partial value loss. The conditions of change from one member of a pair to the other, ch(C₁ --&gt;&gt; C₂), are yet to be determined. </p> <p> These changes, we believe, are only a few of the necessary changes involved in acceptance of loss. One can be sure that acceptance of loss does not imply only the value changes mentioned above, nor only value constructs. </p> <p> Although much further study of C₁ and C₂ is indicated, we feel enough is already known to encourage investigations of ch(C₁ <i> --&gt; </i>C₂). The knowledge to come from such investigations should provide a systematic basis for understanding and aiding the psychological adjustment of the injured. </p> <h3> Acknowledgments </h3> <p> The research project which gave rise to this article might never have started without the encouragement and advice of many people, and in particular of Gordon W. All port, Roger G. Barker, Karl M. Bowman, Albert A. Campbell, Dorwin Cartwright, Lawrence K. Frank, Kurt Lewin, Rensis Likert, Ronald Lippit, Jean W. Macfarlane, Donald G. Marquis, David Shakow, George D. Stoddard, and Donald Young. The active interest and hospitality of Roger G. Barker, Alvin C. Eurich, Paul R. Farnsworth, Ernest R. Hilgard, Quinn McNemar, Calvin P. Stone, Edward K. Strong, and Lewis M. Terman provided a home for the project at Stanford University. </p> <p> The Advisory Board included Ernest R. Hilgard (Chairman), Roger G. Barker, Paul R. Farnsworth, George S. Johnson, Donald E. King, Quinn McNemar, and Calvin P. Stone. Their interest and support helped us to complete this phase of the investigation. The research staff included Dan L. Adler, Tamara Dembo, Eugenia Hanfmann, Helen Jennings, Gloria Ladieu Leviton, Milton Rose, Ralph K. White, and Beatrice A. Wright. </p> <p> The findings are the result of a group endeavor. Some of the members were unable to continue for the whole period, however, and the three acknowledged authors take responsibility for whatever in this paper is subject to criticism. </p> <p> The investigation was furthered by the productive thinking and hard work of Donald Glad, Verda Heisler, Marguerite Q. McFate, and Alice Phillips Rose, all Research Assistants. The following students contributed not only their technical skills but also stimulating and fruitful ideas: Dorothy Groesbeck, Ruth Katz, J. Maurice Rogers, Heber C. Sharp, Nancy Starbuck, William L. Thompson, Helene Veltfort, George Gromeeko, and Marjorie Dwyer. Our secretaries, to whom we are much indebted, were Bertha Bull, Joan Glad, and Joyce James. </p> <p> We highly appreciate the cooperation of the staff and patients at Dibble and Bushnell General Hospitals. To all who served as subjects we are most grateful. </p> <p><b>References:</b></p> <ol> <li>Adler, D., G. Ladieu, and T. Dembo, Studies in adjustment to visible injuries: social acceptance of the injured, J. Soc. Issues, 4:55 (1948). </li> <li>Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 1953. </li> <li>Dembo, Tamara, Der Aerger als dynamisches Problem, Psychol. Forsch., 16:1 (1931). </li> <li>Frank, L. K., Time perspectives, J. Soc. Phil., 4:293 (1939). </li> <li>Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </li> <li>Lewin, Kurt, Richtungsbegriff in der Psychologie, Psychol. Forsch., 19:244 (1934). </li> <li>Lewin, Kurt, The conceptual representation and the measurement of psychological forces, Duke University Press, Durham, N. C, 1938. </li> <li>White, R. K., B. A. Wright, and T. Dembo, Studies in adjustment to visible injuries: evaluation of curiosity by the injured, J. Abnorm. and; Soc. Psychol., 43:13 (1948). </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">This is a good example of how changing a onesided relationship to a mutual one changes the meanings which the relationship originally had for the person (page 9). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A similar practical problem is raised in a much more general area. If ones own state is felt to be valuable, should not comparison with oneself in performing activities be a better incentive than comparison with others and, if so, should not this guide our educational procedures? </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">Dembo, Tamara, Der Aerger als dynamisches Problem, Psychol. Forsch., 16:1 (1931). </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">In the present state of knowledge, we are not able to state whether those who consider or commit suicide after acquisition of a physical injury have had pronounced neurotic trends which prevent them from standing the additional stress of the unfortunate position or whether an otherwise stable individual but with an extreme evaluation of the fortunate position may consider or commit it Also, we may ask whether the extreme evaluation of body whole and bodybeautiful is not itself an expression of instability or strong neurotic trends. There was a time, not so long ago, when little attention was paid to the problems of the good, quiet child; only the boisterous child was considered a problem. Similarly, high self esteem and satisfaction with ones appearance or any other fortunate position is considered healthy and only lack of self esteem is felt to be a problem. We think that extreme self esteem on the basis of comparison with the unfortunate position of others may be an unhealthy and dangerous state of unpreparedness to meet situations of loss or misfortune. From the standpoint of mental health, little attention is paid to preparedness for psychological suffering. Attitudes toward misfortune, as is the case with any other emotional attitudes, need educational and sometimes therapeutic guidance.</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">White, R. K., B. A. Wright, and T. Dembo, Studies in adjustment to visible injuries: evaluation of curiosity by the injured, J. Abnorm. and; Soc. Psychol., 43:13 (1948). </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">Activities which separate one sufficiently from emotionally intense conflicting and frustrating contents seem to give one the possibility of recuperation. To shift at will to less emotionally intense situations, i.e., temporary forgetting, is a blessing and sign of psychological well being or health. When one is under strain, he seems to need it more, but frequently the shift is more difficult. </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">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The study of congenital cases, or those injured in early childhood, would be important for understanding problems of acceptance of loss. Do these people differ in their value systems from those who are injured later in life? It would also be important to study the value structure of those who experienced gain after loss, who changed from a handicapped to a nonhandicapped position (e.g., cured cardiac cases and cases of arrested tuberculosis).</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">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The postulate that the speed of emotional processes is greater than the speed of intellectual ones leads us to further statements. First, in a unit of communication in which a single intellectual thought is conveyed, we can expect to find several emotional meanings. Second, the speed of emotional processes is greater than the speed of intellectual control of them (if we assume that intellectual realization is a prerequisite for intellectual control). Thus, in communication we sometimes convey more than we intend since intellectual control cannot keep pace with feelings. The phenomena of the piling up of emotional meanings (first statement) and of covert meanings (second statement) can be shown if a record of communication is made and if we have enough time to analyze each emotional connotation separately. </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">This study deals with loss, and therefore with distress situations. Omitted in the rest of this chapter are the modifications and extensions which would be necessary to take account of joy and other emotions that could be shared.</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">We do not imply that the reason for aversions is a need to escape the conflict. Nor is the reason something inherent in humans which makes it natural for them to be filled with aversion at the sight of deviations from the normal human form. The ideal of beauty, the Venus de Milo, is a bilateral amputee. The stunted feet of Chinese women were considered beautiful. The heavily padded shoulders of a few years ago exceeded the normal body form. Aversions are visual allergies, symptoms of more general psychological maladjustment and not only of conflict between positive and negative feelings toward the injured.</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">For a discussion of time perspective, see Frank.4</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It would be worth while to study this phenomenon further and, in the search for those who might put themselves below the average, to take as subjects prisoners and different groups of mental patients. Interviews in connection with such experiments are indicated.</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">The findings concerning these relationships (except sympathy, which is discussed in the present monograph) have been reported by Ladieu, Hanfmann, and Dembo (5), by White, Wright, and Dembo (8), and by Adler, Ladieu, and Dembo (1).</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">In no way do we believe that the subjects conscious perceptions of their feelings are the only data worthy of study Many other clues during an interview give us indications of hidden meanings which broaden the understanding of the persons feelings.</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">One would wish that instead of imputing a lower quality to interview data, instead of stressing that how a person thinks he will act does not always correspondto how he will act, attention would be given to the specific conditions under which intentions and attitudes, given an action test, either are or are not carried out.</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">The validity of the interview as an instrument is a separate problem. See next column.</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>6.</b> </td><td class="clsTextSmall">Lewin, Kurt, Richtungsbegriff in der Psychologie, Psychol. Forsch., 19:244 (1934). </td></tr><tr><td class="clsTextSmall"><b> 7.</b> </td><td class="clsTextSmall">Lewin, Kurt, The conceptual representation and the measurement of psychological forces, Duke University Press, Durham, N. C, 1938. </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">Though it may increase them.</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">Thous it may increase them.</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"> By preconcept we mean a term which lacks either a rigid conceptual definition or a precise operational definition. </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">By structure of a social emotional relationship we mean those characteristics which, when interrelated, are necessary and sufficient to describe the nature of the relationship. </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">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">For other methods used in the area of adjustment to physical handicaps, see the critical review of the literature by Barker, Wright, Myerson, and Gonick.2</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">Adler, D., G. Ladieu, and T. Dembo, Studies in adjustment to visible injuries: social acceptance of the injured, J. Soc. Issues, 4:55 (1948). </td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and; Soc. Psychol., 42:169 (1947). </td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">White, R. K., B. A. Wright, and T. Dembo, Studies in adjustment to visible injuries: evaluation of curiosity by the injured, J. Abnorm. and; Soc. Psychol., 43:13 (1948). </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>Beatrice A. Wright, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Research Fellow in Psychology, University of Kansas. Lawrence.</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>Gloria Ladieu Leviton, Ph.D., </b></td></tr><tr><td class="clsTextSmall">Psychologist, LaGrange, Illinois</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>Tamara Dembo, Ph.D., </b></td></tr><tr><td class="clsTextSmall">Associate Professor in Psychology, Clark University, Worcester, Massachusetts.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1956_02_004/1956-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1956_02_004/1956-Autumn-1b.jpg Figure 3 http://www.oandplibrary.org/al/images/1956_02_004/1956-Autumn-3.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 Adjustment to Misfortune-A Problem of Social-Psychological Rehabilitation Creator An entity primarily responsible for making the resource Tamara Dembo, Ph.D., * Gloria Ladieu Leviton, Ph.D., * Beatrice A. Wright, Ph.D. * https://staging.drfop.org/files/original/876ff6602d787cd8bb538c115168499b.pdf 4970b9dd38fb5c1f19b5d27c89c60acc Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_012.pdf Text Any textual data included in the document <h2>Orthotic Maintenance Program for the Myodysplastic Child</h2> <h5>Terry J. Supan, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The faculty of the Southern Illinois University School of Medicine has been actively involved in a comprehensive, multidisciplinary approach to the management of the myelodysplasia child. Since the establishment of the orthotic clinic in July of 1982, a systematic approach to the orthotic-physical therapy needs has proven successful in providing a higher degree of function and fewer complications for these patients. The purpose of this article is to inform the reader of the appropriate orthotic involvement and the high degree of orthotic maintenance which is necessary for this type of patient. By describing the experiences of Southern Illinois University School of Medicine, it is hoped that the reader will gain a more realistic understanding of the orthotist's role in this situation.</p> <p>The types of orthoses run the full gambit from a simple UCB foot orthosis to a complex reciprocal gait orthosis. A consistency with these patients is that as children they develop at a normal rate. A second point with these children is the fact that without orthotic management, effective ambulation would not be possible. Higher levels of lesion necessitate a greater amount of orthotic management. When you combine an intimate fitting plastic orthosis with growth, you can understand the necessity for continuous maintenance and adjustments of their orthotic devices. A regular system of return visits is necessary.</p> <p>The relationship of the myodysplastic child to the orthotist is similar to that of a patient to their general practitioner. They are seen on a routine basis, unlike the medical specialists who only see a patient a limited number of times. This should be kept in mind if an orthotist is considering the possibilities of becoming involved in myodysplastic patient management. An orthotist involved with a clinical practice of scoliosis can associate the nature of their spinal practice with the ambulatory myelominengocele practice that we have developed at SIU School of Medicine. The repetition of clinic visits is very similar to that involved with scoliosis. However, there is an increase of time involvement with the child to make growth adjustments and maintain proper fitting plastic orthoses necessitated by the insensate skin in these children. If a CTLSO is improperly adjusted, it may affect the outcome of the scoliosis treatment, but it will not effect the activities of daily living of the individual. An improperly fitting RGO severely decreases function.</p> <p>Orthopaedic involvement with the myodysplastic child starts within the child's first few days of life. There is a high incidence of associated scoliosis, kyphosis, hip dysplasia and clubfoot deformities. Therefore, the infant must be continuously monitored. If any of these conditions exist, early orthotic intervention may be used effectively. Maintenance devices such as the Pavlik harnesses, thermoplastic TLSOs, and serial casting for clubfeet have all been used effectively.</p> <p>When the child reaches nine months of age, plans for ambulation are considered. If a resistant clubfoot exists, it is dealt with by surgical intervention at this time. A one stage Turco<a></a> procedure is accomplished with post surgical maintenance in an ankle-foot orthosis.<a></a> During this time period, if a dysplastic hip is also prevalent, bilateral molded knee orthoses connected with a spreader bar to maintain the hip in abduction and internal rotation are used. Since the ninth month is the milestone period for standing in the normal child, use of a parapodium<a></a> is considered. Because of the growth spurts which normally occur during this same time period, consistent monitoring of applied devices is necessary. The ankle-foot orthoses must not impinge on either the calcaneous, navicular or metatarsal heads. Proper knee and hip locations in both the knee orthoses and the parapodium must be checked. Children in these devices should return to the clinic or the orthotist every three months.</p> <p>Since the development of the reciprocal gait orthoses,<a></a> children with a thoracic level mye-lominengocele are now candidates for ambulation. This is only possible with aggressive orthopaedic and physical therapy management. Full range of motion of the paralyzed extremities and prevention of flexion contractures of the hip, knee, and ankle is necessary if effective use of the reciprocal gait orthosis is expected. If a dislocated hip exists unilaterally, which would impede the function of the orthosis, surgical intervention would be necessary prior to use of the RGO.</p> <p>Our experience has shown that twenty-four months of cognitive development is the ideal time frame for training of the reciprocal gait orthosis and fitting thereof. Prior to this milestone, communication with the child and the necessity of multiple adjustments to the orthosis limits the effectiveness of the RGO. Once it is determined that a child is a candidate for reciprocal gait ambulation, an extensive physical therapy program is initiated to improve upper extremity strength and increase standing balance.</p> <p>When the child is initially fitted with an orthosis, it is left in the adjustable state as recommended by the development team at Louisiana State University. Extensive post-fitting physical therapy is necessary. During the first week of physical therapy the orthotist repeatedly checks the device so that optimum orthotic ambulation can be achieved. Subtle adjustments of the cable housing length and hip joint locations can mean a difference between an ambulator and a nonambulator.</p> <p>After one month's use of the reciprocal gait orthosis, the correct location of the hip joints and cable should become evident. At that time the hip joints and knee joints can be attached on a more permanent basis. Because of the necessity of numerous adjustments on a growing child, screws instead of rivets are used. High strength Loctite® is used to prevent loosening of the screws.</p> <p>The child returns to the orthotic clinic one month after permanent attachment of the side bars to the RGO. Subsequent to that visit the child is seen every two months for the first five months. Thereafter return visits are decreased to four times a year.</p> <p>The physical therapy routine also diminishes as independence in use of assistance devices is decreased. Initially the child is seen on a daily basis for two weeks. Thereafter, a weekly therapy program is established. As the child progresses from parallel bars, to walker, to forearm crutches, it is no longer necessary to maintain a continuing outpatient physical therapy treatment. Parents and teachers have successfully been taught to monitor the fit of the devices and the ambulatory status of the patient. Periodic physical therapy evaluation for gait deviation prevention is all that is necessary.</p> <p>Growth adjustments and routine maintenance of both the reciprocal gait orthosis and parapodium are accomplished at approximately four month intervals. The use of the pop rivets on the parapodium, make it a relatively easy task to increase the distance between the floor and knee and hip centers. Increases up to one inch between each joint center can be accomplished before the tubular structures of the parapodium must be replaced. Since children are removed from the parapodium at age two, it is only necessary to maintain one size in stock. Because of the presence of static hip and knee joints in the parapodium, the exact alignment of anatomical/mechanical joint centers is not critical for standing. However, if the joint assemblies are extremely malaligned, they will cause impingement during seating.</p> <p>Because of the relative newness of the program, the first child fitted with the RGO has not had to have a replacement of any major component of the orthosis. However, since we are approaching the twenty-month time period, it appears that future replacement of the plastic sections of the KAFOs will be necessary. A review of the adjustments made for growth indicates that the first length corrections were between the knee centers and the ankles. Subsequent growth adjustments were made between the hips and the knees to improve seating comfort. Seating discomfort seems to be the first indicator of improper positioning of the hip joints.</p> <p>Maintenance of the devices have included replacement of Velcro® straps because of wear, replacement of the anterior cable due to breakage at the point of connection between the cable and connector to the hip joint, and the replacement of two thrust bearings in one hip joint. One child also has had the metal pelvic band increased in diameter secondary to pelvic growth. Although the metal pelvic band makes the orthosis heavier and cannot be as form-fitted as the thermoplastic pelvic section, it does have allowance for pelvic widening. In cases of pelvic obliquity, lumbar scoliosis, or lumbar kyphosis, a thermoplastic pelvic section is mandatory. There have been no increases in the maintenance of the thermoplastic versus the metal pelvic band. Because of longitudinal growth between the calcaneous and the malleoli, several of the children needed adjustments in the malleoli area of the ankle-foot section of the orthosis. This is accomplished by localized heating and expansion of the carbon inserts and the polypropylene material. Care should be taken not to overheat the materials.</p> <p>Initial assessment of the ambulatory program for thoracic level myelominengocele children at SIU has been favorable. All parties concerned-the clinic team, the parents, the funding agencies and the children themselves- seem to have accepted the program quite readily. Objective data cannot be determined on such a short range program. Only until such time as multiple years of experience has been gained in several centers will the determination of the cost/benefit ratio prove the worthiness of this program. Subjectively, however, the children seem to be much better off than they would be otherwise.</p> <p>In our own program, four children with spina bifida are in the pre-parapodium stage (younger than nine months). Seven children are in the preambulatory, parapodium stage of growth development. Two children are awaiting fitting of their orthoses pending authorization from state funding agencies. Eight children have been fitted with the reciprocal gait orthoses with wearing time ranging from twenty months to one month duration. Each of these children are followed on a three-month basis by the clinic team with subsequent visits to the orthotist for adjustments. No major deformities or pressure sores have developed on the children who are in the program during this time period. Urinary tract infections and stress fractures have been reduced in the patients fitted with the reciprocal gait orthoses, although every child in the program has had at least one long bone stress fracture prior to being fitted with the reciprocal gait orthoses.</p> <p>In summary, we have shown at SIU School of Medicine that a comprehensive team approach to myelomeningocele should include a program of ambulation for the thoracic level myodysplastic child. With a routine return visit program and follow-up adjustments on the orthotic devices, no major complications have arisen in the system. The use of pop rivets on the parapo-diums, and screws for attachment of side bars on the reciprocal gait orthoses, have contributed to the ready availability of adjustments to the devices. Although there are increases in time constraints involved in dealing with this severe level of disability, the program has subjectively proven to all concerned that this present technique for spina bifida management has proven successful.</p> <h3>Acknowledgments</h3> <p>The author wishes to thank Roy Douglas, C.R, and Carlton Filiauer, C.P.O., for their development of the RGO, and to acknowledge Barbara Sullivan, R.P.T., and John M. Mazur, M.D., for their assistance in the development of our program at Southern Illinois University School of Medicine. The assistance of Melenie Boiser in preparing the manuscript for this article is also acknowledged.</p> <p><b>References:</b></p> <ol> <li>Turco, D.J., "Resistant congenital clubfoot (1979), A one-stage posterior medial release with internal fixation: a folio wup report of 15 year experience." <i>Journal of Bone and Joint Surgery</i>, 61A:805- 814.</li> <li>Supan, T.S., Mazur, J.M., and Johnson, B.S., "Postsurgical Orthotic Management of Resistant Clubfoot," 1984, AAOP National Seminar, Orlando, Florida, to be submitted for publication.</li> <li><a href="http://www.oandplibrary.org/al/1971_02_036.asp">Motlock, W., "The parapodium: an orthotic device for neuromuscular disorders." <i>Artificial Limbs</i>, 15, 13-17, 1971.</a></li> <li>Larson, Paul and Douglas, Roy, <i>L.S.U. Reciprocating Gait Orthosis</i>, Durr-Fillauer Medical, Inc., Chattanooga, TN, 25, 1983.</li> <li>Yngve, David, Douglas, Roy, and Roberts, John, "The Cable-Type Reciprocator's Gait Orthosis in Myelomeningocele," <i>Developmental Medicine and Child Neurology</i>, 25:116-117, 1983.</li> </ol> <div style="width: 400px;"><em><b>*Terry J. Supan, C.P.O. </b> Instructor, Division of Orthopaedics and Rehabilitation, Prosthetic/Orthotic Services, Dept. of Surgery, Southern Illinois University, School of Medicine, P.O. Box 39265, Springfield, Illinois 62708.<br /><br /><br /></em></div> <div style="width: 400px;"></div> Page Number(s) 12 - 14 Year 1984 Volume 8 Issue 4 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 Orthotic Maintenance Program for the Myodysplastic Child Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * https://staging.drfop.org/files/original/c4b9c484b01dbcb349e2f7553d8c16d3.pdf a0e06974f43dc39c32206828207898bb https://staging.drfop.org/files/original/6b9aa45d405b3eb6edf60ed6f2583718.jpg ec3cec476e908cf5388f484ed47c4021 https://staging.drfop.org/files/original/ad87bb362ff24b53b0bd4c87f0bc9055.jpg e2e1755f9d34505fd352ad608b70b1b4 https://staging.drfop.org/files/original/e4ef8c646c8299dea2dcaf82690c7033.jpg 6f834bb52cdba95d3228c37cdfe360fe https://staging.drfop.org/files/original/0495aa63dee60d41844c8045ccfe9f17.jpg 8ed64542446ac701a3e0cb8696d61f00 https://staging.drfop.org/files/original/2b9b8acc8d0d10ae27922541c7846cf9.jpg b1aeeea2be400bc3155d32ec17438c86 https://staging.drfop.org/files/original/838448779f3df30146197fb16d701a12.jpg 67e983e840d84f6fd7d70e0ac5bdc721 https://staging.drfop.org/files/original/2c2e777bb3d61d2e18a76c9eb109d2fc.jpg 3d695f19795573f5c956f14eba7bf3d5 https://staging.drfop.org/files/original/905f9f7a7990bdd2e91147c76b480421.jpg 8097f171d6eaefdbbdd1b0648a85ccbb https://staging.drfop.org/files/original/d365de13e8ef358378928b8d72c355f6.jpg a155984092d328cef91c3a43e36ed846 https://staging.drfop.org/files/original/c00d56cd7eb635ebe196a82082567556.jpg 728482c9abdc3071fab1d4d5a219c141 https://staging.drfop.org/files/original/bc6d72ff9c92b0b0b491c095cb2c1e9a.jpg 3e9426381c4011ee132611a0e63a8988 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_045.pdf Text Any textual data included in the document <h2>Transparent Preparatory Prostheses for Upper Limb Amputations</h2> <h5>Terry J. Supan, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The use of preparatory prostheses for lower extremity amputations has been widely published and publicized throughout the United States. Although techniques may differ from thermoplastic, laminated, or synthetic casting material for the socket, the concept of early fitting with a prosthesis to reduce the volume of the residual limb are fairly well adhered to. However, little has been publicized about preparatory fitting for arm amputations.</p> <p>Since 1982, the Southern Illinois University School of Medicine has extensively used preparatory prostheses within the 30 day post-amputation time period. Techniques have changed gradually over the last four years, but a fairly constant, successful technique has evolved at the present time. Although myoelectric prostheses with their ease of therapy training have been the componentry of choice, the prosthesis design can also use conventional componentry.</p> <p>The technique has also allowed us to utilize different componentry on an experimental basis to best determine the optimum componentry for the individual amputee. Prostheses have been used on all levels of amputation from wrist disarticulation through forequarter amputation (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg"><b>Fig. 1</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg"><b>Fig. 2</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg"><b>Fig. 3</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg"><b>Fig. 4</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg"><b>Fig. 5</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg"><b>Fig. 6</b></a>). Since 1984, all prosthetic interfaces have been fabricated out of transparent material. Materials have either been Surlyn® or Durr-Plex. The transparent materials were chosen to improve monitoring of the residual limb during volume change. Surlyn™ is used for below and above fitting sockets, while Durr-Plex is used for shoulder disarticulation and forequarter frames. With each of these systems, the prosthesis can be altered through heat forming as the patient's volume changes.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg"><strong>Figure 1. Left wrist disarticulation amputation secondary to trauma.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg"><strong>Figure 2. Left wrist disarticulation myoelectric prosthesis with supracondylar cuff to maximize supination and pronation.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg"><strong>Figure 3. Right mid-shaft below-elbow amputation, secondary to trauma and reattachment failure.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg"><strong>Figure 4. Right below-elbow prosthesis with supracondylar suspension and electric wrist rotator. Note that electronic controls, Otto Bock #, are mounted parallel to the electric rotator.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg"><strong>Figure 5. Right humeral neck above-elbow amputation secondary to trauma.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg"><strong>Figure 6. Shoulder disarticulation frame type prosthesis fitted to short above-elbow amputation.</strong></a><br /> <p>Standard electric prosthetic componentry has been used in all cases. However, minor modifications to the prosthesis/componentry interface have been necessary. Componentry which utilizes separate stainless steel electrodes from the amplifiers (Motion Control, VANU, and UNB) have been modified to use the stainless steel electrode developed for the Motion Control systems. Prostheses which utilize one piece electrode amplifiers (Otto Bock, Liberty Mutual) are primarily held in place utilizing Velcro® compression straps (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg"><b>Fig. 7</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg"><b>Fig. 8</b></a>). All loose wires are held in place with either strapping tape or duct tape. Manufacturers' recommendations concerning shielding of wires and electrodes are also followed.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg"><strong>Figure 7. Close-up view of electrode site in Surlyn® wrist disarticulation prosthesis. The area of the Otto Bock electrode extension tabs have been modified in the socket with a Dremmel tool to prevent rotation of electrode on skin.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg"><strong>Figure 8. Otto Bock electrode mounted into preparatory prosthesis. Velcro® maintains the electrode from passing completely through the socket.</strong></a><br /> <p>An amputee's decrease in limb volume is monitored monthly until the volume has stabilized. If revisions of scar tissue, skin grafts, etc., are necessary, it is recommended that they be done during this time period as well. Modifications to the prosthesis must be made to maintain good electrode contact as well as suspension. Sockets may be split and Velcro® compression straps added if necessary. Electrodes may be replaced or locations adjusted if necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg"><b>Fig. 9</b></a>). Although this is easily done with the Motion Control stainless steel electrodes by simply drilling another hole, it also can be accomplished with the Otto Bock or Liberty Mutual electrodes. If a hole saw is used to drill out the new location for the electrode, the cut-out material can be utilized to repair the previous location in the preparatory prosthesis.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg"><strong>Figure 9. Close up view of preparatory below-elbow prosthesis. Hook Velcro® adhesive backing is used to suspend the electrode in the prosthesis. Previous incorrect electrode site is repaired with cut-out from new electrode site. Battery pack is held in place with adhesive backed Velcro® as well.</strong></a><br /> <p>Since 1982, 25 upper extremity amputees have been fit with this system. It has allowed us to closely monitor the development of the maturation process of the residual limb. Adjustments to the prosthesis have been made with minimal fabrication time. Total replacement of the preparatory prosthesis was only necessary in two cases. All other cases could be accommodated by modifying existing prostheses. All but one patient (forequarter amputation) went on to fitting and delivery of their permanent prosthesis. The results of these patients' permanent prostheses are consistent with the findings of Malone, et al.<a></a></p> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg"><b>Fig. 10</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.jpg"><b>Fig. 11</b></a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg"><strong>Figure 10. Posterior view of preparatory shoulder disarticulation prosthesis. Elastic strap superior to the shoulder improves comfort. Split of posterior frame into sections allows sitting comfort without electrode displacement.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.jpg"><strong>Figure 11. Lateral view of shoulder disarticulation prosthesis. Auxiliary switch is used to alternate EMG control between electric wrist rotation, hand opening, and closing.</strong></a><br /> <p><b>References:</b></p> <ol> <li>Malone, J.M., M.D., et al., "Immediate, Early, and Late Postsurgical Management of Upper-Limb Amputation," <i>Veterans Administration Journal of Rehabilitatio</i>n, Volume 21, No. 1, May, 1984, pp. 33-42.</li> </ol> <em><b>*Terry J. Supan, C.P.O. </b> member of the clinical faculty at Southern Illinois University School of Medicine. Correspondence should be addressed to Southern Illinois University, Orthotic and Prosthetic Services, Room 102. 707 North Rutledge Street, Springfield, IL 62702.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 45 - 48 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Transparent Preparatory Prostheses for Upper Limb Amputations Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * https://staging.drfop.org/files/original/8a9d698b5aa9a88b1d78cca1010c8eea.pdf 19dc4e493a77c65d2001e424e6222098 https://staging.drfop.org/files/original/99962c094bd59683119343ed583b5ef4.jpg 39cc66fe8bd0fa42c218e04d12f792fa https://staging.drfop.org/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg 342634e484594f8c0b6ec6fe1e681ed9 https://staging.drfop.org/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg a24f4347ad26657b24aa89700949a9fc https://staging.drfop.org/files/original/8722aae75627f1d176b8d9a189158028.jpg e972a1cac03927a2aafa9101a7ca1f5c https://staging.drfop.org/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg bdd02cd537217663f89754a8cbf9e89e https://staging.drfop.org/files/original/bdccea442ad3ab930b10461937bd5371.jpg be9a619d33b72a6e85e028985e907098 https://staging.drfop.org/files/original/e625aaa21e9345136d836397f35f4a25.jpg a7924af794fc40802662208fcc8abc16 https://staging.drfop.org/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg f673166d26b71b65d9dc04bd19d51530 https://staging.drfop.org/files/original/35e4a19292bc235080a381e346afc9df.jpg 2d9d56f7b3531d006b2ab2c40616d544 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_02_003.pdf Text Any textual data included in the document <h2>Orthotic Correction of Blount's Disease</h2> <h5>Terry J. Supan, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />John M. Mazur, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> <p>Infantile tibia vara is the result of abnormal growth in the proximal tibial epiphyseal late of the tibial plate. Blount<a></a> first identified the condition as osteochondrosis deformans tibialis in 1937. Clinically, tibia vara presents itself as a severe bowing of the proximal tibia, without the associated bowing of the tibial shaft or the femur, which is evident in physiological bowleg. On radiological examination of the child with tibia vara, a beaking of the medial aspect of the tibia metaphysis is noted. In 1964, Langenskiold and Riska<a></a> developed a grading system for chronologically staging the development of Blount's disease. Mitchell, et al.<a></a> advocated the use of the epiphyseal metaphyseal angle (E-M angle) as a simple quantitative measurement for Blount's disease in 1980. This method is useful to determine the severity of the disease and monitor treatment.</p> <p>Historically, the use of orthotic management in the correction of Blount's disease has not proven to be as successful as hoped. The lack of correction and increased laxity of the joint capsule of the knee have been the main reasons for not continuing with orthotic management. To this point, the treatment of choice for individuals with Stage IV or an E-M angle of greater than 30° has mandated that the child undergo one of several types of tibial osteotomies. Because of the high incidence of complications<a></a> and the recurrence of the condition, the authors felt that a new orthotic approach should be investigated. The result of that investigation has been the development of a knee-ankle-foot orthosis. This orthosis has successfully been used in seven cases of Blount's disease.</p> <h3>Orthotic Design</h3> <p>Previous orthoses used in the treatment of Blount's disease have been either a KAFO with a medial side bar only, or a KAFO with bilateral side bars. The medial side bar KAFO incorporated a varus corrective knee pad. The bilateral side bar orthosis is essentially a passive device to maintain the existing condition and to prevent it from getting worse. Neither system has proven to be completely successful in the treatment of Blount's disease.</p> <p>The design criteria established for the development of the knee-ankle-foot orthosis consists of the following:</p> <ul> <li> <p>The design must correct the varus deformity of the tibia.</p> </li> <li> <p>The medial joint capsule should not be distributed by the orthosis.</p> </li> <li> <p>Forces should be applied directly to the tibia and not the full length of the limb.</p> </li> </ul> <p>Because the patient is a growing child, it must be adjustable for growth as well as easily cleaned by the parents. The knee-ankle-foot orthosis which the authors have developed has met all of these criteria.</p> <p>Stress to the medial joint capsule was prevented by using an inversion of the supracondylar suspension technique used for below knee prostheses.<a></a> By having a medial thigh section extend beyond the joint space to the area of the medial tibial condyle, we were able to reduce the possibilities of applying stress to the joint space itself (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg"><b>Fig. 1</b></a>).</p> <strong><a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Figure 1</a>. Bilateral KAFO's for Blounts with stainless steel medial side bar, thermoplastic femural section, and elastic tibial strap. Femural section protects the knee joint while the elastic applies maximum force to the apex of the tibial curve.</strong><br /> <p>A dynamic system was used to apply corrective forces to the tibia. The use of an elastic material to provide dynamic forces has been well documented.<a></a> A six-inch wide elastic gusset material with velcro closures provided an adjustable and continuously applied force to the tibia (<a href="/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg"><b>Fig. 2</b></a>). The maximum force applied to the limb with the elastic material is at the apex of the curve (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg"><b>Fig. 1</b></a>). This allows the maximum amount of correction with minimum amount of force. The velcro allows easy removal for laundering. All orthoses are provided with two sets of elastic straps.</p> <strong><a href="/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg">Figure 2</a>. Cross section of leg and orthosis at mid-tibial level. The relationship of the sidebar, elastic, velcro, and limb are shown.</strong><br /> <p>The orthosis needed to be strong and adjustable because these children are growing and extremely active. The side bars are made of stainless steel which overlap for growth adjustment only between the knee and ankle (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg"><b>Fig. 1</b></a>). The knee-ankle-foot orthosis was not made adjustable proximal to this area in order to maintain the tibial extension of the thigh piece in its proper relationship to the tibial condyle. The patient's foot is maintained in a high top shoe which is attached to the medial side bar by means of a free ankle stirrup.</p> <h3>Prescription Criteria</h3> <p>The E-M angle is used to determine whether the patient meets the criteria for orthotic management of the Blount's disease. The E-M angle is measured on an anterior/posterior x-ray of the knee. To construct this angle, a line is first drawn through two points on the base of the proximal tibial epiphysis, selecting the first point at the base of the normal lateral side of the epiphysis and the second medial point as far away from the lateral side as possible, but at the base of the normal non-depressed epiphysis. Next, determine the midpoint at the base of the epiphyseal center, then draw a second or metaphyseal line from the medial tip of the metaphyseal peak to the midpoint of the epiphyseal center (<a href="/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg"><b>Fig. 3</b></a>). If this E-M angle is equal to or greater than 20°, then orthotic intervention is recommended. Mitchell et al. determined that the mean E-M angle for normal children was 3°-11°. Orthotic management is maintained for a minimum of nine months and at such time as the E-M angle is less than 15°. If the child is over eight years of age, orthotic correction will not be achieved. Based on our experience, orthotic management in stages I through III tibia vara can be effectively corrected with orthotic management. Aggressive treatment is necessary to achieve these results. Stages IV and V Blount's Disease and children over eight years of age need surgical treatment.</p> <strong><a href="/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg">Figure 3</a>. Method of measuring the E-M angle.</strong><br /> <h3>Case Study</h3> <p>A white male, age 3, was presented at the orthotic clinic by his parents because of bowing of his right lower extremity (<a href="/files/original/8722aae75627f1d176b8d9a189158028.jpg"><b>Fig. 4</b></a>). Clinical examination showed bilateral tibia vara. Bilateral standing AP radiograms were obtained. The E-M angle determined on these radiograms was 20° bilaterally (<a href="/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg"><b>Fig. 5</b></a>). The child was fitted with the bilateral KAFO's (<a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg"><b>Fig. 6</b>A</a>) and a new set of standing AP radiograms was obtained which showed no difference in the E-M angle at that time (<a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg"><b>Fig. 6</b>B</a>).</p> <strong><a href="/files/original/8722aae75627f1d176b8d9a189158028.jpg">Figure 4.</a> Clincal appearance of B.D. at age 3 with bilateral Blounts Disease.</strong><br /><br /><strong><a href="/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg">Figure 5</a>. Standing A/P radiograms show E-M angles of 20° bilaterally.</strong><br /><br /><strong><a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Figures 6A (top) and 6B (bottom).</a> B.D. fitted with bilateral KAFO's. X-rays show no change at time of fitting.</strong><br /> <p>For the next six months, B.D. wore his bilateral KAFO's 23 hours a day with the knee joints in the locked position during weight bearing. After one week's wearing time, the patient no longer objected to wearing the devices and adapted his lifestyle accordingly. No restrictions were placed on the child concerning his daily activities.</p> <p>At his six-month checkup, new radiograms, both in and out of the KAFO's, were obtained. The E-M angle at that time was determined to be 15° bilaterally. Clinically, the child appears to have less bowing of his tibia as well. It was determined at that time that the side bars needed to be lengthened, which was done. It was decided that the parents could then allow the child to use the orthoses in the unlocked position during the daytime, but to return to the locked position at night. Because of growth of the child's feet, a shoe change was necessary.</p> <p>At nine months, the patient was again presented to the clinic. Once again the orthoses were lengthened (<a href="/files/original/e625aaa21e9345136d836397f35f4a25.jpg"><b>Fig. 7</b></a>). New standing AP radiograms were also obtained, showing no significant alterations from the previous exam at six months (<a href="/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg"><b>Fig. 8</b></a>). Day use of the KAFO was discontinued.</p> <strong><a href="/files/original/e625aaa21e9345136d836397f35f4a25.jpg">Figure 7.</a> Sidebars were lengthened twice during the treatment period. One shoe transfer was also completed.</strong><br /><br /><strong><a href="/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg">Figure 8.</a> Radiogram taken after 9 months of treatment show an E/M angle of less than 15° as well as less bowing of the tibial shaft.</strong><br /> <p>The patient returned for a twelve-month evaluation. No significant changes had occurred clinically in the patient's extremities (<a href="/files/original/35e4a19292bc235080a381e346afc9df.jpg"><b>Fig. 9</b></a>), thus use of the orthoses was discontinued.</p> <strong><a href="/files/original/35e4a19292bc235080a381e346afc9df.jpg">Figure 9</a>. Orthotic treatment discontinued after 12 months. Clinical examination shows normal lower limbs.</strong><br /> <h3>Summary</h3> <p>This successful use of orthotic management in the early stages of Blount's disease has been proven at Southern Illinois University School of Medicine. An orthosis was designed to specifically meet the established criteria of correcting the tibial deformity, reducing the stress on the medial joint capsule, and allowing adjustability for growth. The device has been used in seven cases of tibia vara with excellent results in all cases. The E-M angle of the affected tibias have been reduced to less than 15°. Aggressive treatment in the early stages of Blount's disease will reduce the necessity of tibial osteotomies with their significant level of complications.</p> <p><b>References:</b></p> <ol> <li>Blount, W.P., "Tibia vara osteochondrosis deformans tibia," <i>J. Bone Joint Surg.</i>, 19, 1-29, 1937.</li> <li>Langenskiold, A.N., Riska, E.B., "Tibia vara osteochondrosis deformans tibia: a survey of seventy-one cases," <i>J. Bone Joint Surg.</i>, 46-A, 1405-1420, 1964.</li> <li>Mitchell, E.I., Chung, S.M.K., Dask, M.M., Greg, J.R., "A new radiographic grading system for Blount s disease," <i>Orthopaedic Review</i>, Vol. 9, No. 9, 27-33, 1980.</li> <li>Steel, H.H., Sandral, R.E., Sullivan, P.D., "Applications of tibial osteotomy in children for genu varum or val gum," <i>J. Bone Joint Surg.</i>, 53-A, 1629-1635, 1971.</li> <li>Marschael, K., Nitschke, R., "Principles of the patellar tendon supracondylar prostheses," <i>Orthopaedic Appl. Journal</i>, Vol. 21, No. 1, 33-38.</li> <li>Clancy, J., Landseth. R.E., "A dynamic orthotic system to assist pelvic extension: A preliminary report," <i>Orthotics and Prosthetics</i>, Vol. 29, No. 1, 3-9, March, 1975.</li> </ol> <p><em><b>*John M. Mazur, M.D. </b> John M. Mazur, M.D., Associate Professor, Department of Surgery, Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine.</em></p> <em><b>*Terry J. Supan, C.P.O. </b> Terry Supan, C.P.O., Instructor, Department of Surgery; Director, Orthotic/Prosthetic Service, Southern Illinois University School of Medicine, Room 102, 707 North Rutledge Street, Springfield, Illinois 62702.<br /><br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 3 - 7 Year 1985 Volume 9 Issue 2 Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-06.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-09.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-02.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-07.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 Orthotic Correction of Blount's Disease Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * John M. Mazur, M.D. * https://staging.drfop.org/files/original/7b50b9442fee7b3a075030bce26d5247.pdf c642ea8fa545bc78a7515b88282350b9 https://staging.drfop.org/files/original/1bf96f25f8dad3e8a90a0f93f54b53e3.jpg 5be960caa128ae75975d9e0ace0cc9a0 https://staging.drfop.org/files/original/3c801b7d07539462b4ac10842de5efcd.jpg a96f3e7dc9ed31455ba28a3c1da6dfe8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_022.pdf Text Any textual data included in the document <h2>Follow-up Experience with an Orthosis Combining the Supracondylar Knee Orthosis and the Spiral Orthosis</h2> <h5>Thomas A. Marün, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p><b>Fig. 1</b>, <b>Fig. 2</b></p> <strong><a href="/files/original/1bf96f25f8dad3e8a90a0f93f54b53e3.jpg">Fig 1</a>. Side view of orthoses similar to that described by Mr. Martin in his article. (The photographs supplied by Mr. Martin proved to be unusable.)</strong><br /><br /><strong><a href="/files/original/3c801b7d07539462b4ac10842de5efcd.jpg">Fig 2.</a> Posterior view of the same orthoses as in Fig. 1. These photos are supplied courtesy of H. Richard Lehneis, Ph.D., CPO.</strong><br /> <p>A seventy-one year old woman, post polio of long duration, presented herself to our facility with a Supracondylar Knee Orthosis<a></a> that had a spiral type AFO<a></a> attached to it over ten years ago. She had fractured the AFO component just proximal to the malleolus, about one year ago. Another facility had attempted to replace the Nyloplex® spiral AFO with polypropylene material. Her ankle was fixed at 120 degrees plantar flexion. Our investigation indicated that her knee went into genu recurvatum despite the SKO, hence the problem-how to attach the spiral unit to the SKO and duplicate the same alignment that she had been comfortable with after all these years. It is noteworthy that the SKO was held in position by a waist strap.</p> <p>It was our opinion that the SKO no longer fit due to laxity within the knee cavity itself. She was quite adamant, however, that her brace system had been working well and it was our job to fix it. She declared that the waist belt was no problem and further stated, in no uncertain terms, that she wanted what she had because it had been of good service for over a decade.</p> <p>Possibly being more persistent than intelligent, we proceeded. We were unsuccessful in our attempts on three separate occasions in reapplying the spiral type AFO. We finally tried #4134-30 percent and #4110-70 percent polyester resin, laminated with four layers of fiberglass and two layers of glass, and used 1/16" polypropylene welding rods that ran the entire length, one inch apart.</p> <p>Using the old holes of the SKO, we were unsuccessful in obtaining satisfactory alignment when attaching the spiral unit. Therefore we were forced to tape the two units together until we had a compatible arrangement. Once the two components were riveted together, she had some problems in gait, especially between heel strike and foot flat, clearly indicating that the SKO was affecting the knee by not allowing it to go into recurvatum.</p> <p>In summary, we feel that in using the resin as opposed to the Nyloplex® (we used the same plaster mold) we may have compromised some flexibility, but gained, through rigidity, a successful duplication of past gait patterns.</p> <p>Presently this woman is walking better than formerly and is quite satisfied with our results.</p> <p><b>References:</b></p> <ol> <li>Dr. H. Richard Lehneis, CPO, "Bio engineering Design and Development of LE Devices, " Institute of Rehabilitation of Medicine, New York University Medical Center, p. 55, October, 1972.</li> <li>ibid., p. 60.</li> </ol> <div style="width: 400px;"><em><b>*Thomas A. Marün, CPO </b> President Baja Orthotic and Prosthetic Services, 205 Church Street, Chula Vista, California 92010<br /><br /><br /></em></div> Page Number(s) 22 - 22 Year 1984 Volume 8 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1984_03_022/1984_03_022-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_03_022/1984_03_022-2.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 Follow-up Experience with an Orthosis Combining the Supracondylar Knee Orthosis and the Spiral Orthosis Creator An entity primarily responsible for making the resource Thomas A. Marün, CPO * https://staging.drfop.org/files/original/10c1e9153313406ba4f5bb6316536cb0.pdf f021c880f280590c0b2349861906bbcb https://staging.drfop.org/files/original/dc11864cea6523c87bf2d8df4550c001.jpg 13279d0e9cb832a37dc538a352203e0b https://staging.drfop.org/files/original/2002e46ffabbd7a8026db85c3669de1f.jpg 74ffcd886b527321c2f9d37afc60ab20 https://staging.drfop.org/files/original/9dc4487b2acddd05e4f0f442510b35b9.jpg d5f724d51a1e6ba2b8a1d03c305f1774 https://staging.drfop.org/files/original/3a68d5d8a5f6b3952661c4bbd46eefa7.jpg 89904eeb58e41489800af4cb2a49a63e https://staging.drfop.org/files/original/77c9d3c2d4a941dc2c53cdf6f0a49971.jpg fc10f1203fdabd37b416196d917e1a9b https://staging.drfop.org/files/original/1ba9f329202448af3fa4efbfd9070888.jpg 2f146206c850edfddfda674098294ccb https://staging.drfop.org/files/original/35727e9c9abf2b58afcb30a82a68b630.jpg 6e3ea0d5ebea2f60d1d2cf5edb70215a https://staging.drfop.org/files/original/7880f6b348c16563637e568b84221d13.jpg 1b1a6610e78623175fbdc6336c343ba5 https://staging.drfop.org/files/original/bda95fea38a30663bb14a54fdd0bf252.jpg 003b6c53652ab72a46888a097359d477 https://staging.drfop.org/files/original/1c9248ec6e5c79bd34a6b0e521ddc916.jpg d08a866941e3cec5031a61f6feb966fa https://staging.drfop.org/files/original/c604af9b9225d4ffc11d1b6d9f2b0fdf.jpg db1f4c9447ff9977f7a3c7a7cbc0d8ac https://staging.drfop.org/files/original/d289c21c42aa9f609743bcb0fe52e10a.jpg 5cee6ff75cd02de689a5b21010742089 https://staging.drfop.org/files/original/ee73aa307cf4e9cc566ca1852eb9efa2.jpg 386ce91b1d4443ce1250cd660c0715ab https://staging.drfop.org/files/original/4a3d7f3112ca91a59eaf1ff5a9a5a204.jpg ee3ea0c538854c55e5170f52570aba84 https://staging.drfop.org/files/original/b830cc45412e5424f35cc65c231b8d5b.jpg 0fcd7e975fb49b493c0e6d7c0191bc84 https://staging.drfop.org/files/original/b2e854fc9a5e33325ed8ec746dda8ae0.jpg 2f339c44ea64b52504a784b6443b4a77 https://staging.drfop.org/files/original/6de37e945a0e41d8484dc77c16bc3cd6.jpg 04bdad71e4b68a0386a544b9b4121882 https://staging.drfop.org/files/original/febbd73f2648976234d696c9b757b7ae.jpg d7658aff6e0000e75444773e217cde8e https://staging.drfop.org/files/original/d5b7a908de158673aff7c895d77eba42.jpg fe328b7b8ee047f1d66414ae1226bf7e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_013.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 13 - 30 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_013.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_013.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The NYU Transparent Socket Fabrication Procedure</h2> <h5>Thomas Grille <a style="text-decoration:none;">*</a><br />Ronald Lipskin <a style="text-decoration:none;">*</a><br />Richard Hanak <br /></h5> <p>It has been recognized for a long time that a transparent socket that could be made to fit the stump would be a useful tool in studying the relationship between the amputation stump and the socket of a prosthesis. Early attempts by a number of investigators to devise sockets of acrylics such as Plexiglas and Lucite were abandoned because of the difficulty encountered in controlling the contours and because of the inordinate amount of time required for fabrication of a single socket.</p> <p>In 1966, the New York University Prosthetics and Orthotics group undertook a comprehensive study to develop a practical method of fabricating a transparent socket using newer materials and fabrication techniques.</p> <p>The criteria for the selection of the transparent material to be utilized for the socket were that it be water-clear with good transparency, have adequate strength and fracture resistance, and be non-toxic. The method of fabrication was to be reasonably simple and was not to require an excessive amount of actual working time or sophisticated equipment; the materials and equipment were to be readily available.</p> <p>Two basic approaches were explored: vacuum forming and casting.<a style="text-decoration:none;">*</a> Transparent polycarbonate sheet material was used in the attempts to make a socket using the vacuum forming method. Below-knee sockets were made by this method, but it was necessary to form the socket in two parts and to bond them together, a procedure which was time-consuming and which required extreme care if accuracy was to be obtained.</p> <p>Both epoxy and polyester resins were tried for casting transparent sockets. Satisfactory results could be obtained with epoxy resins, but excellent results were obtained consistently with polyester casting resins when RTV silicone rubber was used on the outer surface of a male plaster slush mold and the casting surfaces were covered with polyvinyl chloride film. This article describes the procedures, in a step-by-step fashion, for fabrication of a transparent socket using polyester casting resins.</p> <h4>Silicone Male Mold</h4> <p>A conventional hard socket is supported on a wood attachment block during the fabrication of the silicone rubber male mold. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>1. Using approximately five layers of plaster bandage, the proximal trim line of the conventional socket is built up to the level that existed prior to trimming (about 1 in. above the proximal end of the socket with the interior surface made reasonably flat). After the plaster bandage has hardened, any rough interior areas are sanded smooth, and any plaster that interferes with the interior contour is removed.</p> <p>2. To facilitate separation of the silicone shell from the hard socket, the interior surface of the hard socket is sprayed with Dow Corning Silastic RTV Mold Release. <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>3. In order to retain the liquid silicone rubber in the hard socket, masking tape is used to form a V2-in.-wide rim around the proximal edge of the plaster-bandage buildup.</p> <p>4. Dow Corning Silastic D RTV Silicone Rubber is mixed with 5% by weight of Silastic D RTV thinner. One-half to one lb of silicone is used for BK sockets and 1-1/2 to 2 lb are used for AK sockets, depending upon socket size.</p> <p>5. Stannous octoate catalyst is added in a ratio of 100 drops or 2.2 gm to 1 lb of silicone rubber. This provides a 10-min working and a 1-hr curing time, which is the optimum for this procedure. The working time can be changed by varying the amount of catalyst. (Although this catalyst recommendation differs from the product-use instructions, its use is suggested because it has been found to be more convenient.) If stannous octoate is not available, a proportion of one part of standard catalyst to five parts of silicone rubber is used. <b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>6. The mixture is poured into the hard socket, then the socket is rotated by hand so that the entire inner surface is covered. After this has been accomplished, the socket is rotated only in one direction to insure an even distribution of the mixture to a uniform thickness of approximately % in. The rotation (in one direction) is continued until the mixture is set (10-15 min); the mixture is then allowed to cure at room temperature for 45 min. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A uniform wall thickness of approximately 1/8 in. is important in order to provide adequate shock absorption during break-out and to avoid the formation of an undersized socket. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>7. The silicone-rubber shell is pulled away from the medial wall, and a slit is made down the medial side of the socket. The slit will simplify the removal of the completed male mold by permitting the hard socket to be spread open. The slit is started 1/2 in. below the proximal brim and ended 2 in. short of the distal edge. (A wooden tongue blade and a clamp can be used to keep the silicone shell away from the medial wall while cutting the socket.) <b>Fig. 6</b> - <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <p>8. The male mold will be fabricated with a hollow core in order to simplify breaking it out of the transparent socket. With the silicone shell in the hard socket, a plaster slush mold is poured to a 3/4-in. thickness, except at the distal end, where the thickness should be approximately 1-1/2 in. The plaster is allowed to set. <b>Fig. 8</b> - <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <p>9. A pipe drilled with a few vacuum holes is inserted as a mandrel into the slush mold, and secured at its distal end with additional plaster. The middle section of the mold is filled with paper, and plaster is added at the proximal end of the mold to secure the mandrel. The plaster is allowed to set. <b>Fig. 10</b> - <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <p>10. To separate the completed male mold from the hard socket, the plaster-bandage buildup is removed, the socket is opened along the slit, and the socket is slipped off. <b>Fig. 12</b> - <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <p>11. To permit the application of vacuum to the undercut areas, 1/8-in. holes are punched through the silicone shell and 1/8-in. holes are drilled through the underlying plaster. The holes must be cut through to the void space in the male mold. <b>Fig. 14</b> - <b>Fig. 15</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <h4>Female Mold</h4> <p>12. An alignment pin is used to insure correct alignment of the distal ends of the male and female molds during casting of the transparent socket. A hole 1/2 in. in diameter is punched in the silicone shell, and one 1/2 in. in diameter and 3/4 in. deep is drilled into the distal aspect of the male mold. An alignment pin, cut 1/2<i> </i>in. in diameter by 3 in. long of nonferrous metal rod. is inserted into the distal hole. <b>Fig. 16</b> - <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <p>13. In order to provide a 1/4-in. wall thickness for the transparent socket, a 1/4-in. Dacron felt sleeve, a 1/8-in. Dacron felt sleeve, and a cotton stockinette sleeve are prepared, all to fit over the male mold. Compression eventually will reduce the thickness of the sleeves to the desired 1/4 in. Holes 1/2 in. in diameter are cut in the ends of the sleeves to permit clearance of the alignment pin. The two felt sleeves are pulled over the male mold and trimmed even with the proximal edge of the mold. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>AK Sockets Only</i></p> <p>To reinforce the proximal-lateral wall, a 5-in. x 7-in. strip of 1/8-in. felt is attached to the outer sleeve with Barge cement (<i>a</i>).</p> <p>Because of limited space between the male and female molds for AK sockets, a means for pouring the polyester resin into the completed female mold must be provided by creating a lip, or inlet, at its proximal anterior brim (<i>b</i>). A triangular piece of 1/4-in. felt is rolled to form a funnel and fastened with Barge cement to the anterior brim of the outer sleeve so that the top of the funnel is even with the top surface of the mold. (The funnel is not needed in the below-knee socket fabrication, because in that case there is adequate space between the male and female molds.)</p> <p>14. To facilitate alignment of the male and female molds, and to insure a uniform wall thickness of the transparent socket, the felt is cut away in the region above the posterior socket trim line as illustrated. The female mold will be contoured so that a proximal surface of this mold will contact the corresponding surface of the male mold. <b>Fig. 19</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>BK Sockets Only</i></p> <p>The felt layers are cut out in the region above the popliteal trim line. The cutout should not cross the popliteal trim line. <b>Fig. 20</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>AK Sockets Only</i></p> <p>The Dacron layers are trimmed in the flat areas above the posterior and medial brims, leaving approximately 1 in. of uncut material above the socket trim lines. <b>Fig. 21</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>15. The stockinette sleeve is now pulled over the felt on the male mold and tied to the mandrel. <b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>16. To provide for the transparent socket pedestal, a piece of 1/32-in.-thick plastic sheet is wrapped around the distal end of the male mold, over the sleeve, beginning at the point where the male mold starts to slope in and extending to the distal end of the alignment pin. The vertical seam and horizontal juncture line are sealed with tape. <b>Fig. 23</b> - <b>Fig. 24</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <p>17. Plaster is poured into the cylindrical cavity formed by the plastic sheet, leaving 1/2<i> </i>in. of the alignment pin exposed above the plaster level. The plaster is allowed to set, and the plastic sheet is removed. <b>Fig. 25</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>18. An inflated balloon is inverted over the lay-up and pushed downward as the air is slowly released. The distal end of the balloon is tied off around the alignment pin, and the proximal end around the mandrel. The balloon is then covered with a coat of silicone spray. <b>Fig. 26</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>19. To fabricate the female mold, 4-in. plaster bandage is wrapped around the balloon-covered male mold, starting at the distal end and overlapping each previous wrap by approximately 3 in. until a 4- to 6-layer thickness is achieved. Care is taken to avoid using excessive tension while applying the plaster bandage so as to prevent compression of the felt and reduction of the wall thickness of the transparent socket. In addition, the undercuts (<i>e.g., </i>the patellar region in BK sockets) are minimized or reduced by bridging the bandage in that area. <b>Fig. 27</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide a good receptacle for the exposed length of the alignment pin, it is covered with additional plaster, and the plaster is allowed to set. <b>Fig. 28</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>20. The balloon and stockinette are trimmed off to expose the proximal end of the mold. <b>Fig. 29</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>21. Using a combination square or a strip of metal bent to 90 deg as a guide, orientation lines are drawn on the proximal ends of the molds to provide references for their realignment. Two lines on each of the four sides are sufficient. <b>Fig. 30</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>22. The molds are separated, and the felt and stockinette lay-up is removed from the inside of the female mold.</p> <p>23. The plaster pedestal is broken out of the female mold, and the balloon and the alignment pin are removed without breaking the pin's receptacle.</p> <p>24. At this point, a slit is made in the female mold to simplify its removal from the transparent socket after casting. Starting 1 in. below the proximal rim on the medial side, a cut is made vertically along three-quarters of the socket length. The cut is covered with two vertical layers of plaster bandage on the exterior surface. The interior surface is smoothed where necessary. <b>Fig. 31</b> - <b>Fig. 32</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <p>25. To complete the mold, 1/16-in.-dia vacuum holes are drilled in the undercut area of the female mold to insure the correct surface contour on the transparent socket. <b>Fig. 33</b> - <b>Fig. 34</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <h4>Alignment Of The Molds And Casting</h4> <p>26. The outer surface of the female mold is covered with a 1/4-in. felt sleeve. A PVA bag is pulled over this sleeve, and both covers are trimmed even with the proximal edge. A vacuum tube is attached to the distal end of the PVA bag and secured with plastic tape.</p> <p>27. A heavy coating of Vaseline petroleum jelly is applied to the inside surface of the female mold. <b>Fig. 35</b> - <b>Fig. 36</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <p>28. The end of a second PVA bag is fastened to the alignment pin with a rubber band and then both are inserted (glossy side in) into the alignment pin receptacle in the female mold. The interior PVA bag is lapped over the exterior PVA bag and sealed with pressure-sensitive tape. At least 4-in. overlaps must be provided because this PVA bag will later be fastened to the male mold mandrel. <b>Fig. 37</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>29. Vacuum is applied and the wrinkles are smoothed out on the interior PVA bag. This lining provides the smooth exterior surface of the transparent socket. <b>Fig. 38</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>30. A PVA sheet (glossy side out) is pulled over the male mold and fastened to the mandrel with plastic tape. The sheet is reinforced around the alignment pin with plastic tape, and a 1/2-in. hole is cut through the tape and the PVA bag for the alignment pin. Vacuum is applied and the wrinkles in the PVA sheet are smoothed out. <b>Fig. 39</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>AK Sockets Only</i></p> <p>The valve body may be placed before or after casting. If placement is done before casting, the valve body is filled with beeswax and glued with Barge cement to the PVA sheet on the male mold in the appropriate location. The valve body must be so located that it will not subsequently contact the wall of the female mold during the casting procedure. <b>Fig. 40</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>31. The female mold is placed in a bench vise or other supporting device, with the proximal end up and proximal edges horizontal. The male mold is oriented in the female mold by means of the alignment pin and placed all the way down on the pin. <b>Fig. 41</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>BK Sockets Only</i></p> <p>The posterior surfaces of the molds are butted in the region superior to the popliteal trim lines, and the orientation marks are aligned. The molds are taped together securely to maintain the alignment.</p> <p><i>AK Sockets Only</i></p> <p>The surfaces superior to the posterior and medial brims are butted and the orientation marks aligned. The molds are secured with tape. <b>Fig. 42</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>32. One to 1-1/2 qt of polyester casting resin for below-knee or 2 to 3 qt for above-knee sockets (depending on the size) are combined with the catalyst, with constant stirring. The manufacturer's instructions are followed regarding the amount of catalyst required to obtain a "slow setting time." Ideally, the resin should have a 1/2-hr gel time, which is adequate time for pouring. The resin is poured slowly and continuously while the female mold is simultaneously tapped to prevent any air bubbles being entrapped in the casting. <b>Fig. 43</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>33. After the resin has set to a soft gel (about 30 min), the tape around the PVA bags is removed, and the outer PVA bag and Dacron sleeve are removed. The male mold PVA bag is punctured around the pipe, and the female mold PVA bag is pulled secure and tied to the mandrel. <b>Fig. 44</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>34. After the resin has set to a firm gel (about 1 hr after pouring), the plaster strips are peeled off the slit in the female mold. The female mold is then removed by spreading the slit open, with care being taken not to tear the PVA bag on the transparent socket. The resin is allowed to cure for an additional hour at room temperature. <b>Fig. 45</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>35. The vacuum equipment is removed. The transparent socket (on the male mold) is heated in the oven at 165 deg F for 4 hours. The oven is turned off, and the socket is left until the oven cools to 125 deg F. This heat-treating helps to eliminate any internal stresses that may have developed during the curing phase. <b>Fig. 46</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Finishing The Socket</h4> <p>36. The PVA bags are cut along the proximal edge of the male mold. To protect the transparent socket surfaces from scarring, the PVA bags are left in place. The plaster slush mold is carefully chiseled away, and the mandrel and silicone shell are removed. <b>Fig. 47</b> - <b>Fig. 48</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </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 /> <p>37. The socket is cut down to the proximal trim lines, using a band saw and electric sander. The rough edges are smoothed by hand-rubbing with fine-grade sandpaper. The transparency can be restored to these edges by applying a surface coating of resin to the area, covering with a PVA sheet, and allowing to cure.</p> <p>38. Any flashing on the interior surface around the alignment pin is removed, and the bottom of the hole is sealed with tape. The hole is filled with resin and allowed to cure.</p> <p><i>AK Sockets Only</i></p> <p>If the valve body was placed before the casting, a hole saw of the same size as the valve body diameter is now used to bore through to the valve body. To improve the boring angle, the distal corner of the socket pedestal is sawed and ground down. <b>Fig. 49</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the valve body has not yet been placed, the anteromedial corner of the socket pedestal is sawed and ground off to provide a flat surface. Then, using a hole saw of the same size as the valve body diameter, a hole is bored through the socket wall. The valve body is carefully secured in place with either polyester resin or epoxy cement so that the inner surface of the valve body is flush with the inner surface of the socket. <b>Fig. 50</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>39. Before the socket is attached to an adjustable leg, the pedestal base is sanded flat and to the proper alignment angulation, using a disk sander. <b>Fig. 51</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>BK Sockets Only</i></p> <p>Suspension-strap retainers are attached to the below-knee socket with #8-32 flat-head machine screws. The holes may be countersunk by using an inside countersink tool. <b>Fig. 52</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>40. The socket attachment plate is fastened to the transparent socket by drilling and tapping eight holes in the pedestal base and securing with flat-head machine screws. <b>Fig. 53</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>41. The PVA bags are removed, and the completed transparent socket is polished with silicone spray and a soft cloth. (This spray is also a good lubricant to facilitate donning the socket.) <b>Fig. 54</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Completed above-knee socket mounted on an adjustable leg. <b>Fig. 55</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Completed below-knee socket.</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">R. Lipskin and T. Grille, The Development of the NYU Transparent Socket Fabrication Technique, November 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>Ronald Lipskin </b></td></tr><tr><td class="clsTextSmall">Present address: Prosthetics Center, Bioengi-neering Research Service, 252 Seventh Ave., New York, N. Y. 10001.</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>Thomas Grille </b></td></tr><tr><td class="clsTextSmall">Now with Key Mfg. Co., Brooklyn, N. Y. 11207.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-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 The NYU Transparent Socket Fabrication Procedure Creator An entity primarily responsible for making the resource Thomas Grille * Ronald Lipskin * Richard Hanak  https://staging.drfop.org/files/original/cc46ad414ca9f0d932c9c1bd427dabc4.pdf 497441a68e5f2a4eef555521963106c4 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_010.pdf Text Any textual data included in the document <h2>The New Revolution</h2> <h5>Timothy B. Staats M.A., C.P.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The recent development and proliferation of advanced and precision fitting techniques in prosthetics have caused many prosthetists to reevaluate those principles which were held sacred for the past twenty years. In the last three years in particular, both below-knee and above-knee prosthetics have undergone tremendous changes.</p> <p>Many progressive practitioners recognize that the term "Patellar Tendon Bearing (PTB)" is no longer considered descriptive of a well designed below-knee socket and use the term only in a historical sense. The term Total Surface Bearing better describes what has superseded PTB philosophy.</p> <p>In above-knee prosthetics, a greater revolution is in the offing. Now the CATCAM (Contour-Adducted-Trochanteric-Controlled Alignment Method) socket is shaking the underpinnings of the Quadrilateral above-knee socket design. For those of us who are "dyed-in-blue-and-gold-UCLA-Quad-socket" prosthetists, it is both difficult and exciting to see the development and confusion a rival design causes throughout the profession. I am sure that thirty years ago the "wood-socket-plug-fit" prosthetists shared a similar feeling when the quadrilateral socket and later the introduction of plastics caused their world to turn upside down.</p> <p>The point is that change and improvement are inevitable. You can fight it and it will flow over you like a river, or you can go with the flow and learn to adapt to new techniques. I have been asked repeatedly what I think about the use of multiple check socket fittings, CATCAM, alginated check sockets, and the Flex-Foot. The list goes on and on. American prosthetists in particular must understand that we are in the midst of a full blown revolution and the results of this revolution will set the path we follow for the next couple of decades. Rather than question what is right or wrong without really having proof of either, I have chosen a path as the director of a prosthetics education program of "pouring fuel on the fire." What better time or place for controversy than at UCLA, where the first school was started over thirty years ago.</p> <p>Is all this extra precision and care really necessary to accurately fit an artificial limb? The answer is quite simple, and if you are an amputee the question is repulsive. If superior techniques that can improve the quality of the care provided to amputees are available but are not used, it is nothing less than criminal.</p> <p>There are those who would question: how much of a good thing is enough? That is a question that the patient must answer and the prosthetist must decide based on knowledge and education. The fact that many of the newer techniques and fitting regimes demand more time and effort than methods which have been in use for twenty years is entirely a separate issue. While it may not be possible to provide these services for the reimbursements, which are now received from payment sources, this does not mean that the techniques do not work or are wrong. It only means that the third party payers are ignorant of changes which have occurred in our profession and must be introduced to the benefits of new procedures.</p> <p>This same principle applies to prescribing physicians. It is totally fair to say that a physician who took his prosthetics-orthotics training over five years ago is now out of date. The same is true for practitioners who have not upgraded their practices through educational opportunities during this period.</p> <p>It is always uncomfortable when you begin to wonder whether you are doing the best you can for your patient. It is even more uncomfortable when you know you are not. We should never be satisfied with our work and never doubt that a better job can be done. With such a philosophical upheaval running rampant through our profession, the time for learning is now. Are you satisfied with application of outdated techniques, or are you willing to enter a new era of prosthetic and orthotic practice? The choice is yours.</p> <em><b>*Timothy B. Staats M.A., C.P. </b> Timothy Staats, M.A., CP., is Adjunct Assistant Professor and Director of the Prosthetics &amp;Orthotics Education Program at UCLA, Rehabilitation Center, 1000 Veteran Avenue, Rm 22-41, Los Angeles, CA 90024.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 10 - 11 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The New Revolution Creator An entity primarily responsible for making the resource Timothy B. Staats M.A., C.P. *