16 20 371 https://staging.drfop.org/files/original/d30c1f6a28ca1ae9b9872748df353b4b.pdf bea9517e3f9ca479497da6bb9f227e0e https://staging.drfop.org/files/original/a750a9bac1e87d07cab481c17ed8f158.jpg b460a689a9405e966300e9e773112751 https://staging.drfop.org/files/original/5eabccec270f1f333b918958142dcddf.jpg d490768fd85d0c0b8018f49d16a85e86 https://staging.drfop.org/files/original/5600e2c8cd5d1d88fa9b9dddfdbaa0ab.jpg 9bc59a50d9db0fc1942fd3df98eefa38 https://staging.drfop.org/files/original/b43844ab7b3bfbbcd3bed5d518fcb726.jpg 6522bd5c2e9c92baab4bd7fc742b28e0 https://staging.drfop.org/files/original/4226f93b09b83f690ff1aef286187577.jpg 99fd1f5e60ad04e0e2460c25f9c7e4a2 https://staging.drfop.org/files/original/360d6f76108292390a3bec738558a811.jpg 0d9a1a37077e0ab9f498bc9af862178a https://staging.drfop.org/files/original/dd200e756e224fc90ceb749aad4eb9d6.jpg 34afd61cb2dfbd620fd9e679a63df337 https://staging.drfop.org/files/original/60695ce3ce74c38c73e7ed31980752dc.jpg 41736e0e8258aee5b7615ab1059beead https://staging.drfop.org/files/original/50b652b809ec11dde34512c0dc88a00e.jpg 00068c0d3e0c590537e88b76a244b348 https://staging.drfop.org/files/original/722ac0844615e93397f059ec7b613b07.jpg e7dc454326291f80d2c206b06069c227 https://staging.drfop.org/files/original/035759827aa596e9d8af6a33567f9b91.jpg abc557d705dcabcb1bd8e8bec39a40f6 https://staging.drfop.org/files/original/0b12783a5e83b0a240c3ad7712390754.jpg 79e5817d76fa326b48a2d869f93fd564 https://staging.drfop.org/files/original/979a838ad229b33f0d97d2aa39e41e77.jpg 28b748a551d55bed689fa297ddcf4c68 https://staging.drfop.org/files/original/9ca6580af83082e91121cf0bf46ba5d9.jpg f76154c15e8fd69532e5cbc59df9dd58 https://staging.drfop.org/files/original/0b5165ead816fe48b4cfe8d2d2365829.jpg 9e4ce3a48cbe047abc17a4594fbab36d https://staging.drfop.org/files/original/ca076e884f850efcd021fb6492261232.jpg 2c324897b3b5d60061bcffe678d897ba Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_118.pdf Text Any textual data included in the document <h2>The UCLA Total Surface Bearing Suction Below-Knee Prosthesis</h2> <h5>Timothy B. Staats, M.A., CP.&nbsp;<a style="text-decoration: none;">*</a><br />Judd Lundt, B.S., A.E.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>While there was clear evidence to support examination of suction as a suspension technique for below-knee prostheses<a></a> in the early 1950s, overwhelming activity was in a direction that led ultimately to the development of the PTB design.<a></a> What is truly remarkable is the almost blind obedience that the practitioners and educators have given to PTB theories, a recognition that has rendered them all but untouchable gospel. Introduction and widespread use of transparent check sockets has probably done more to cause the prosthetist to question the accuracy of his PTB fitting methods than any other development in the last decade. Inaccuracy in socket fit that this powerful tool has revealed has led to the obvious conclusion: more precise casting and modification methods are required. This is the intent of the technique described here.</p> <p>This paper presents a departure from PTB philosophy and technique. The methods described freely borrow from and recognize individuals who have developed alternative ideas, many of which have been integrated into the UCLA Total Surface Bearing Suction Below-Knee Prosthesis. The substance of this paper includes suction as the obvious mode of suspension. However, the essence of suction suspension, and of this article as well, is the critical anatomical accuracy of the socket fit. We refer to it as the total surface bearing or TSB technique. Without TSB, successful long-term suction suspension cannot be achieved. With TSB, the prosthetist can achieve suction if desired or may choose to fit with a sock and without suction if so indicated. Whatever the case, the final result will be improved fit and better patient comfort.</p> <h3>Suction Suspension</h3> <p>Suction below-knee prostheses are unique in that they do not require auxiliary suspension systems such as straps, cuffs, thigh lacers, or sleeves to maintain the socket on the residual limb. This is not to suggest that auxiliary suspension need not be employed as an extra measure of protection, particularly with a very active patient. However, in principle no other suspension should be required (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg"><b>Fig. 1</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg"><strong>Figure 1. UCLA Total Surface Bearing Suction Prostheses.</strong></a><br /> <p>Three variations of suction socket are discussed in this article. The first is the "tension suction" variation.<a></a> This socket is made vol-umetrically smaller than the residual limb. Suction is maintained in the same manner as with the rigid above-knee suction prosthesis. This is probably through tension placed on the skin, thereby enhancing the friction between the tissue and the socket. Normally, a valve is placed at the distal end to release air while the socket is being applied. The second classification is "atmospheric suspension," mentioned by Murphy<a></a> in 1950 and later by others.<a></a> In atmospheric suspension, a non-elastic, but flexible interface is used, which virtually collapses around the residual limb when the prosthesis is unweighted. The third type of suction will be called "active compression suction." In this case, the socket interface is made of an elastic or elastomeric material which must be stretched or rolled over the residual limb, thereby gripping the skin through compression as well as through friction created between the skin and the socket.<a></a></p> <h3>Fitting Variables</h3> <p>The primary concern of any prosthetist attempting to fit a suction below-knee prosthesis should be the general health of the residual limb tissues. The UCLA experience has been similar to studies by Holmgren<a></a> and Bedouin.<a></a></p> <p><i>Types of Patients</i></p> <p>The suction below-knee prosthesis, properly fitted, appears to stimulate circulation and can be used on vascular amputees as well as amputations due to other causes. The suction below-knee may actually help to more quickly stabilize tissue fluid volume. Ages of patients have ranged from five to 88 years.</p> <p><i>Skin Problems</i></p> <p>A suction below-knee prosthesis virtually eliminates skin problems caused by movement and friction created between the residual limb and the socket interface. Problems of skin irritation related to hygiene and allergic reaction are covered in a later section.</p> <p><i>Bony Prominences</i></p> <p>Grevsten,<a></a> using x-ray evaluation of suction below-knee fittings, found that the movement of skeletal anatomy inside the socket is less than one-half that inside ordinary PTB sockets. The UCLA experience, which employs a more intimate casting and cast modification technique (TSB), suggests an even greater reduction in skeletal movement. More importantly, few problems with bony prominence pain or discomfort were reported by patients in the over 150 fittings conducted at UCLA and other locations during the teaching of this technique.</p> <p><i>Length</i></p> <p>We have found no correlation between residual limb length and the ability to wear a suction below-knee prosthesis. Fittings and suction suspension have been successfully achieved with residual limb lengths as short as 3 1/2". However, these are not all long-term results.</p> <p><i>Volume</i></p> <p>More important was the finding that many residual limbs initially fit with suction would lose this effect within one or two hours of wear. There is an immediate fluid volume adjustment. Patients fit with suction over longer periods of weeks and months will continue to experience residual limb volume changes until a point of volume stability is achieved. This normally will occur within six weeks. Any loss of body weight will certainly contribute to loss of suction as well.</p> <p><i>Shape</i></p> <p>Generally, with enough effort almost any shape residual limb can be fit with suction. However, to achieve suction with conical shape residual limbs, whether bony or fleshy, can be difficult. With such cases, it is often necessary to enlarge the gastrocnemius muscle bulge area of the socket while tightening slightly proximal to this to maintain suction. Many prosthetists might question the long-term effect of this technique on the health of the residual limb. Short term effects have not been adverse and results look encouraging.</p> <p><i>Patient Cooperation</i></p> <p>Patients who intend to wear suction below-knee prostheses must be intelligent, cooperative and aware of the critical nature and accuracy required in this type of fitting. Numerous adjustments may be required during the first several months to maintain the intimacy of the fit. The patient must fully understand the function of the valve and the socket liner. It is imperative that any patient wearing a suction below-knee prosthesis, no matter how effectively fit, wear an auxiliary suspension as a back-up in case loss of suction does inadvertently occur.</p> <h3>Comparison of Theories</h3> <p>In the below-knee prosthesis, suction is a mode of suspension that can only be maintained through a precisely fit socket. A major aim of this article is to present a technique whereby such a fit can be achieved. Development of the total surface bearing (TSB) below-knee socket combines a staged precision casting method with a significantly different model modification to yield this result. In order to understand these differences, it is necessary to contrast the TSB and the more traditional PTB sockets.</p> <p>The basic philosophy of the patellar tendon bearing below-knee prosthesis can be stated as follows: Increase weight bearing on areas of the residual limb over pressure tolerant areas and relieve pressure over those areas which are pressure sensitive. With the total surface bearing below-knee prosthesis weight is distributed over the entire surface of the residual limb, including areas which have in the past been considered pressure sensitive. In TSB, the accuracy of fit and careful use of measurements has eliminated the need for relief buildups over bony areas of the residual limb during the plaster casting and model modification procedures. The resulting corrected model for a TSB socket is thus distinctly different from that developed in accordance with PTB modification techniques.</p> <h3>Evaluation and Measurement</h3> <p>Measurements include all standard below-knee prosthetics parameters. The following additional considerations are necessary.</p> <p><i>Circumferences</i></p> <p>Carefully located circumferential measurements are taken at one inch intervals. The intervals are laid out from a bony landmark which can be defined accurately during the plaster casting procedure. Normally, the apex of the head of the fibula or the distal anterior tip of the tibia are chosen, depending on which is more prominent. The tibial tubercle may also be used. However, it is necessary to measure at least one interval more proximal when this location is chosen. In very fleshy or redundant residual limbs, it is wise to select the fibular head as some elongation may occur during casting which will obscure the distal end.</p> <p><i>Length</i></p> <p>The length measurement must be accurately gauged from the distal end of the residual limb to both the medial tibial plateau and to the inferior edge of the patella while under forceful upward loading.</p> <p><i>Evaluation</i></p> <p>Patients with chronic skin problems or burn scar tissue may not be suitably fit in sockets where the skin is directly in contact with the socket liner, unless the interface surface is impervious to body fluids. Perspiration can cause maceration even in healthy skin and an appropriate interface must be selected in such cases.</p> <h3>Plaster Casting Technique</h3> <p>An essential element of a successful TSB socket is a precisely cast residual limb. The diagonal four stage casting technique which draws from work adapted from Fillauer,<a></a> Gleaves,<a></a> Tranhardt,<a></a> Morris,<a></a> Hayes,<a></a> Stokosa,<a></a> and Vinnecour<a></a> was developed to best achieve that end. Unusual elements of the technique include:</p> <ol> <li> <p>Sheer nylon stockings for an ultra-thin barrier between skin and plaster, resulting in a more accurate cast.</p> </li> <li> <p>A beveled anterior first stage splint which is very accurately tailored to encompass the head of the fibula, the shaft of the tibia, and the entire medial flare. This first stage (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg"><b>Fig. 2</b></a>) is carefully molded to all bony anatomical structures. If properly applied, it will establish the medio-lateral dimension within 1/8" of patient measurement in most situations and require little or no model modification of the anterior aspect of the medial flare of the tibia.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg"><strong>Figure 2. The entire medial tibial flare and all bony prominences are carefully molded.</strong></a></li> <li> <p>A second stage of elastic plaster bandage which is wrapped with about half the available stretch applied. This stage must not extend more proximal than about 1" to 1 1/2" below the crease of the skin in the popliteal fold. The anterior stage is maintained in position during this second procedure with firm proximal compression. As the second stage sets, the proximal posterior aspect is lightly compressed to help define the antero-posterior dimension of the cast. The medial lateral dimension is never sacrificed in any attempt to decrease the antero-posterior dimension.</p> </li> <li> <p>A third stage splint, which creates the posterior brim shape and completes the basic cast used when a non-supracondylar trim line, is desired. The salient point of the third stage is the hand molding of the plaster bandage in the hamstring tendon region. When properly applied, the posterior brim will appear premodified with a diagonal trim which accommodates the lower anatomical insertion of the medial hamstring muscle group. It is necessary to do four things simultaneously to create an acceptable third stage, and generally will take considerable practice before re-peatable accuracy and skill is achieved. It is necessary first to locate and create the shape of the tendons; secondly, compress the antero-posterior dimension of the cast both proximally and compression-ally; third, mold the medial and lateral posterior areas of the third stage to prevent looseness in the hamstring areas proximal to the medial tibial plateau region; and fourth, spread the fingers of both left and right hands to stretch the plaster bandage to prevent a ridge from forming in the posterior aspect between the second and third stages (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg"><strong>Figure 3. The posterior trim and hamstring muscle reliefs are created during the wrap casting procedure.</strong></a></li> <li> <p>A fourth stage splint is used when supracondylar suspension is planned. It is applied in a manner similar to that used in Fillauer's three stage casting technique.</p> </li> </ol> <h3>Alginate Pressure Fitting</h3> <p>The first step in the fitting process occurs immediately after the hardened cast is removed. Through application of dental alginate to the inside of the wrap and a refitting on the patient, a more intimate contour is achieved. Though somewhat of a messy procedure, this will minimize the need to remove plaster from the model during modification. When casting very obese patients or those with excessive redundant tissue, this step may not be successful and may result in distortions in the final model.</p> <p>The nylon stockings are carefully removed from the cast and a hole is cut in each of the distal, lateral, medial, and posterior aspects to permit air to escape when the alginate is applied. The holes should be approximately 1/4" in diameter and should be cut using a knife. (A hand drill or drill press will likely grab the fabric in the wrap and destroy it.) About eight to ten ounces of dental alginate are mixed to a thick, but creamy consistency and quickly applied to the entire inner surface. The cast is replaced on the residual limb and forced proximal with moderate pressure. Alginate should exude from all cut holes (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg"><strong>Figure 4. The wrap cast is alginated and pressure fitted.</strong></a><br /> <p>The instant the alginate stops flowing from the holes, they are covered with the hands or fingers to prevent further leakage. Any excess alginate can be smeared about the proximal brim to perfect the fit in this area (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg"><b>Fig. 5</b></a>). This procedure must be conducted quickly and precisely or air pockets will occur. If air pockets do occur, we have found that additional algination attempts have been unsuccessful.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg">Figure 5. The completed diagonal four stage wrap cast.</a><br /></strong><br /> <h3>Total Surface Bearing Model Modification</h3> <p>The antero-posterior and medial lateral are modified exactly to residual limb measurements. The anterior modification of the anteroposterior is markedly different from the PTB "Bar." The TSB modification follows the shape of the anatomy in this region as shown in the xeroradiograph of the below-knee amputation (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg"><strong>Figure 6. Xeroradiographs lateral view of below-knee amputation. Notice the shape proximal to tibial tubercle.</strong></a><br /> <p>Notice that the shape of the tibia angles posteriorly immediately above the tibial tubercle. Plaster removal follows this shape. The inferior edge of the patellar area is modified as though the patella were being lifted proximally about 1/4". In other words, the true tibial plateau is below the inferior edge of the patella in most cases (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg"><b>Fig. 7</b></a>). The posterior aspect of the model normally requires only smoothing or only slight reduction to establish the correct AP.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg"><strong>Figure 7. Modification inferior to patella simulates shape of anatomy rather than "PTB" patellar bar.</strong></a><br /> <p>Plaster is removed from the posterior aspect of the medial flare of the tibia. This half moon shape sweeps into the medial hamstring area. Up to 3/8" of plaster may be removed in a very redundant residual limb. It is not unusual to see a medial hamstring 1/2 to 3/4" lower than the lateral side. Generally, the lateral side hamstring can be kept almost at tibial plateau level and is maintained at this level across the popliteal fossa.</p> <p>Absolutely no buildups are applied to the crest of the tibia, the head of the fibula, the anterior distal aspect of the tibia, or any other bony prominences. Reliefs are created by removal of plaster from around these areas to accentuate their shapes and to compress the tissues. Usually no more than 1/8" of plaster is carved away using a curved blade flexible knife (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-08.jpg"><b>Fig. 8</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-08.jpg"><strong>Figure 8. No plaster buildups are added to master model. Plaster is carefully removed around bony prominences and over bony prominences.</strong></a><br /> <p>The model is next measured for circumferences using the previously established bony landmark as a guideline for accurately locating the measurement levels (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-09.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-09.jpg"><strong>Figure 9. Circumference measurements of master model are reduced below patient measurements to achieve suction.</strong></a><br /> <p>It is generally found that the model at this point will be approximately at the residual limb measurement or somewhat larger, even if fairly liberal modifications have been performed. If the model were to be smoothed and a socket fabricated at these measurements (0" to +1/8") it will result in about a two-ply heavy cast sock fit or about one "Socket Liner Stump Sock."<a></a> However, this may not in itself achieve suction.</p> <p>In order to create a suction fit, the model must be carefully reduced in its circumferential measurements starting from a point approximately one inch above the tibial plateau and proceeding distally the entire length of the cast. As a beginning, a minimum of 1/2" of tension reduction less than the patient's measurements is applied at each measured level. Ultimately, in a new patient (any patient who has never worn a suction socket) the tensions may well reach 3/4" to 1" less than the original anatomical measurements. However, it is not a simple matter of initially bringing the tensions on the model to these values. This is inadvisable and potentially harmful for the patient. A gradual reduction process over time must be followed in order to achieve the results just stated.</p> <p>In pilot studies and in pilot courses conducted at UCLA in 1984, an attempt to empirically arrive at appropriate TSB suction tension values was made. Each prosthetist was asked to carefully record how much reduction in residual limb measurements was required to finally achieve suction suspension. The compiled results of these efforts suggest an initial tension value of 3/4" is necessary at each level to achieve suction. This value may vary depending on residual limb musculature, length, and tissue type.</p> <h3>Check Sockets</h3> <p>It is advisable, if not imperative, to use transparent check socket fittings to confirm the accuracy and precision of the wrap cast and subsequent model modifications. The UCLA technique involves two types of check sockets: flexible check sockets and more conventional rigid check sockets.</p> <p><i>The Flexible Check Socket</i></p> <p>A check socket is vacuum formed using 1/8" Surlyn® plastic. On a five to seven inch residual limb this will result in a very thin socket probably no thicker than 1/32". A valve is located distally to release air from the socket as it is donned (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-10.jpg"><b>Fig. 10</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-10.jpg"><strong>Figure 10. A flexible check socket is vacuum formed with small valve placed distally.</strong></a><br /> <p>Lotion or Vaseline® is used to lubricate the surface of the residual limb to aid in donning<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-11.jpg"><b>Fig. 11</b></a>). Flexible socket fit can be confirmed by direct palpation of the anatomy from the outer surface. Any air spaces or otherwise loose areas are located and subsequently corrected on the model. It is not unusual for this flexible socket to hold suction even if inadequate tensions were applied to the model (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-12.jpg"><b>Fig. 12</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-11.jpg"><strong>Figure 11. The flexible check socket is "wet" fit to the patient.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-12.jpg"><strong>Figure 12. Suction, total contact, volumetric and anatomic accuracy of check socket are determined in the flexible check socket.</strong></a><br /> <p>Accordingly, if the socket is made rigid by an application of a roll of fiberglass casting tape to the outer surface, suction will invariably be lost almost immediately. This demonstrates one of the many problems facing anyone wishing to fit or wear a suction below-knee prosthesis. The flexible socket in this case is exhibiting atmospheric suction. The socket collapses around the residual limb as any attempt is made to remove it. Rendering the socket rigid transforms this flexible membrane into a rigid socket and as the socket wall cannot move, suspension is lost.</p> <p><i>The Rigid Check Socket</i></p> <p>A rigid check socket may be used after the model corrections, determined by the fit of the flexible check socket, have been performed. With the rigid fitting, it is common to find the need to increase tension values to an average of 5/8" to 3/4". It must be assumed that fluids rapidly leave the residual limb as a more rigid, accurate fitting socket is applied. It might also be speculated that the muscles flatten out somewhat as excess fluid leaves the residual limb. Examination of residual limbs in properly fit rigid transparent suction check sockets after several hours of wear reveal good color and lack of a distal discoloration which one might expect in a "tight" socket.</p> <h3>Socket Materials</h3> <p>A variety of materials and fabrication techniques have been examined for their application to the suction socket. Varying levels of success have been achieved; however, there are usually trade-offs involved. Suction may be achieved with a removable liner/insert alone that keys into the prosthesis much like a liner in a PTB socket. A prosthesis may also be constructed with a hard suction socket with no liner or with a soft liner that is permanently attached. In any case, some type of valve is usually necessary, installed either in the liner, in the socket, or at the end of a tube extending from the distal end of the socket to the outside finish lamination of the prosthesis. Valveless liners are also possible; they will be discussed later.</p> <p>In considering a method of constructing a suction socket, it is important to realize that there will be no sock to absorb moisture; the patient will likely require some type of powder, cream or lotion application to don the socket, and the skin will be in direct and intimate contact with the inner material. All of these factors dictate a non-porous, easily cleaned material that will minimize the growth of bacteria, yet provide the necessary cushioning and comfort for daily or specialized activities. Whichever approach is taken, the prospects of success are limited only to the ingenuity of the prosthetist and the materials employed.</p> <p><i>Hard Socket Variations</i></p> <p>This is perhaps the most difficult variation with which to achieve success since the demands of precision required for fit and comfort are the highest. Firm residual limbs of good muscle mass are the most likely candidates for this design.</p> <p>The hard socket is undoubtedly the easiest to fabricate, and for the patient is the easiest to keep clean. Even if accepted by the patient, these sockets will feel hard and, while suitable for walking, they are probably not appropriate for heavy activities such as running. However, hard sockets, with the addition of a single nylon sheath, have been very successful in the long-term with low activity level patients. Flexible acrylic and polyester laminates backed on the outer surface with soft foams such as PE-LITE™ or Aliplast™ have enjoyed about the same level of success as a hard socket. Patients report that these sockets feel hard despite the padding. Additionally, allergic skin reactions seem to be more common when flexible resins are used. Minute cracking in the interface may create a breeding ground for bacteria or lead to skin irritation through surface friction.</p> <p>A number of thermoplastic liners have been successfully fit (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-13.jpg"><b>Fig. 13</b></a>). Some have been quite comfortable, notably the "total flexible brim" variation suggested by IPOS<a></a> and Sabolich.<a></a> Both are frame-supported polyethylene designs. Since thermoplastics may exhibit "cold flow" and may actually shrink, they are not ideal materials. An interesting characteristic of thin thermoplastic sockets is the enhanced capability of atmospheric suction. However, this advantage is basically negated by a lack of long-term durability. The suggested ease of refabrication and/or inexpensive nature of replacement does not hold up to criticism by patient used to no-nonsense prosthetic care. Another negative characteristic of thin thermoplastic liners such as Surlyn® and polyethylene is the inability to make adjustments after fabrication.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-13.jpg"><strong>Figure 13. Surlyn® inner flexible socket with outer frame fitted in 1985 as a suction below-knee prosthesis.</strong></a><br /> <p>A major point of consideration in fitting any socket material that directly contacts the skin is the coefficient of friction at the interface. There are definite differences which are recognized empirically and clinically, but not objectively related to prosthetic fit in the below-knee as well as in above-knee suction sockets. For example, Surlyn® and Durr-Plex both seem to have a surface which adheres very well to slightly damp skin. When these surfaces are lightly sanded, they lose some of this gripping capability. This can be both a positive and a negative factor, depending on the skin tolerance of the patient involved.</p> <p>Generally, hard socket variations of suction below-knee prostheses, while feasible, are not very practical for most patients. Moreover, the instance of inadvertent loss of socket suction must be expected. This is not really considered a problem since we recommend that auxiliary suspension be worn even on the best suction below-knee fitting.</p> <p><i>Soft Socket Variations</i></p> <p>Early suction liners were made of leather backed with Neoprene™. Even when given a sealant coating, the leather will begin to deteriorate and develop offensive odors in a fairly short period. However, good comfort has been achieved as has adjustability. Replaceability is not really possible in this variation.</p> <p>PE-LITE™ and Surlyn®-backed PE-LITE™ have both been successfully used for soft suction liners (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-14.jpg"><b>Fig. 14</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-15.jpg"><b>Fig. 15</b></a>). It wears fairly well and can be cleaned with baking soda, vinegar, or rubbing alcohol to eliminate both odor and dirt. These liners will likely pack-out in time, and thus, normal prosthetic delivery should include a duplicate. Replacement duplication after wearout of thermoplastic foam liners is not really practical to the level of precision necessary to maintain suction.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-14.jpg"><strong>Figure 14. Pelite™ liner with Plastozote distal end, distal valve and Surlyn® outer shell fitted as suction below-knee prosthesis in early suction below-knee courses at UCLA in 1985.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-15.jpg"><strong>Figure 15. The TSB Suction below-knee can be fitted on almost any length below-knee residual limb. Auxiliary suspension is not shown in this diagram but is recommended for all suction below-knee wearers.</strong></a><br /> <p>Another major advantage of these materials is that they may be easily added to or otherwise adjusted. By use of selectively placed materials of varying durameters, comfort can be achieved in very bony patients and those with poor skin conditions. It is important to further note that some foams are not closed cell and will, therefore, permit moisture, dirt, and bacterial buildup which may not be easily removed. However, coatings have been developed which may solve the interface cleansing problem. Additional considerations in the use of a liner coating are potential allergic reactions, alteration of friction and shock absorption characteristics of the liner material, and adequacy of adherence.</p> <p>Foam liners, it must be remembered, provide comfort by absorbing load forces of axial, shear, and torque. The shock of impact is absorbed in the compression of the foam or in the compression of the gases within the individual cellular structure of the foam. Any buildup of heat within a liner could lead to problems for the patient in an intimate suction fit.</p> <p>In summary, soft foam liners are very practical from the point of view of comfort and the ability to adjust to maintain fit. Their major drawbacks are that they change shape with wear and they do get dirty and smell if not meticulously cleaned daily.</p> <p>Three known types of silicone liners are presently in use or in experimentation at this time. Koniuk<a></a> reported fabricating cast silicone liners (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-16.jpg"><b>Fig. 16</b></a>) which can be later duplicated from the same mold. There have been some problems with tearing of these liners in early phases of development, but this is viewed as a materials problem only. Early liners were fairly thick and heavy which can be detrimental. Some problems of skin reaction to direct contact with silicone have been reported. Since silicones are relatively inert, skin irritation most likely may be attributed to friction between the skin and the liner. It may actually be holding the skin too well. Some patients may also be allergic to the catalysts used in the preparation of the silicone elastomer.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-16.jpg"><strong>Figure 16. Silicone below-knee socket liner with expulsion valve installed.</strong></a><br /> <p>Experiments with very thin laminated sheath-like silicone liners have been attempted with some positive initial results. However, adjustments are not possible because of the inability to cement to the material, a characteristic of the entire silicone group. Bedouin has reported using fills between the socket liner and the outer lamination as a means of reestablishing lost suction.</p> <p>Kristinsson<a></a> has demonstrated a preformed silicone liner which either rolls on or is pulled on the residual limb. The effect is to create distension of the distal tissues. Some problems have been seen in initial demonstrations, among which are tearing of the liners during application, some discomfort by patients with a hairy limb, and heat build-up. It may be too early in the development of these direct-contact silicone liners to determine with fairness their ultimate practicality. It is certainly true that lack of adjustability will likely continue as a source of considerable concern.</p> <p>A relatively new system, the PM Liner, developed by Peyton Massey<a></a> has been used as a suction below-knee liner. While proprietary in nature, it appears to be a vinyl-like foam which may be heated and formed with ease directly over the below-knee model. It has the comfort and padding of silicone but is much easier to work with and does not migrate as is the tendency with some silicone materials. Massey has been adapting this liner for use with adhe-sives so as to make it possible to glue patches of similar material to the PM Liner.</p> <p>A new concept in liners under development, called the Socket Liner Stump Sock,<a></a> offers an additional variation for potential use with a suction below-knee prostheses. It is a neoprene sock that is fabric-backed on both sides. When properly fitted, it maintains suspension by compression. The problem with this variation at present is that the smooth surface of the cloth outer face of the liner against the smooth inner socket surface does not provide sufficient friction to hold suspension. A coating is under development to resolve this problem. This liner offers an excellent compromise for the patient wishing to have an intimate TSB fit without complete suction. There is reportedly very little or no motion between the liner and the residual limb.</p> <p><i>Suction Below-Knee Valves</i></p> <p>Several specialized valves have been developed for the suction below-knee prosthesis although any valve can probably be used. An important feature in a valve for suction below-knee application is air expulsion capability. With such a valve, the patient simply forces his residual limb into the socket to expel the air through the distal end. Problems experienced with all valves have been accessibility and leakage brought on by inability to securely bond the valve seat to the liner.</p> <h3>Auxiliary Suspension</h3> <p>As has been previously emphasized, auxiliary suspension is mandatory on all suction below-knee prostheses. Sleeve type suspension offers the best compromise of comfort, security, and maintenance of suction. Cuff suspension in all forms has been tried, but cannot assist in sealing the socket to the residual limb. Three types of sleeves should be considered.</p> <p><i>The Latex Sleeve</i></p> <p>This provides the best seal and the most positive suspension, but has the problem of skin irritation, durability, odor, discoloration, and loss of shape.</p> <p><i>The Neoprene Sleeves</i></p> <p>These offer an acceptable seal that, while not as positive as the Latex, are acceptable so long as the sleeve has been properly manufactured. Neoprene sleeves are similar to Latex sleeves with respect to skin rashes and durability. Daily cleansing with alcohol can greatly reduce the incidence to skin problems. Providing the patient with multiple sleeves and proper hygienic education will reduce the incidence of skin rashes.</p> <p><i>Cloth Lined Neoprene Sleeves</i></p> <p>While these sleeves do not work well for total suspension, they can afford a margin of back-up for good suction wearers.</p> <h3>Some Suggestions for Skin Problems</h3> <p>For any serious rashes or other skin conditions, the patient should always be directed to his physician. A number of techniques have been tried by patients to clear up simple rashes. One technique is to wear a "Baggie®" or a thin polyethylene sheet directly against the skin of the residual limb until the rash clears. Some patients wear this inner protection at all times as a method of preventing rashes which might be caused by friction. When used with sock fittings, this will keep moisture out of the sock, thereby helping to prevent skin maceration. Some athletic patients apply transparent surgical tape over areas that are known to be prone to skin breakdown during heavy sports activities. Some brands that have been successfully used include 2nd Skin™, Op-Site, and Bioclusive Pads®.</p> <h3>Conclusion</h3> <p>The suction below-knee prosthesis, while an excellent option for some patients, may for others be the triumph of valor over reason. Should the decision be made to proceed with suction, both the prosthetist and patient must be completely aware of the long and difficult route involved. There will be obvious changes in the residual limb following initial fit which will require socket adjustment and refabrication over an extended period. There will probably be the need for some experimentation with materials and fabrication methods to arrive at an optimum fit for the patient. However, once these factors have been resolved, the results of a well-fit suction socket will be a marked improvement in patient comfort, satisfaction, and in a prosthesis that the patient "feels" is more a part of his person.</p> <p>If, on the other hand, suction is not a goal, the Total Surface Bearing casting and modification techniques that support a suction fit are entirely valid for every below-knee fitting regardless of the socket interface or method of suspension. In the view of the authors, these improvements over more traditional methods of below-knee prosthetics have been long overdue. Clearly, the superiority of Total Surface Bearing has been established and undoubtedly is the most important dividend of the research and education on suction below-knee fittings.</p> <h3>Suggested Readings</h3> <ul> <li> <p>Roberts, Ruth, "Suction Socket Suspension for Below-Knee Amputees," <i>Archives Physical Medicine and Rehabilitation</i>, Vol. 67, March, 1986, pp. 196-199.</p> </li> <li><a href="poi/1978_01_003.asp"></a> <p><a href="poi/1978_01_003.asp">Grevsten, S., "Ideas on Suspension of Below-knee Prosthesis," <i>Prosthetics Orthotics International</i>, 2, 1978, pp. 3-7.</a></p> <a href="poi/1978_01_003.asp"></a></li> <li> <p>Grevsten, S., "Patellar Tendon Bearing Suction Prosthesis Clinical Experiences," (Uppsala) <i>J. Medical Science</i>, 82, 1977, pp. 209-220.</p> </li> <li> <p>Grevsten, S. and L. Marsh, "Suction-type Prosthesis for Below-Knee Amputees: Preliminary Report," <i>Artificial Limbs</i>, 15, Spring, 1971, pp. 78-80.</p> </li> <li> <p>Pearson, J.R., S. Grevsten, B. Almby, and L. Marsh, "Pressure Variation in Below-Knee, Patellar Tendon Bearing Suction Socket Prosthesis," <i>J. Biomechanics</i>, 7, 1974, pp. 487-496.</p> </li> <li><a href="cpo/1984_03_004.asp"></a> <p><a href="cpo/1984_03_004.asp">Murphy, E., "Sockets, Linings, and Interfaces," <i>Clinical Prosthetics and Orthotics</i>, Vol. 8, No. 3, Summer, 1984, pp. 4-10.</a></p> <a href="cpo/1984_03_004.asp"></a></li> <li> <p>Schuch, M. and A.B. Wilson, "The Use of Surlyn® and Polypropylene in Flexible Brim Socket Designs for Below-Knee Prostheses," <i>Clinical Prosthetics and Orthotics</i>, Vol. 10, No. 3, Summer, 1986, pp. 105-110.</p> </li> <li> <p>Kay, H. and J. Newman, "Report of Workshop on BK and AK Prostheses," Orthotics and Prosthetics, Vol. 27, No. 4, December, 1973. Abrahamson, M., et al., "Improved Techniques in Alginated Check Sockets," <i>Orthotics and Prosthetics</i>, Vol. 40, No. 4, Winter, 1987, pp. 63-67.</p> </li> <li> <p>Pritham, C, "Suspension of the Below-Knee Prosthesis: An Overview," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 2, June, 1979, pp 1-20.</p> </li> <li> <p>Holley, Teresa, "The Suction BK Prosthesis," UCLA Prosthetics Education Program term paper, 1984.</p> </li> </ul> <p><b>References:</b></p> <ol> <li>Murphy, E., "Lower Extremity Components," <i>Orthopaedic Appliance Atlas</i>, Vol. 2, J.W. Edwards, 1960.</li> <li>Radcliffe, C.W. and J. Foort, <i>The Patellar-Tendon-Bearing Below Knee Prosthesis</i>. University of California, Berkeley, Biomechanics Laboratory, 1961.</li> <li>Grevsten, S., <i>The Patellar Tendon Bearing Suction Prosthesis</i>. 1977 Functional Studies, Doctoral Thesis, University of Uppsala, Sweden.</li> <li>Bedouin, Leo, personal communication, Dan Muth Company San Francisco, California, 1981-March, 1987.</li> <li>Friestadt, Ake, "The Swedish Suction BK Prosthesis," presentation at UCLA Advanced below-knee Prosthetics Seminar, October, 1984. Contact Een Holmgren Co., Uppsala, Sweden.</li> <li>Murphy, E.F., "The Fitting of Below Knee Prostheses," Klopsteg PE, Wilson PD (eds), <i>Human Limbs and their Substitutes</i>, New York, McGraw Hill, 1954, pp. 693-735.</li> <li><a href="cpo/1986_02_093.asp">Sabolich, J. and T. Guth, "Below Knee Prosthesis with Total Flexible Socket: Preliminary Report," <i>Clinical Prosthetics and Orthotics</i>, Vol. 10. No. 2, Spring, 1986, pp. 93-99.</a></li> <li>Kristinsson, O., "The ICEROSS System," lecture at UCLA Advanced Below-knee Prosthetics Techniques Seminar, Fall, 1986. Contact: Ossur hf. Reykjavik, Iceland.</li> <li>Holmgren, G., "The Patellar Tendon-Bearing (PTB) Suction Prosthesis," <i>Disability</i>, Strathclyde Bioengineering Seminars, August, 1978, MacMillian Press, Chapter 47.</li> <li>Grevsten, S. and U. Eriksson, "Stump-Socket Contact and Skeletal Displacement in Suction Patellar Tendon Bearing Prosthesis," <i>J. Bone and Joint Surgery</i>, 56, 1974, pp. 1692-1696.</li> <li>Fillauer, C, "A P.T.B. Socket with a Detachable Medial Brim," <i>Orthotics and Prosthetics</i>, Vol. 25, No. 4, December, 1971, pp. 26-34.</li> <li>Gleaves, J.A.E., <i>Moulds and Casts for Orthopedic and Prosthetic Appliances</i>, Charles C. Thomas Publishers, Springfield, Illinois, 1972.</li> <li>Tranhardt, T., "Trimlines for Prosthetics," lecture to California Association of Prosthetists and Orthotists, Lake Tahoe, California, Spring, 1978.</li> <li>McQuirk, A. and A. Morris, <i>Controlled Pressure Casting for PTB Sockets</i> (Teaching Manual), Hangers, Roehamptom Lane, London, England, 1982.</li> <li>Hayes, R., "A Below-Knee Weight Bearing, Pressure Formed Socket Technique," <i>Orthotics and Prosthetics</i>, Vol 29, No. 4, December, 1975, pp. 37-40.</li> <li>Stokosa, J., "Prosthetics for Lower Limb Amputees," in Haimovici, H., Vascular Surgery, Norwalk, Connecticut, Appleton Century-Crofts, 1984.</li> <li>Vinnecour, K., "Clinical Below Knee Prosthetics," lecture at UCLA Prosthetics Education Program Advanced below-knee Symposium, Fall, 1983.</li> <li>Cascade Orthopedics, Chester, California.</li> <li>Staats, Timothy, "Advanced Prosthetics Techniques for Below-Knee Amputations," <i>Orthopedics</i>, 8, 1985, pp. 249-258.</li> <li>IPOS Manual, "Below Knee Supracondylar Flexible Socket," IPOS-USA, Niagara Falls, New York, 1982.</li> <li>Koniuk, W., "A Pure Silicone Below-knee Socket Liner," lecture at American Academy of Orthotists and Prosthetists at San Francisco, California, Winter, 1986.</li> <li>Mr. Peyton Massey, New Life Laboratory, Santa Monica, California.</li> </ol> <em><b>*Judd Lundt, B.S., A.E. </b> Prosthetics-Orthotics Education &amp;Research at the UCLA Division of Orthopedic Surgery, 1000 Veteran Avenue, 22-56 Rehabilitation Center, Los Angeles, California 90024.</em><br /><br /><em><strong><b>*Timothy B. Staats, M.A., </b></strong>CP. Prosthetics-Orthotics Education &amp;Research at the UCLA Division of Orthopedic Surgery, 1000 Veteran Avenue, 22-56 Rehabilitation Center, Los Angeles, California 90024.<br /><br /><br /></em> Page Number(s) 118 - 130 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-16.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 UCLA Total Surface Bearing Suction Below-Knee Prosthesis Creator An entity primarily responsible for making the resource Timothy B. Staats, M.A., CP. * Judd Lundt, B.S., A.E. * https://staging.drfop.org/files/original/848c4d3ac131b5dd1f6aa772c7f8a431.pdf e817c23d305059d5eb0443856e4b4387 https://staging.drfop.org/files/original/36b983688348af4a118989fc5fb897c9.jpg 6cb2b221554b0b485d8fc79981ef09a6 https://staging.drfop.org/files/original/24dfe7339220fe553a1c64a284121f9f.jpg a77726724bb605b1b62088c61fa199fe https://staging.drfop.org/files/original/30555cd9d726c783eed81b24037c5cd4.jpg 9a82f709360468920d35880d9de0a173 https://staging.drfop.org/files/original/426fd84a7ec08befbdd52faee128f558.jpg f857fbf49e56777769bc3f0b1a131af4 https://staging.drfop.org/files/original/b4c608d131a05575666bb7d89f3e757a.jpg dc4cf48f9a16720c6e9c13db8d6428ab https://staging.drfop.org/files/original/ee370f1cc7c95a6fe60c95c4f0819351.jpg df2aa330418617744cac4fc848f4db40 https://staging.drfop.org/files/original/1ec16330c2317e239c81f3dca00e95eb.jpg 4cf2e1cb947b42839a66044354310fee https://staging.drfop.org/files/original/6b9d52df99dff7d840e2ec6557a4b1ac.jpg 348b4c2cc2203c0a6e6442d32a5dd6da https://staging.drfop.org/files/original/c847a8882afd28e78043d628ef01b4d1.jpg 1191ffe8bde507257ac7dcd9dd61efad DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_001.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 1 - 5 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Method of Early Prosthetics Training for Upper-Extremity Amputees</h2> <h5>Timothy V. Reyburn, MAJ., AMSC <a style="text-decoration:none;">*</a><br /></h5> <p>Over the past ten years, there have been gradual changes in the treatment and training of patients who have had upper-limb amputations.<a></a> This paper discusses early training techniques used over a two-year period at Valley Forge General Hospital on 67 (32 above-elbow and 35 below-elbow) amputees. Thirty-four of the amputees were treated from July 1968 to February 1969, and 33 from February 1969 to July 1970.</p> <p>Prior to February 1969, there was no separate ward for amputees, and each patient was placed on a ward appropriate to his overall disability, rather than according to his amputation. The upper-extremity amputees were pretrained in the leather-laced practice prosthesis with plaster-shell insert. However, this type of practice prosthesis was not fitted to the patient's stump until all wounds had healed and drainage had ceased. Consequently, preprosthetic training was delayed, and unilateral patterns could develop in the interim. When the patient did receive his practice prosthesis, training was initiated, with limited practice periods in occupational therapy for one hour a day. At first, the amputee wore the practice prosthesis only in the clinic. After he had mastered its operation and could tolerate the socket for longer periods, he was allowed to wear it the entire day. The patient was instructed to remove the prosthesis at night and to use the standard stump-wrapping procedure to control edema. A major problem during the training period was the constant separation of the plaster socket from the leather-laced cuff. Also, the functional alignment and the appearance were anything but desirable (<b>Fig. 1</b>). The therapist noted that the patients did not voluntarily wear their practice prostheses outside the supervised clinic environment. It was apparent that a more functional and streamlined type of practice prosthesis was urgently needed. In February 1969, the chief of orthopedics organized a separate amputee service, and a new training plan was initiated. The successful treatment of lower-extremity amputees by a technique in which a rigid dressing and plaster pylons were applied immediately after surgery lead to the hypothesis that a similar procedure might be beneficial for upper-extremity amputees. A practice prosthesis that consisted of a plaster socket with the terminal device and cable attachments embedded within the outer shell was fabricated (<b>Fig. 2</b>). From February 1969 to July 1970, 30 patients were fitted with the device (three amputees could not be fitted, because of transfer, infection, etc.). Their ages were between 19 and 39; the average age was 22 years.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. A leather-laced practice prosthesis with plaster-shell insert. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Adapted above- and below-elbow practice prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The key to a successful practice prosthesis is a firm, nonconstrictive, well-made socket. Both the above- and below-elbow sockets must be formed firmly and evenly to control swelling and to forestall blisters from developing by movement of the stump within a poorly fitting socket. Fabrication of the plaster-of-paris socket and prosthesis is relatively easy, and the procedure is basically the same for both above- and below-elbow prostheses.</p> <p>For the below-elbow socket, a layer of stockinet is pulled over the stump (<b>Fig. 3</b>) and extended two or three inches above the elbow, which allows for a fold and a trim on the proximal end. The distal end of the stockinet is cut and folded smoothly over the stump. Double thicknesses of three-inch plaster roll are thoroughly soaked and placed lengthwise on the stump. An area is left open ventrally to allow room for maximum flexion of the forearm. Circular, non-constricting, single-thickness wraps are then applied (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The first layer of stockinet applied to a below-elbow stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Application of plaster to the below-elbow stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For an above-elbow socket, the stump is completely covered with stockinet. The distal end of the stockinet is cut and folded smoothly over the stump. Double thicknesses of three-inch plaster roll are thoroughly soaked and placed lengthwise on the stump (<b>Fig. 5</b>). Each strip is ended three or four inches distal to the axilla to facilitate removal of the piaster socket. Circular, nonconstricting, single-thickness wraps are then applied. The lateral proximal apex is reinforced in order to provide a firm base for attachment of the lateral harness buckle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Plaster being applied over the stockinet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Aluminum struts are attached to the prosthetic appliance and plastered into the socket (<b>Fig. 6</b>). When the socket is finished, a figure-eight harness with a Northwestern ring is fitted to the patient, and a terminal device is attached to the practice prosthesis. All of the cable, base-plate, and harness connections are adjusted for each patient. Once the connections are attached and in proper alignment, the patient is trained to operate the practice prosthesis (<b>Fig. 7</b>). Additional sockets are fabricated if stump shrinkage exceeds the thickness of two single-ply stump socks. This basic prosthesis is used by the patient until he receives his final prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Affixing aluminum struts and a terminal device to the plaster socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. A below-elbow amputee learns to operate the terminal device on a practice prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because these prostheses have proved so acceptable to the amputees, a plaster socket is fitted immediately upon the patient's admission. A below-elbow amputee can be fitted and can start to use his prosthesis all in the same day. An above-elbow amputee, if not ready for a practice prosthesis, is fitted with a plaster-shell socket and figure-eight harness (<b>Fig. 8</b>). Anterior and posterior elastic straps are attached to the plaster shell to provide an even upward pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. An above-elbow amputee fitted with a plaster shell with figure-eight harness and Northwestern ring. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The plaster shell replaces the standard elastic wrap and provides an exercise modality for the patient. The protection provided by the hard plaster shell and the non-constricting but firm pressure against the patient's stump are superior to that provided by an elastic-bandage wrap. An elastic bandage, when wrapped properly, is firm distally and becomes less and less firm proximally. The wrap is thus very unstable, and it readily falls off. The plaster shell provides a more constant pressure, and the elastic straps can be adjusted easily.</p> <p>Once the patient masters his practice prosthesis, he is assigned to a work-therapy job, which usually is related to his future vocational interest. The ability to use his prosthesis on the job convinces the patient that he can function normally, which is another step in preparing the man for his permanent prosthesis and eventual discharge. If the patient cannot perform a certain function with his prosthesis, a therapist shows him how to solve the problem. The ability to hold grain sacks, handle meat knives, and lift pails are just a few of the everyday tasks that can be taught in work-therapy assignments.</p> <p>At this point in his rehabilitation, the patient receives a thirty-day leave. It is during this period that the amputee can really give his prosthesis a workout, by wearing it around the house and using it while doing repair work or mechanical tasks. Completely relying on his prosthesis is the best way for him to work out any problems in its operation. He learns what works best for him, and this knowledge is of great value when he is sent to the prosthetist for the fitting of the permanent prosthesis. After the patient receives his permanent prosthesis, he needs no further training; he can operate it with maximum efficiency, and all that is needed is a final check-out. After minor pressure points and alignment problems are adjusted, the patient is ready for discharge.</p> <p>If necessary, amputees can be fitted while their stumps were still open and in traction. The importance of skin traction cannot be overemphasized; 75 percent of the amputees received for treatment needed some type of skin traction before being fitted.</p> <p>The skin-traction weight is removed, and the traction ties are folded back over the stump end. Another stockinet is then pulled over the skin traction, and a plaster socket is fabricated over both.</p> <p>Although at first only the less open stumps were fitted in this manner, the method was so successful that we used it on grossly open stumps, and the fittings were accomplished without difficulty (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Stump ready for fitting with practice prosthesis and traction still maintained. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training sessions in occupational therapy with the practice prosthesis are a tremendous boost to the patient's well-being. After the training session, he removes the prosthesis, reties the traction, and attaches the traction weights. As skin coverage and healing improve, skin-traction time becomes less, and practice-prosthesis-wearing time increases.</p> <h3>Discussion</h3> <p>Acceptance of the permanent prosthesis by the 30 patients fitted after February 1969, and their functional use of it, was evaluated. The degree of acceptance and functional use decreased as the level of amputation increased, with positive acceptance of the long below-elbow prosthesis and a gradual rejection of the shoulder-dis-articulation prosthesis. Every patient was given and trained with an APRL (Army Prosthetic Research Laboratory) hand. Two of the 30 patients preferred the APRL hand to the hook; both of these had shoulder disarticulations.</p> <p>The post-February 1969 patients were fitted three to four weeks earlier than the pre-February 1969 patients. Duration of hospitalization remained about the same, but the post-February 1969 patients were on work therapy and were productive three to four weeks earlier.</p> <p>Ease of fabrication and patients' acceptance of the streamlined practice prosthesis were noted. The patients' stumps tolerated the hard-shell sockets without difficulty.</p> <p>Early fitting over open stumps and over skin traction is possible. Edema is reduced and the stump is desensitized while the patient uses his prosthesis.</p> <p>Rehabilitating the upper-extremity amputee to normal activities as soon as possible requires a total team approach. Close coordination among the physicians, nurses, physical therapists, occupational therapists, and prosthetists is necessary. If everyone on the team understands the problems of the upper-extremity amputee, then all can work together in directing and guiding his treatment.</p> <p><b>References:</b></p> <ol> <li>Bailey, Ronald B., <i>An upper extremity prosthetic training arm</i>, Amer. J. Occup. Ther. 24:5:357-359, July-August 1970.</li> <li>Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, <i>The Management of Lower-Extremity Amputations</i>, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969, p. 11.</li> <li>Sarmiento, Augusto, Newton C. McCollough III, Edward M. Williams, and William F. Sinclair, <i>Immediate postsurgical prosthetics fitting in the management of upper-extremity amputees</i>, Artif. Limbs 12:1:14-19, Spring 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bailey, Ronald B., An upper extremity prosthetic training arm, Amer. J. Occup. Ther. 24:5:357-359, July-August 1970.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, The Management of Lower-Extremity Amputations, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969, p. 11.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Newton C. McCollough III, Edward M. Williams, and William F. Sinclair, Immediate postsurgical prosthetics fitting in the management of upper-extremity amputees, Artif. Limbs 12:1:14-19, Spring 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Timothy V. Reyburn, MAJ., AMSC </b></td></tr><tr><td class="clsTextSmall">Now Chief of Occupational Therapy, Fort Riley, Kans. 66442.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Method of Early Prosthetics Training for Upper-Extremity Amputees Creator An entity primarily responsible for making the resource Timothy V. Reyburn, MAJ., AMSC * https://staging.drfop.org/files/original/704be8285e9e81b00a548f4079273dd0.pdf 8d139ddf679c176348350d328a543afd https://staging.drfop.org/files/original/49cf18e648ecc82d654ec1eff2291631.jpg c1cfed36a05f0a2fc50153fd5c760913 https://staging.drfop.org/files/original/75674097e4e35c77fdec5a976ff86d62.jpg 9f31ccdf0294986d2aea9d550887f50f https://staging.drfop.org/files/original/6e8abc5344c8c89a34bb7bb7e58e2657.jpg 6093fff8491a17af6fc0bb951f2df011 https://staging.drfop.org/files/original/37d0211a1c3964d660b5475199ef272d.jpg e15ab0ecdc3c30f04f9a0f88d1e7f911 https://staging.drfop.org/files/original/074ff2c61033b2276ba9ba6b32d533dc.jpg 18833eb4185b3218e31d0f5a35889396 https://staging.drfop.org/files/original/25f6feb898b3105da3d22efedaad8b5f.jpg 14cd923437e363674f1305376f929c93 https://staging.drfop.org/files/original/98c6f90be1d6a610b1532fee234863eb.jpg 77448c6435f7e839884d481f8bb7c0bc https://staging.drfop.org/files/original/bf8014ecf9aef0436238851fa1474e8e.jpg a485adc4c47126a56ef395422b794cc0 https://staging.drfop.org/files/original/a3f8fed82c099bfaf63d22effee25dc9.jpg 3aafbd4368cc3968a6ed5d0bf3d576af https://staging.drfop.org/files/original/63989f61bdf02ae37100a3e5d28a3065.jpg 3b2ff7b083f358ef57a6a637a5333dc6 https://staging.drfop.org/files/original/6a514f0e2ba1bfd9ba93437672e576c3.jpg 17049ac032017d5b129e9629dd56a9f4 https://staging.drfop.org/files/original/dd2a27378293b40a365d988be7038823.jpg 487fe803ef2ffdf12201d3e066227729 https://staging.drfop.org/files/original/79421da1d5927a2f575339efaaae587a.jpg 7727b475ea61106ccba34b7e0a8fea80 https://staging.drfop.org/files/original/85780afcefa210b16b3180eb1a8a32c7.jpg 0929c4e5349737a970d707389cc7e591 https://staging.drfop.org/files/original/80b1690efe4254fee0a6b928f0221b73.jpg b35fcbb513359778fadce4c9655b88ac https://staging.drfop.org/files/original/a7b48775e41332452941b1805803de4f.jpg 2d1f4f535f9b9df473d2a83b9a61d6db https://staging.drfop.org/files/original/354cad5e63e3f2ee432a2a43b8af480f.jpg f54280fbcdcd946cade07b9a0e67cf76 https://staging.drfop.org/files/original/8932dd244d2f177f348642bab3474157.jpg a9162486c8f3c0b05d8e402bb14cb9cc https://staging.drfop.org/files/original/172fcac01d1f6b60da95c9da079d9b0c.jpg 29f465e6e6425c776b16326e64e5ec8a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_004.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 4 - 34 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_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Lower-Extremity Clinical Study-Its Background and Objectives</h2> <h5>VerneT. Inman, M.D., Ph.D., <a style="text-decoration:none;">*</a><br />Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p> If it may be postulated correctly that the most satisfactory artificial leg is the one which most nearly simulates the static and dynamic behavior of the natural limb it replaces, the successful practice of lower-extremity prosthetics poses a twofold requirement. The first is an intimate and detailed knowledge of the characteristics of the normal leg in all common activities, and the second is the ability to reproduce as nearly as possible, by a combination of design and fit of the substitute limb, the kinetic and kinematic features essential to normal locomotion. In the Artificial Limb Program, principal responsibility for fundamental studies in normal and amputee gait and in lower-extremity prosthetics has, since 1945, resided in the Prosthetic Devices Research Project at the University of California, Berkeley Campus. </p> <p> But the problems facing the leg amputee are not wholly prosthetic. Many, indeed, are clearly medical. For the amputee, being no longer the whole normal individual, manifests gross structural and physiological changes to be dealt with successfully only by the physician. </p> <p> The Lower-Extremity Clinical Study being conducted jointly by the Department of Engineering, University of California, Berkeley, and the University of California Medical School, San Francisco, and in cooperation with the U. S. Naval Hospital, Oakland, has as its chief objectives the analysis of medical problems inherent in the amputated state and the application of fundamental knowledge to practical problems in the management of lower-extremity amputees. Current techniques and practices in the fitting of leg amputees still are so varied from place to place and from prosthetist to prosthetist that some orderly means has been wanting for establishing what is, everything considered, the best prosthetics practice in the lower extremity. Designed to close the gap between basic work in the laboratory and work in the field, the Clinical Study is an outgrowth of the fundamental research in locomotion conducted earlier by the Berkeley Project. </p> <h3>The Background </h3> <p> For a number of years during World War II a group at the University had been conducting research in the field of biomechanics and had published data relating to the behavior of the upper extremity. In the autumn of 1945, therefore, the University was approached by a representative of Northrop Aircraft, Inc., a company which at that time was already engaged in prosthetics research<a></a> under contract with the then Committee on Artificial Limbs of the National Academy of Sciences- National Research Council. It was requested that the University group undertake an investigation aimed at providing information that could be utilized in the design and construction of lower-extremity prostheses. </p> <p>The suggestion having been taken under advisement, the entire Committee on Artificial Limbs met at the University shortly thereafter to consider the proposal and to evolve details of contractual arrangement. Out of this meeting came two basic observations. One was that, inasmuch as the financial support for the work was to come from public funds, any information derived from the contract would have to be shared with all other contractors participating in the Artificial Limb Program as well as with the general public. The other was that, in the opinion of the conferees, between five and seven years of study would be required before sufficient detailed and quantitative information could be accumulated to effect substantial improvement in lower-extremity prostheses.<a></a> At the outset, the University group insisted that it be kept free of the task of developing prosthetic devices-that it simply be permitted to investigate normal human locomotion and to furnish the collected data for others to use. The original concept of the scope of the project-as a program of basic research in human locomotion-has been adhered to up to the present time, the only deviations having involved development of experimental devices<a></a> needed to assist in the locomotion studies. </p> <p> The early years, then, were spent in working out techniques suitable for recording objectively the motions and the forces involved in the gait of man.<a></a> Of course, the investigators took advantage of all the previous work in this field, not only that done by other contractors<a></a> participating in the Artificial Limb Program but also that contained in material, particularly that of Elftman<a></a> published in the United States and in foreign countries over a period of many years. By 1947, enough data had been accumulated to publish a comprehensive report<a></a> on the walking pattern of normals and of leg amputees.<a style="text-decoration:none;">*</a> </p> <p> Attempts to translate the results of basic research into criteria for the improvement of prosthetic devices led to the second phase of the project, that is, to developmental research, an area that involves engineering and prosthetics technology. During the last few years, this phase of the project has been conducted on a relatively small scale. As devices were prepared for trials by amputees, the problem of fit and alignment had to be attacked, and hence fundamental studies were undertaken in this area in order to establish a set of basic principles and techniques.<a></a> Because fitting and alignment contribute most to the comfort and therefore to the success of any artificial leg, the validation of these principles and techniques formed the basis for embarking on the third phase of the project, the Lower-Extremity Clinical Study, an activity that provides a laboratory where medical and prosthetic problems can be handled under controlled conditions. It offers an opportunity to see how individual solutions may be obtained by applying a set of general principles based on biomechanical considerations. Until recently, the study group has been concentrating on the problems of the above-knee amputee because that case appeared to offer neither the most difficult nor simplest set of circumstances. </p> <h4> The Locomotion Studies </h4> <h5> <i>Muscle Physiology</i> </h5> <p> When the Prosthetic Devices Research Project first was organized, man was viewed as a machine, the object being to measure the displacements, accelerations, and forces required in human locomotion.<a></a> But man is more than a single machine. He is powered by a complicated system of many internal engines served by muscles. Accordingly, the study was broadened to include the field of muscle physiology.<a></a> Investigation of the behavior of the musculature during normal locomotion (<b>Fig. 1</b>) revealed the basic action of the various muscles involved<a></a> It was shown that in locomotion each muscle acts when it is near its rest length but that it acts for a very short period of time in each walking cycle.<a></a> This action makes the contraction essentially isometric and limits the activity of each muscle fiber to a few twitches. Under these conditions the muscle works with minimal energy and maximum tension, which helps to explain why a person can walk considerable distances without tiring. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical electromyographic summary curves, in this case for the hamstring group. Ten subjects. Cadence: 95 steps per minute, level walking. Data from UC studies 102. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Upon working out the speed of contraction, it was found that, if muscles are halved, their contractile velocities likewise are halved (<b>Fig. 2</b>). Utilizing a profile electromyographic recording (electromyogram rectified and dampened to give a relatively smooth line), and taking the maximum amplitude in a given cycle as 100 percent, the average durations with an amplitude greater than 75, 50, or 25 percent are approximately 0.04, 0.1, and 0.2 second, respectively.<a></a> Since it seems probable that the profile electromyographic amplitude largely indicates relative numbers of active motor units, it would appear that most of the units participating in this phasic action are active during bursts of 0.1 to 0.2 second only. According to Weddell<a></a>, at a repetition rate of 20 per second or less most motor units would fire in each cycle one to four times only. In such a case, any temporal summation taking place at neuromuscular junctions would not be effective fully, and the action of a motor unit, at least in a normal phasic pattern like locomotion, would not have the character of a sustained tetanus. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Relation between the maximum speed with which a muscle can contract and the weight with which it is loaded. When the length of the muscle is halved, its speed of contraction is also halved. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> As a result of these investigations, in 1947 the group at Berkeley, noting the earlier work of Blix<a></a>, was first to call attention to the length-tension relationships existing in human muscles<a></a> and thus laid the basis for the decision to use certain muscles for the cineplastic technique.<a></a> The characteristics of the length-tension diagram have since proved to be of fundamental importance in devising prosthetic aids for upper-extremity amputees.<a></a> The cineplastic muscle tunnel, comprising a skin-lined tube placed through the distal end of a muscle, permits an amputee to utilize effectively his own muscle forces for activating an artificial arm or hand. But in order to operate a cineplastic prosthesis efficiently, it is necessary that the muscle be near its rest length, so that it can generate a force sufficiently large and so that it can shorten enough to carry out necessary movements.<a></a> Appearing in publications as early as 1949, the work conducted at the University of California has been recognized by Buchthal<a></a> of the University of Copenhagen as the best so far done on normal human muscle dynamics. </p> <h5> <i>Energy Requirements</i> </h5> <p> In another study, an investigation was made of the dissipation of energy (<b>Fig. 3</b>) in human locomotion.<a></a> Results showed that approximately 50 percent of the energy consumed in walking is used simply in bouncing up and down, that is, in vaulting over one leg and then the other. The other half is used in the oscillations of the legs. It is therefore apparent that, if the amputee is not to be subjected to unduly large energy demands, he must have a smooth pathway of displacement of the center of gravity of the body.<a></a> Any deviation from the smooth, natural locus of the center of gravity means excessive dissipation of energy and consequent degradation into heat.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 3. Typical moment-angle diagram for the leg of a normal subject during level walking. From Bressler [sic] and Berry (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Contrary to much popular belief, man not only pushes his way through space. He also <i>pulls </i>his way.<a></a> Indeed, deceleration of the swinging leg, not push-off from the other toe, provides the greater part of the energy for locomotion, the proportion attributable to deceleration of the swinging leg being about 4, that attributable to push-off only 3. Energy is absorbed by the knee to decelerate the leg and foot during the swing phase, but not all of the energy so absorbed is lost.<a></a> A considerable portion is stored and returned to the system in the later part of the swing phase to impart continued forward acceleration at the time when most of the body's potential energy is lost.<a></a> Thus locomotion is due not only to the push of the member in support but also to the pull of the deceleration in the swinging knee. </p> <p> Because the above-knee amputee has no calf group, and therefore cannot contribute the equivalent of this force at push-off, it was suggested that some conservation of energy might be effected in a prosthetic device without an ankle joint.<a></a> That this was a correct deduction has since been demonstrated (<b>Fig. 4</b>) in the Stewart-Vickers leg,<a></a> in which the ankle is locked at toe-off until 20 deg. of knee flexion has occurred.<a></a> It has the highest net output and the lowest total input of all legs tried to date (<b>Fig. 5</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Cadence changes observed in above-knee amputees asked to walk at "normal" speed first with a conventional limb and then with the Stewart-Vickers (locked ankle) prosthesis 114. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Energy characteristics of the normal ankle compared with those of the conventional leg and the Stewart-Vickers leg. Top, total input, total output, and net output of both ankles per stride. Bottom, input and output of each ankle per step. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Amputee Pain </h4> <p> Intimate contact with amputees led to the early investigation of pain as related to the amputee patient.<a></a> In 1946 a team of interviewers set out to question amputees in various hospitals, particularly in the Veterans Administration Hospitals and in the Naval Hospital then at Mare Island. Over a period of a year and a half, detailed histories were obtained from 80 patients. As a result of this review, further funds were provided by ACAL to establish a Pain Clinic at the University of California, primarily to evaluate pain as found in the amputee. Established in August 1949, the clinic functioned until January 1953. </p> <p> In June 1952, an analysis of 218 amputees was reported.<a></a> In this study, which constitutes one of the largest series on record, the type and frequency of pain in the amputee were explored. Because it was thought that perhaps deficiencies in stump circulation might contribute to the pain experienced by the amputee, circulatory studies were undertaken. Concurrently, innervation of the deeper tissues was studied.<a></a> Sections of tissue were taken from periosteum, muscle, and skin, and the nerve supply to these tissues was demonstrated by a methylene blue technique. </p> <p> One of the most intriguing aspects of this investigation was the work with normal individuals in whom irritative lesions purposely were produced in the deeper tissues.<a></a> With the authors, some 75 medical students, and three laboratory assistants serving as subjects, 0.5 to 1.0 cc. of 6-percent saline solution was injected systematically into the paravertebral muscles at each intervertebral level from the atlanto-occipital area to the lower sacrum. Five subjects were used in the testing of each injection site, a total of 140 individual observations being made. Although the distribution of pain approximated a segmental plan, it also overlapped considerably and differed in location from the conventional dermatomes. It was found that, in any irritation of deep somatic tissues, pain did not restrict itself to the area of injection but tended to radiate distally into the extremities. Injection of 6-percent saline into any given interspinous level produced in the normal a characteristic pain distribution that was remarkably constant from subject to subject. The distribution of pain referral from deep structures in the normal suggested similar investigations in the amputee. To elicit the sensation of the phantom limb, it was necessary to inject the salt solution into the appropriate interspace. In the normal, radiation of pain into the lower limb was most marked when the interspinous tissue between L4 and L5 was affected, and in the above-knee amputee the L4-L5 interspace also gave the best response. The immediate reactions of amputees resembled those reported by normals-a rapid onset of pain close to the site of injection and then, in the case of L4-L5 injection, radiation into the buttocks and the posterolateral aspect of the thigh. In nearly all instances there occurred a rapid "filling" of the absent areas of the phantom limb, the subjects usually evidencing surprise at the sudden totality of a phantom limb even though the new portions were seldom, if ever, immediately painful. </p> <p> Severe pain was a frequent feature in the portion of the phantom present before injection. After injection the pain often spread into the newly "filled in" portion of the phantom limb. Transient pain following injection occurred in phantom limbs regardless of the existence of preinjection pain. But in many cases involving pre-existing phantom pain, a secondary decrease in the amount of pain followed the injection, in some but not in all instances the decrease being preceded by a transitory accentuation of the pre-existing pain. Occasionally, the decrease reached the point where no pain was felt, so that the amputee experienced the first complete relief in many months. </p> <p> The decrease in pain is even more remarkable when one considers that it is brought about by the application of a noxious stimulus to a tissue remote from the phantom itself. For example, in an above-knee amputee who had undergone amputation two months before the investigation, there was a phantom sensation of the "foot" only, the phantom being very painful with the sensation of severe constriction of the great "toe" (<b>Fig. 6</b>). When saline was injected into the L4-L5 interspace, much of the intervening phantom limb was filled in almost immediately, the anterior aspect of the "leg" becoming the most prominent part. Soon after the phantom was "completed," the preexisting pain in the "foot" increased in intensity and area. This state continued for five or six minutes, whereupon the pain began to decrease and continued to do so until, in another five minutes, it had disappeared completely. Numbness, but not pain, remained in the "foot" only. In some instances even phantom awareness disappeared after saline injection. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Effect of interspinous injection of saline on the painful phantom limb of one subject. A, Phantom before injection. B, Radiation of sensation induced by injection of 6-percent sodium chloride solution. C, Residual sensation following injection. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In general, the saline injections had greater effects on phantom limbs than on real ones, a peculiar susceptibility best illustrated by the effects of mid-line injections. An accurately placed mid-line injection in a normal subject produces very little radiation, the severe pain being confined to a rather small area in the immediate vicinity of the injection. In the case of the amputee, however, such minimal radiation in the trunk is accompanied by profound effects on the phantom extremity. Every conceivable change in phantom form and phantom pain can result from interspinous injection of an irritating hypertonic saline solution, the changes probably stemming from the sudden increase in the sensory inflow at the particular segmental level. </p> <p> Out of these observations came, then, one method of treating phantom pain, for when a small amount of hypertonic saline was injected into the appropriate segmental interspinous ligament, the phantom experience was changed and pain occasionally was relieved. This finding led to the use of hypertonic saline for the treatment of various painful conditions. Although permanent cures resulting from such techniques are not numerous, the method may prove to be a valuable addition to the modern medicine chest, which is by no means rich in effective pain palliatives.<a></a> </p> <p> It deserves to be noted that, in seeking the origin of the phantom experience, one must look not only for direct involvement of the nerves of major nerve trunks. The entire segment of the extremity must be investigated for any irritative skeletal lesions arising from the joints, the muscles, or the connective tissues of the stump or from portions proximal to the stump. </p> <h3> Evolution of Basic Data </h3> <p> From the basic studies now has come much information of value in prosthetics. As early as 1947 it was determined<a></a> that in normal walking the leg rotates in space internally and externally about 15 deg. on the average (<b>Fig. 7</b>). That this horizontal rotation of the extremity might be of some importance in human locomotion has since been known as the "Berkeley fetish," and as far as is known no one has yet taken cognizance of the fact in any successful limb design. In 1950 it was suggested<a></a> that it would be of considerable value if deceleration at the end of the swing phase could be incorporated through some sort of variable-cadence knee joint. This has been done in at least one device, the U.S. Navy above-knee leg,<a></a> now available commercially (see <i>Digest, </i>this issue, page 65). Several others currently are under development. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 7. Typical relative rotations of the pelvis, femur, and tibia in normal, level walking. Data from UC studies </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At the same time it was suggested that, inasmuch as the above-knee amputee can obtain no forward propulsion by contraction of the calf group, the ankle joint is of little use- that, indeed, if an ankle joint with rubber bumpers is used, energy is lost by hysteresis of the bumpers. As already mentioned, the improved performance of the Stewart-Vickers leg, in which the ankle is locked at toe-off up to 20 deg. of knee flexion, proves the validity of the original observation. Similarly, it was pointed out that, because of the interrelationship between the ankle-foot function and the knee-joint function, greater stability would be required of the knee joint were the articulated ankle to be abandoned. </p> <p> In 1953, Saunders, Inman, and Eberhart<a></a>, summing up the results of all the basic studies, pointed out that there is an interrelationship between all displacement patterns of all segments of the lower extremity, that there are six major determinants in locomotion, that modification of one results in modification of the others, and that any changes in the knee or ankle, either in normal or in amputee, are necessarily accompanied by compensatory changes in the remaining joints. Basically, locomotion is the translation of the center of gravity through space along a pathway requiring the least expenditure of energy (<b>Fig. 8</b>). The six major determinants of the pathway are pelvic rotation, pelvic tilt, knee flexion, knee extension, knee and ankle interaction, and lateral displacement of the pelvis. Serial observations of irregularities in these determinants provide insight into individual variation and a dynamic assessment of pathological gait, which may be viewed as an attempt to preserve the lowest possible energy consumption by exaggerating motions at unaffected levels. Compensation is reasonably effective with the loss of one determinant, that at the knee being the most costly. Loss of two determinants makes effective compensation impossible, the cost of locomotion in terms of energy then being increased threefold, with an inevitable drain upon the body economy. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The sum of the effects of the six determinants of gait. The pathway of the center of gravity is a smooth curve in both horizontal and vertical planes. From Saunders, Inman, and Eberhart<a></a>, by permission of The Journal of Bone and Joint Surgery. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> With regard to the surgery of amputation, the studies in muscle physiology suggested that considerable improvement might be effected in lower-extremity prosthetics were muscles fixed in the distal end of the stump so that they could not retract.<a></a> As previously pointed out, retraction of these muscles means shortening, and shortening means an inability to develop natural tensions. More recently the studies have suggested that, in order to retain normal weight-bearing through the shaft of the femur, more attention should be paid to the possibility of end-bearing rather than to the more conventional method of weight transmission through the ischial seat. All of these ideas, derived from the results of the early studies on locomotion, were offered to the limb industry by the University group in the hope that designers or manufacturers would incorporate the recommended features into new prostheses. </p> <h3> The Clinical Study </h3> <p> In the spring of 1953, after years of basic study, the question arose as to what might be done toward applying to the amputee problem some of the knowledge gained. After several months of discussion, the UC Prosthetic Devices Research Project accepted a proposal to institute the so-called "Clinical Study," the principal objective being to draw upon the pool of fundamental knowledge, to attempt to apply it toward the solution of practical problems, and to see whether or not there would emerge certain definite devices or methods which could be passed on to the artificial-limb industry and to prosthetists. Last year, then, the clinical program was established, and currently it is the center of attention. </p> <p> To organize such a clinical study obviously required a limbshop and examining rooms. Through the kindness of the Navy, space was afforded at the Navy Prosthetics Research Laboratory at the U.S. Naval Hospital at Oakland, California. There the setup includes a small limbshop where prosthetics work is done, a medical examination room, fitting and training rooms, an evaluation and photography room, and conference rooms, the entire operation being conducted in cooperation with the limb industry. Through the Industry Advisory Committee, amputees are selected on the basis of referral by limbshops, by physicians, by rehabilitation agencies, by the Veterans Administration, and by direct personal contact. After preliminary screening by the Clinical Study Group, an individual is selected only with the approval of the Industry Advisory Committee, and all of the work is done with the knowledge, assistance, and cooperation of the artificial limb industry. </p> <p> Because it is concerned primarily with research, the Clinical Study is not a commercial operation, and consequently production is not high and is not supposed to be. Thus far only 16 subjects have entered the clinic. Of these, 10 are unilateral above-knee amputees ranging in age from the teens to the seventies, two are bilateral above-knee cases, one is a bilateral above-knee/below-knee case, two are hip-disarticulation cases, and one is a unilateral below-knee case. Five are in the follow-up stage, six in the postfitting adjustment stage, three in the fitting stage, and two in the pre-prescription stage. All save one have been complicated cases, presenting difficult problems that nobody else wished to tackle. From particular cases such as these have come practical answers for other difficult cases. </p> <p> A thorough and complete study-from the medical, biomechanical, and prosthetic points of view-is made of each case, and individual problems are diagnosed and corrected. To find the best possible solution in any particular case requires a knowledge of what attempts have been unsuccessful and why they failed, for sometimes a great deal more is learned by determining why one proposed solution failed than by determining why another was successful. </p> <h4> The Clinic Team </h4> <p> The clinic team consists of an orthopedic surgeon, a prosthetist, a physical therapist or amputee instructor, and sometimes an engineer<a></a>. This group makes the initial evaluation and provides a prescription<a></a> based on complete data including a medical history, an analysis of existing condition of the stump and of the rest of the body, and an evaluation of the old prosthesis. The prescription is reviewed by the Clinic Study Panel, including several orthopedic surgeons, a psychiatrist, a prosthetist from industry, and an engineer familiar with prosthetic problems. Once the prescribed device is fitted, the results are viewed by the Panel, and the reasons for success or failure are documented fully so that the case may serve as an example for future reference. No experimental devices are used in the clinic program. Only those devices available commercially are fitted to the subjects. </p> <h4> Industry Participation </h4> <p> Active participation by individual members of the artificial-limb industry has not yet started, but plans are now being made for such activity in the immediate future. That part of the program will involve working with prosthetists, screened by the industry, who will visit the clinic for a period of orientation. They will follow cases through the clinic study and then be assigned a shop case on a cooperative basis. The clinic team will act initially as a review committee in preparing the prescription, but the individual prosthetist will fill the prescription in his own shop. After fitting, the amputee and the prosthetist will return to the clinic for evaluation. This procedure provides a twofold check. It evaluates the prosthetist's degree of efficiency and tests the validity of the clinic's method of prescription. </p> <h4> Prosthetic Problems </h4> <h5> <i>Crotch Pressure</i> </h5> <p> Because enough time has now elapsed to be sure that more than temporary success has been achieved, some general ideas can be discussed with a fair degree of confidence. The most common complaint heard by the group relates to crotch pressure. In every instance, however, the condition has been eliminated. Correcting for excessive crotch pressure involves two things-the right socket shape and correct alignment (page 35). Proper socket shape is ensured by providing for ischial-gluteal bearing (which prevents sinking into the socket), by controlling the anteroposterior dimension, and by raising the height of the socket brim. </p> <h5> <i>Localized Socket Pressure</i> </h5> <p> The next most common complaint relates to edema. Rarely has there been a case of the suction socket where edema could be traced to high negative pressure alone. Excessive crowding or tightness invariably were contributing factors. Edema may result principally from a high rate of pressure change at any point along the length of the stump. Because emphasis has been placed on socket shape near the top brim, not enough attention has been given to good fit throughout the length of the stump. Any constrictions or ridges, including those formed by muscle groups, cause pressure changes that interfere with venous return. The inside finish of the socket also may be a factor. In one instance, for example, a severe case of edema was alleviated by providing the socket with a smooth, high-gloss finish. </p> <h5> <i>Socket Brim</i> </h5> <p> Skin irritation around the socket brim also is a source of annoyance and discomfort. Accordingly, dermatologists are cooperating in the program. They examine amputees having skin problems and outline procedures for therapy, including the taking of biopsies of the skin. Pigmentation is evaluated to determine whether or not it is due to capillary hemorrhage caused by decreased suction or whether it is merely a pigmentation that often occurs in areas of friction. Out of this study should come a routine test and a new modality of skin care for the leg amputee. </p> <p> Again, the condition can be eliminated by controlling the shape and height of the anterior and lateral brim above the ischial seat. Medial width also is a controlling factor because it determines the total amount of pressure exerted by the front of the socket to maintain stability on the posterior weight-bearing surface. And, as in the case of edema, the inside finish is important in preventing skin damage. Sitting discomfort, a complaint often heard, usually is relieved by using a flat back, by not having the inside edge of the seat too sharp, and by ensuring that any channel for gluteal relief is not too large. </p> <h5> <i>Alignment</i> </h5> <p> Alignment is a continuing problem, and the development of guiding principles is most important. Although general principles are comparatively simple to state, to understand them fully and to apply them to individual cases is difficult. One of the objectives of the clinical program is to apply to typical problem cases the alignment principles developed through fundamental research and to develop examples showing how these principles can be applied, why they work, and the end-results that can be obtained. Naturally, the best results are obtained when the stump is so oriented as to take full advantage of the remaining hip musculature. There is a growing body of information relating to a number of common problems-problems associated with changing from a pelvic belt to a suction-socket leg; problems concerning the very muscular stump with prominent hamstrings or with some particularly firm muscle or muscle groups isolated in the stump; problems of the short and the long above-knee stump; problems caused by the flabby stump; and problems of inside finish. </p> <h4> Medical Problems </h4> <p> Often the problems of the amputee, both in the lower extremity and in the upper, stem not from an ill-fitting prosthesis. More often the problems can more properly be termed medical. Accordingly, the Clinical Study includes investigation of those aspects of amputee rehabilitation related to physiological changes associated with loss of limb. </p> <h5> <i>Pain</i>-<i>Phantom and Real</i> </h5> <p> As pointed out long ago<a></a>, loss of the normal limb so often is followed by the appearance of some form of phantom limb that, when a patient does not acknowledge one, it is suspected that he is withholding information or that the phantom has been repressed. Statistics show that the phantom is a normal phenomenon in the sense that most amputees have it. It is pathological, however, in the sense that the amputee perceives something that actually does not exist. </p> <p> In general, awareness is a matter of degree and, to some extent, a matter of verbal conventions. Some amputees say that the phantom has the same unobtrusive quality as does the material counterpart, that it appears only when called upon. Sometimes the amputee has difficulty in remembering that the phantom is unreal and that it does not serve in the capacities of its living predecessor. The normal person is not particularly aware of his limbs unless his attention is drawn to them in some way. Except under the impact of a sudden stimulus, or when a special effort is made, preferably together with a movement, our awareness is potential and shadowy in nature. With the eyes closed, and with the limb at complete rest, awareness is, in fact, not too far removed from mere imagination. To make certain that the limb exists, we move it, look at it, or rub some part of it. The amputee cannot conduct such an empirical test. </p> <p> Sometimes the patient can sense his lost limb as acutely as he can the remaining real one, and he often can imagine that he can "move" the phantom. More often, however, the phantom draws attention to itself by some "abnormal" sensation which makes the amputee more aware of it than he is of his real limb. Fortunately, only a small percentage of all phantoms habitually are painful. Some typical ones are shown in (<b>Fig. 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The phantom limb, a phenomenon of almost universal occurrence among amputees. A, Phantom toes and ankle, reported more frequently than are other phantom parts of the amputated lower extremity. B, Mild "tingling," characteristic of the painless phantom, is often described in terms of "crawling ants." C, The "telescoping" phantom, in which the foot, over a period of time, gradually approaches the stump and finally disappears within it. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Frequently the "foot" seems to shorten and approach the end of the stump. The patient illustrated in Figure <i>9C </i>experienced "telescoping" of the phantom, a phenomenon which, contrary to the observations of most other writers on the subject, was found infrequently in the Berkeley series. It is true that relatively undifferentiated parts like the calf and the forearm commonly are not felt. Some phantoms of distal parts are, from their onset, situated at the normal distance from the trunk. Others always seem to be located closer to the stump than normal. A few patients experience a gradual shrinkage of intermediate phantom parts, as has occurred over a period of years in the subject illustrated in (<b>Fig. 10</b>). In this case, all that remains of the shrunken ghost are the "toes," and these have come to lie not in empty space, as is the rule, but inside the stump. Not infrequently a phantom which has shortened may, on application of a prosthesis, lengthen and actually become identified with the artificial limb. Thus, in one instance, a young above-knee amputee felt as though the shortened "foot" were appended to the stump. When he wore his prosthesis, however, the phantom foot felt as though it were in the position corresponding to that of the artificial foot. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. A rare and peculiar form of phantom experience. Here the two "toes" seem to reside within the stump itself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Awareness of the missing member may or may not be described as basically unpleasant, but it is subject to intermittent unpleasant sensations-itching, tingling, or pain (<b>Fig. 11</b>). As pointed out by Livingston <i>, </i><a></a> the pattern of the painless phantom bears no resemblance to the areas of distribution of the major peripheral nerves. Thus the partial nature of the phantom cannot be ascribed to the affection of certain nerve lesions in the stump. Rather, the pattern of the phantom seems to relate to the most mobile parts and to those serving the highest degree of sensory function. But a substantial number of amputees experience, at one time or another, some sort of painful phantom of varying duration (<b>Table 1</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The painful phantom, of fairly common occurrence among amputees at one time or another. Only some 30 percent experience no phantom pain at any time. Probably about 10 percent face persistent and sometimes incapacitating pain. A, Among the similes used to describe a phantom pain is "as if my toes are being crushed by a hammer." B, Pain experienced at the site of an injury leading to amputation, such as a fracture, often persists as a part of the phantom pattern. C, The "hot wire" sensation and involuntary cramping of phantom toes are among the other frequent manifestations. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><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> How many amputees have pain? Taking into consideration the inadequacies of follow-up information, the subjective character of the pain experience, and the semantic difficulties beclouding the term "pain," a conservative estimate would be that 80 percent of all amputees are substantially free of pain and are either being trained for useful work or else are already actually so engaged. It is likely that, of the remaining group, possibly half are faced with severe intermittent or persistent pain. Because of persistent, incapacitating pain, approximately 10 percent of all amputees never get into a limbshop, never get out of the doctor's office. They become narcotic addicts and often commit suicide. Where pain enters the phantom syndrome, it may assume large clinical importance. If it is excruciating and persists for long periods, it may take a devastating toll of the whole personality and physical well-being. </p> <p> In describing severe pain, we all use a vocabulary taken from common objects known to produce injury. Lesser pains are described in terms of cutaneous and deep sensations. Thus we speak of "pressure," of "pins and needles," of "sharp" pains and "dull" aches, of "stabbing" and "shooting" pains. It seems unlikely that man at his present stage of evolution ever will devise a specific terminology for pain because he has no special organ for observing his discomforts. No matter how introspective a person may be, his account of pain always is phrased in imagery taken from other fields of experience. Nothing could be more real than these sensations, but we say "as if" to give them intelligible expression. The vocabulary is metaphorical. </p> <p> It is not surprising, therefore, to find amputees using language akin to that of the torture chamber when they try to do justice to their agonies. They hardly go further than anyone else in telling about physical sufferin. Nor do they hallucinate when they talk about "ropes" and "vises," for they remain aware of the imaginary character of these similies. It is possible, however, that, as the tearing and squeezing sensations are felt in a part of the body known to be missing, the suffering is heightened and the imagery made more vivid by the ghostly character of the phantom. </p> <p> It has been argued that phantom sensations are hallucinations because they entail a belief in the reality of an absent object, or that they are illusions because irritations of the stump are being misinterpreted, or that they are normal sensations because the cerebral representation of the once-present member still is intact. Some workers have correlated the type of sensation with the "level" of its origin in the nervous system, painful sensations being ascribed to pathological conditions of the cut nerve end in the stump or to mental aberrations. But classifications of either the amputee's descriptions or of the presumptive causes bringing about the sensations have thus far been unsatisfactory. The various frames of reference used in the statistical survey at Berkeley do, in fact, overlap. Duration and frequency of pain have some influence on the complaint of severity. Tingling and burning seem to be more superficial and, however annoying, more tolerable than do tearing, stabbing, cramping, squeezing, and crushing. It should be understood, however, that there are degrees of each of these and that, as such, intensities may, to a point, be compared with each other. </p> <p> It is obvious that a patient's account of his painful feeling is colored by his personality. The way a person describes such experiences depends not only on the abnormal processes causing them but also on his imagination, his previous experience, his learning, his cultural inheritance, and his vocabulary. But any view which discounts the abnormal physiological processes and credits only their "mental" interpretation is probably in error. The complexity of the nervous system and its integration into one functioning whole does not favor the idea that there is one chief recipient and executive who sorts out the messages from the various parts of the body and, in the case of pain, edits them as writhings and groans or as sentences made up of more or less colorful language. It seems improbable that there is simply one stimulus arising somewhere in the organism and that the ego reacts to this stimulus in a more or less stoic way. A so-called "neurotic" or "imaginative" disposition is likely to pervade the most "bodily" of processes, while a steadfast person is apt to have a stomach and blood vessels no more stable than his emotional display. </p> <p> Regardless of individual personalities, however, there is a certain uniformity in the complaints of pain-stricken amputees. Although the matter has not been explored from the point of view of psychophysiological typing, it appears that pain phenomena cannot be predicted either from the age of the patient or from the age of his phantom. By the same token, racial or cultural background and physical or mental make-up cannot be used to predict pain phenomena. Nor have the local pathological factors before, during, and after amputation-the factors that might be held responsible for the appearance of pain-been elicited. </p> <p> Aside from the problem of the painful phantom is that relating to painful stumps (<b>Fig. 12</b>). Amputees may have spontaneous stump pain. Or they may have so-called "trigger points," certain areas which, on slight pressure, tend to produce a flash of pain persisting for various intervals of time. Patients have complained of circumscribed areas of pain in the stump even though palpation revealed no corresponding point of tenderness. These two conditions usually are found together. Nodularities in the stump often are palpable, as indeed they are, on a minor scale, in other subcutaneous parts of the body. Some of these are tender, some are not; some are and some are not connected with phantom pain. In fact, separate places in the same stump may represent exclusive triggers-one for stump pain, the other for phantom pain. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Types of stump pain. About a third of the clinical reports of pain refer to discomfort in the stump rather than in a phantom part. Stumps may be painful to the touch (A) or spontaneously (B). Frequently present are "trigger points," pressure upon which gives rise to pain over a larger area, either in the stump or in a phantom or both (C). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> But the conditions prevailing at the end of the stump, including such nodules as the famous "amputation neuroma," do not provide a basis for intelligent speculation. The mere fact that stimulation of a presumptive neuroma often produces pain in the phantom is no proof for the theory that the "cause" of this pain lies solely in the periphery. In order to be disabused of such a notion, one has only to look at certain cases of known diseases of the central nervous system or at. complete transections of the spinal cord. In the latter, the brain receives no communications from the stump. In cases of painful diseases of the central nervous system, stimulation of the normal peripheral tissues having their nervous connections with the diseased part of the central nervous system often produces an abnormal sensation, including pain. This phenomena always is referred to the periphery. Nobody sounds convincing when he says that he feels pain in the brain or spinal cord. The central nervous system has no conscious sensory representation of itself. The mere description of a painful sensation does not permit detection of its origin. The origin has to be deduced from circumstantial evidence which, in the case of amputees, is lacking. Even where sensations are "triggered off" from the periphery, they can be completed only by participation of the central nervous system, and disturbances may occur anywhere along the line. </p> <p> We are confronted with the anomaly that stimulation of a certain trigger point within the stump arouses not a distant, painful phantom but one incorporated in the flesh of its own trigger. The specificity of this trigger further is illustrated by the fact that, on the opposite side of the same stump, there may be another tender spot, stimulation of which sets up increased local stump pain. </p> <h5> <i>Circulatory Problems</i> </h5> <p> Investigation of circulation in the amputee reveals that the stump acts as though it were poikilothermic, that is, it has no ability to change its temperature. Rather, the temperature of the stump matches that of the surroundings, as occurs in a cold-blooded animal. </p> <p> Studies concerning the relationship of the vascular system to pain in amputees have been conducted along three general lines. First has been evaluation of the status of the circulatory system in amputation stumps, both in patients suffering from phantom or stump pain and in amputees free of pain. The second has involved clinical and laboratory studies of selected nonamputee patients suffering from pain syndromes possibly related in pathophysiology to phantom pain. And finally tests have been conducted with various sympatholytic drugs and blocking procedures, first with respect to their effects on phantom-limb pain and related pain syndromes and second in regard to their effects on the circulation of blood in stumps and in painful limbs. </p> <p> Studied in detail were 43 amputees, 31 without known vascular disease (Group A) and 12 suffering from vascular disease either as the underlying cause of amputation or as a concomitant to the amputation (Group B). Pain in the stump or phantom limb was an important problem for 15 of the patients in Group A and for 8 of those in Group B. The remainder described varying degrees of phantom awareness but denied that pain existed or, if it did exist, that it was disturbing. </p> <p> One method of investigation was simple clinical examination. In that survey, stumps appearing to have an adequate blood supply were found, when exposed to air at room temperature, to be almost uniformly cold to the touch as compared with the opposite extremities. In oscillometric tests, the pulse of arterial blood into the stump was found to be significantly smaller than that into the normal limb (<b>Fig. 13</b>). In skin tests with histamine, the appearance of normal flares and wheals indicated that local denervation could not account for the failure of the skin to warm during generalized body warming. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Pulsations recorded during generalized vasodilatation in a below-knee amputee. Oscillometric records show a smaller amplitude of pulsation in the blood vessels supplying the stump (A) than in those supplying the sound limb (B). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> (<b>Fig. 14</b> and <b>Fig. 15</b>) indicate graphically the results of surface-temperature measurements on the normal extremities and on the stumps of two amputees. <a></a> Skin temperature was measured after initial exposure of the body to cool air in a room with controlled atmosphere, the subject being exposed until finger and toe temperatures were stabilized. Recordings were made by means of thermocouples taped to the skin of the stump and to the contralateral extremities at multiple points along the length of the limb, the thermocouples being applied symmetrically so that points equidistant from the trunk could be compared. All such measurements were made with the subject in a basal state and exposed to room air between 17deg and 21deg C, conditions leading uniformly to constriction of the cutaneous vessels of the extremities in normal subjects. Under such circumstances, a temperature gradient exists between the proximal and distal portions of a normal arm or leg, so that the surface temperature of a finger or toe is several degrees lower than the temperature at points near the trunk. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Surface temperatures in the upper extremities of a below-elbow amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 65 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Surface temperatures in the lower extremities of an above-knee amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 74 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Temperatures then were recorded during maximal vasodilatation induced by oral administration of whiskey and wrapping the trunk in an electric blanket. After vasodilatation, the gradient is abolished or reversed in the normal limb, finger and toe temperatures rising to 30deg C or higher. </p> <p> At the end of the initial cooling period, when subjects had been exposed to cool room air for periods of from 30 to 150 minutes, the surface temperature at the distal end of the stump almost invariably was cooler than was the skin at a symmetrical point on the corresponding intact limb. Analysis of the temperature gradients found after cooling showed further that, in at least a third of the Group A amputees and in half of the Group B amputees, the stumps were cooler than were the opposite extremities, not merely at the distal ends but for distances of from 20 to 55 cm. from the ends. </p> <p> In one instance a patient was put in a room at 18deg C with nothing across his body except a towel. Over a period of two hours the body temperature was lowered to a point just above that at which shivering occurred. The temperature of the toe in the normal extremity dropped to a low level. When the patient suddenly was given 2 ounces of whiskey and warm water and had an electric blanket placed across his chest, the temperature of the normal extremity rose rapidly. But the temperature of the stump remained constant during the entire procedure, a phenomenon characteristic of all amputation stumps. </p> <p> A total of 40 amputees (28 Group A, 12 Group B) were subjected to one or more vasodilatation tests, and the responses of 45 stumps were observed. Of these, nearly two thirds failed to warm significantly at a time when the skin temperature of the normal extremities had risen to 30deg C as a result of indirect or "reflex" vasodilatation. Only occasionally did stumps show evidence of significant vasodilatation. It occurred with higher frequency in those patients with underlying or concomitant vascular disease than in amputees of Group A. Thus, of 11 stumps in which the temperature rose to the same level as the corresponding point on the contralateral limb, or even to levels reflecting "ceiling" blood flow for skin, only six were among the 32 stumps of Group A patients, and five were among the 13 stumps of Group B patients. In brief, a smaller proportion of stumps showed vasodilatation in Group A patients (one fifth) than in Group B patients (two fifths). </p> <p> In the majority of trials, experiments with other methods of inducing vascular relaxation were equally ineffective in causing a rise in stump temperature. In a total of eight intravenous injections of vasodilator drugs, the temperature of the stump increasedonlyslightly on two occasions (2.5deg C or less). A rise in temperature was effected once with Priscoline (2-benzylimidazoline hydrochloride) and once with tetraethylammonium chloride. Injections of prccaine in the region of the lumbar sympathetic ganglia produced a significant warming of the stump in one of two cases only. No correlation was found between the degree of phantom or stump pain experienced by these patients and the extent to which slump temperature fell during the initial period of exposure or the extent of stump warming during generalized vasodilatation. Amputees rarely complained of stump or phantom pain during these experiments, even though they were subjected to extremes of temperature requiring rapid vasomotor adjustments. </p> <p> The ease with which stumps become cool on exposure to a cold environment can be attributed to two factors. First, surface-volume relationships in stumps favor cooling. Second, less blood passes through the stump than through comparable portions of the intact limb because, in the stump, distal tissues are absent. Apparently the shunts between the arterial and the venous side, which permit an increased volume of blood to flow through the extremity, are located distal to the wrist joint and to the ankle joint. In amputations at or above the wrist or ankle, therefore, flow of blood to the extremity is impaired. Normally, body heat is lost chiefly through radiation from hands, head, and feet. When the body is deprived of one of these radiating "fins," the remaining stump cannot be warmed. Neither can excess heat be radiated away, and for that reason an amputee often finds intolerable an environmental temperature that is quite acceptable to the normal. The amputee is distressed in a heated room, while the normal subject suffers no discomfort. Since the radiating mechanism is lost with amputation of an extremity, and since the only other means of cooling is through evaporation of sweat, the amputee is more likely to be troubled with problems of perspiration. </p> <h5> <i>Skeletal Changes</i> </h5> <p> In addition to problems of pain and changes in circulation, the amputee sometimes is troubled by decalcification of the stump and adjacent portions of the pelvis, a change that occurs when the body weight no longer is borne along the axis of the major articulations but along the prosthetic weight line (page 36). Because in an osteoporotic extremity the covering of the bone is more sensitive than is that in the normal, a decalcified bone often becomes exceedingly tender and develops spontaneous pain. </p> <p> An interesting fact is that the joint itself, in (<b>Fig. 16</b>) the hip joint, begins to show early degenerative changes because it no longer transmits weight. In future studies it should be possible to evaluate more closely what changes are to be expected in the proximal articulations of an amputation stump, and more particularly in the joint cartilage covering the articulations, as a result of elimination of normal weighi-bearing through thesearticulations. Obviously, the only way la preveni osteoporosis and increased sensitivity is to resort to some type of end-bearing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16 Roentgenogram of an above-knee amputee, showing skeletal changes that occur when the hip and the remainder of the leg on the amputated side are deprived of the normal stimulation of weight-bearing </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In the younger leg amputee, moreover, especially in growing children, other bony deformities develop (<b>Fig. 17</b>). Instead of the normal curvature of the neck of the femur, there develops a valgus deformity as is seen in polio and in dislocated hips. And finally, of course, because of loss of the mass of the limb, one must expect to find scoliosis and other abnormalities in the spine (<b>Fig. 18</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Complicating deformities in juvenile amputees. When amputation is necessitated in childhood, defects often occur in the subsequent growth of related bony structures. Here, for example, the pelvis is smaller, and the pelvic-femoral angle larger, on the amputated side than on the sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Scoliosis, a postural defect often a sequel to amputation of the lower extremity. Loss of the weight of the amputated limb leads to habitual compensatory positioning of other body elements and thus complicates rehabilitation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3> Summary </h3> <p> In summary, it may be said that, first, amputation produces changes in musculature, not only the familiar contractures and atrophy <i>{50,88) </i>but other changes as well. If a muscle is cut in half, its ability to shorten is decreased. A mid-thigh amputation decreases the effective normal range of motion of the hamstring group. If the hamstring group is cut in half, the velocity of contraction is halved, and an amputee thus afflicted cannot therefore perform certain functions with any degree of facility. </p> <p> The mechanism of normal level walking requires the expenditure and distribution of considerable energy, for which the body depends largely upon the leg musculature. Thus, the handicap resulting from loss of any part of the leg is due not only to the loss of support but also to the loss of power available from the muscles. The skeletal structure of a normal limb can more or less easily be simulated in a prosthesis, but such a device has little value without simultaneous provision for the necessary power. Accordingly, an understanding of the energy characteristics of normal level walking is important in considering the design criteria for artificial legs. Judging from the results of the energy studies at Berkeley, at a given pace an above-knee amputee uses two and a half to three times as much energy as does the normal. The adverse effect of this overexertion is only further complicated by the fact that heat production is increased at a time when the radiating mechanism has been impaired. In the manufacture of any lower-extremity prosthesis, then, an important consideration, is to design the substitute limb for maximum energy conservation. </p> <p> Medical problems are common to all amputees. Some of them, for example those related to circulation, cannot be solved, but proper surgical procedures help to preserve the musculature and skeletal structures of adjacent joints. Moreover, many things can be done to relieve pain, both spontaneous phantom pain and the tender trigger points occurring in stumps. All amputees suffer some discomfort at one time or another. They are bothered by skin changes occurring over the bony prominences, by edema at the distal end of the stump, and by attritional lesions occurring in the folds of the groin (<b>Fig. 19</b>). A minor skin lesion can disable a leg amputee completely, especially when it means staying off the leg or going on crutches. Increased perspiration and poor ventilation of the stump in the prosthesis may close the sweat glands and make the skin susceptible to fungal diseases, and contact dermatitis may result if the patient is allergic to certain materials used in the manufacture of the prosthesis. Such problems must be solved by socket fit, by alignment, or by other procedures. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Problems of fit. Among them are irritation and swelling in the crotch area, edema at the stump end, and tenderness at pressure points. Because such problems are more or less readily corrected by proper fit and alignment, they are less medical than prosthetic, although chronic skin irritation may need the attention of a dermatologist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> From the Clinical Study have come valid recommendations concerning fit, alignment, and functional characteristics. As already noted, some horizontal rotation (between 9 and 15 deg.) is desirable in an artificial leg. Further, increased stability in the knee joint increases the leg amputee's sense of security. Some conservation of energy can be effected by eliminating the articulated ankle joint. And finally, the matter of appearance deserves consideration. In this regard, attention must be given to the color, contour, and texture of the artificial leg. </p> <p> In the last analysis, the problem of the leg amputee is more than that of providing him with a prosthetic device. He has many medical problems, including pain, abnormalities in circulation, heat intolerance, and skeletal and muscular changes. The prosthetic device itself raises other problems-conservation of energy, proper alignment, comfort, and cosmetic appearance. The Lower-Extremity Clinical Study is concerned with the solution of all these problems. The manner in which solutions are sought is shown in (<b>Fig. 20</b>), where the central area represents the pool of fundamental knowledge accumulated over a period of nine years. As the amputee moves around the circle, each problem is studied and solved before he is allowed to move into the next phase of processing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Functional organization of theLower-Extremity Clinical Study:. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To date, pain and skin irritation have been the predominant problems, and study groups are being organized to investigate these areas in detail. Study groups also have been organized to investigate skeletal and muscular changes. At each step in the process, the panel itself often is faced with difficult problems. For example, the question of evaluation always is present, and it is not easy to determine whether or not the amputee actually has benefited from the time and effort devoted to his case. But as each difficulty is solved, the information derived is placed at the disposal of all those concerned, not only those within the Clinic Study Group but also all others whose interests lie in the field of amputee management. Seminars are held weekly to ensure that the information is brought to the attention of all interested persons. Eventually, all of the problem-solving data stemming from the investigations will appear in educational publications and will be available to members of the artificial-limb industry. </p> <p> Finally, it may be said that the University group has no intentions of producing prosthetic devices and, indeed, makes excursions into that field only when it is necessary to develop experimental models pertinent to the study. </p> <p> The only function is to produce sound ideas that can be used by the artificial-limb industry in the manufactuie and fitting of improved prostheses. The study must, however, continue to be active until the basic scientific information can be translated into useful guides for the professions involved in the rehabilitation of the amputee. </p> <h3> Acknowledgments </h3> <p> For the illustrations appearing in this article, the authors are indebted to two people in particular. Thomas Raubenheimer, of the Department of Medical Illustration, University of California Medical Center, San Francisco, prepared the charcoal halftones. With the exception of <b>Fig. 8</b>, all line drawings were worked up by George Rybczynski, free-lance illustrator of Washington, D. C. </p> <p><b>References:</b></p> <ol> <li>Adel Precision Products Corp., Burbank, Calif.,Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947. </li> <li>Alldredge, Rufus H., The cineplaslic method in upper-extremity amputations, J. Bone and; Joint Surg., 30A:359 (1948). </li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. 4.</li> <li>'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </li> <li>Bechtol, Charles 0., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9. </li> <li>Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Berry, F. R., Jr., Angle variation patterns of normal hip, knee and ankle in different operations, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 21, February 1952. </li> <li>Blaschke, A. C, General energy considerations and determination of muscle forces in the mechanics of human bodies, University of California (Los Angeles), Department of Engineering [Contractor's Memorandum Report No. 9 to the Advisory Committee on Artificial Limbs, National Research Council], September 1950.</li> <li>Blaschke, A. C, and C. L.Taylor, Biomechanical considerations in cineplasty, University of California (Los Angeles), Department of Engineering, Special Technical Report 18, 1951. </li> <li>Blaschke, Alfred C, and Craig L. Taylor, The mechanical design of muscle-operated arm prostheses, J. Franklin Inst., 266:435 (1953). </li> <li>Blix, Magnus, Die Lange und die Spannung des Muskels, Scandinav. Arch. f. Physiol., 6:150 (1894). </li> <li> Bradley, C. A, and Son, Inc., and Catranis, Inc., Syracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and foot position; toe pick up and foot providing lateral, plantar and dorsal flexion, July 1947. </li> <li>Bresler, B., Use of energy methods for evaluation of prostheses, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </li> <li>Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </li> <li>Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </li> <li>Brown, E., and N. Foreman, Studies of skin temperature and of indirect vasodilatation in amputation stumps, Am. J. Med., 10:112 (1951). </li> <li>Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </li> <li>Close, J. R., and V. T. Inman, The action of the ankle joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1952. </li> <li>Close, J. R., and V T. Inman, The action of the subtalar joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 24, May 1953. </li> <li>Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, 1(3):47 (September 1954). p. 58. </li> <li>Cunningham, D. M., Components oj floor reactions during walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950. </li> <li>Eberhart, Howard D., The objectives of the lower extremity prosthetics program, Artificial Limbs, May 1954. p. 4. </li> <li>Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomtor [sic] mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213 (1951). </li> <li>Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Elftman, H., A cinematic study of the distribution of pressure in the human fool, Anat. Rec, 69:481 (1934). </li> <li>Elftman, H, The measurement of the external force in walking, Science, 88:152 (1938). </li> <li>Elftman, H., The rotation of the body in walking, Arbeitsphysiol., 10:219 (1938). </li> <li>Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1938). </li> <li>Elftman, H., Forces and energy changes in the leg during walking, Am. J. Physiol., 125:339 (1939). </li> <li>Elftman, H., The function of muscles in locomotion, Am. J. Physiol., 125:357 (1939). </li> <li>Elftman, H., The function of the arms in walking, Human Biol., 11:529 (1939). </li> <li>Elftman, Herbert, The work done by muscles in running, Am. J. Physiol , 129:672 (1940). </li> <li>Elftman, H., The action of muscles in the body, Biol. Symposia, 3:191 (1941).</li> <li>Elftman, H., Experimental studies on the dynamics of human walking, Trans. N. Y. Acad. Sci., 11:1 (1943). </li> <li>Elftman, H., The bipedal walking of the chimpanzee, J. Mammalogy, 25:67 (1944). </li> <li>Elftman, H., The carrying angle of the human arm as a secondary sex character, Anat. Rec, 91:49 (1945). </li> <li>Elftman, H., The orientation of the joints of the lower extremity, Bull. Hosp. Joint Diseases, VI-.139 (1945). </li> <li>Elftman, H., Torsion of the lower extremity, Am. J. Phys. Anthropol., N.S. 3:255 (1945). </li> <li>Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207 (1951). </li> <li>Elftman, Herbert, The functional structure of the lower limb, Chapter 14 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Elftman, Herbert, and John T. Manter, The axis of the human foot, Science, 80:484 (1934). </li> <li>Elftman, Herbert, and John Manter, Chimpanzee and human feel in bipedal walking, Am. J. Phys. Anthropol., 20:69 (1935). </li> <li>Elftman, H., and J. T. Manter, The evolution of the human fool, with especial reference to the joints, J. Anat., 70:56 (1935). </li> <li>Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and; Joint Surg!, 36A:981 (1954) </li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Felkel, E. O., Determination of acceleration from displacement-time data, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 16, September 1951. </li> <li>Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </li> <li>Goodyear Tire and; Rubber Company, Akron, Ohio, Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a foot prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947. </li> <li>Gordan, G. S., B. Feinstein, and H. J. Ralston, Effect of testosterone upon atrophy of denervated skeletal muscle, Exper. Med. and; Surg., 7:327 (1949). </li> <li>Hosmer Corp., A. J., Santa Monica, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee dis-articidation amputations; work arms for wrist disarticulations, below and above elbow amputations; work tools and devices for vocational rehabilitation; hydraulic control to actuate hooks and hands used on work arms; improved design hook, 1947. </li> <li>Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and; Joint Surg., 29:607 (1947). </li> <li>Inman, V. T., Theoretical requirements of a lower-extremity prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, December 22, 1950. </li> <li>Inman, V. T., Innervation of the extremities, 3rd Biennial Western Conference on Anesthesiology, The California Society of Anesthesiologists and the Northwestern Society of Anesthesiologists, Los Angeles, 1953. p. 22. </li> <li>Inman, V. T., B. Feinstein, and H. J. Ralston, Some observations on electromyography, Am. J. Physiol., 155:445 (1948). </li> <li>Inman, Verne T., H. J. Ralston, J. B. deC. M. Saunders, Bertram Feinstein, and Elwood W. Wright, Jr., Relation of human electromyogram lo muscular tension, University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1951. </li> <li>Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Inman, V. T., H. J. Ralston, J. B. deC. M. Saunders, B. Feinstein, and E. W. Wright, Jr., Relation of human electromyogram lo muscular tension, Electroencephalog. and; Clin. Neuro-physiol., 4:187 (1952). </li> <li>Levens, A. S., V. T. Inman, and J. A. Blosser, Transverse rotation of the segments of the lower extremity in locomotion, J. Bone and; Joint Surg., 30A:859 (1948). </li> <li>Libet, B., Neuromuscular facilitation by stretch, and the duration of muscular activation in locomotion, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 563. </li> <li>Libet, B., and B. Feinstein, Analysis of changes in electromyogram (EMG) with changing muscle length, Am. J. Physiol., 167:805 (1951). </li> <li>Libet, Benjamin, and Bertram Feinstein, Human electromyogram, Surg. Forum, W. B. Saunders Co., Philadelphia, 1952. p. 415. </li> <li>Libet, Benjamin, H. J. Ralston, and Bertram Feinstein, The effect of stretch on action potential in muscle, Biol. Bull., 101:194 (1951). </li> <li>Libet, B., and E. W. Wright, Jr., Facilitation at neuromuscular functions by stretch of muscle, Fed. Proc, 11:94 (1952). </li> <li>Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </li> <li>Mitchell, S. Weir, Phantom limbs, Lippincott's Mag. Pop. Lit. So, 8:563 (1871). </li> <li>National Research and Manufacturing Company, San Diego, Calif., Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947. </li> <li>New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown lest of the Navy above-knee prosthesis, May 1951. </li> <li>New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953. </li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council (Contract VAm-21223), A report on prosthesis development, 1947. </li> <li>Northwestern Technological Institute, Evanston, III., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arms, arm harnesses, hands, and hooks; mechanical testing of artificial legs, 1947. </li> <li>Pare, A., from T. Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </li> <li>Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </li> <li>Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 1949. </li> <li>Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950. </li> <li>Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951. </li> <li>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </li> <li>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </li> <li>Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</li> <li>Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </li> <li>Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </li> <li>Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </li> <li>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </li> <li>Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (1952). </li> <li>Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </li> <li>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </li> <li>Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </li> <li>Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </li> <li>Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (1949). </li> <li>Ralston, H. J., E. W. Wright, Jr., B. Feinstein, and V. T. Inman, Effect of stretch upon action potential of voluntary muscle, Am. J. Physiol., 159:586 (1949). </li> <li>Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </li> <li>Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </li> <li>Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </li> <li>Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (1953). </li> <li>Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </li> <li> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (1947). </li> <li>Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, |Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, April 1950. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, 2nd ed., August 1953. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, The pattern of muscular activity in the lower extremity during wilking, September 1953. </li> <li>Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </li> <li>Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </li> <li>Wagner and Catranis, op. cit., p. 511. </li> <li>Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (1944). </li> <li>Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (1954). </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>16.</b> </td><td class="clsTextSmall">Brown, E., and N. Foreman, Studies of skin temperature and of indirect vasodilatation in amputation stumps, Am. J. Med., 10:112 (1951). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Mitchell, S. Weir, Phantom limbs, Lippincott's Mag. Pop. Lit. So, 8:563 (1871). </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Pare, A., from T. Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </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">Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 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>5.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team, Artificial Limbs, January 1954. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (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>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown lest of the Navy above-knee prosthesis, May 1951. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </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>79.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Levens, A. S., V. T. Inman, and J. A. Blosser, Transverse rotation of the segments of the lower extremity in locomotion, J. Bone and; Joint Surg., 30A:859 (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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (1953). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and; Joint Surg!, 36A:981 (1954) </td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Inman, V. T., Innervation of the extremities, 3rd Biennial Western Conference on Anesthesiology, The California Society of Anesthesiologists and the Northwestern Society of Anesthesiologists, Los Angeles, 1953. p. 22. </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>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Wagner and Catranis, op. cit., p. 511. </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>20.</b> </td><td class="clsTextSmall">Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, 1(3):47 (September 1954). p. 58. </td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </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>78.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Inman, V. T., Theoretical requirements of a lower-extremity prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, December 22, 1950. </td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomtor [sic] mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207 (1951). </td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Elftman, Herbert, The functional structure of the lower limb, Chapter 14 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>13.</b> </td><td class="clsTextSmall">Bresler, B., Use of energy methods for evaluation of prostheses, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Blaschke, Alfred C, and Craig L. Taylor, The mechanical design of muscle-operated arm prostheses, J. Franklin Inst., 266:435 (1953). </td></tr><tr><td class="clsTextSmall"><b>101.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </td></tr><tr><td class="clsTextSmall"><b>107.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, April 1950. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The cineplaslic method in upper-extremity amputations, J. Bone and; Joint Surg., 30A:359 (1948). </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. 4.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Blaschke, A. C, and C. L.Taylor, Biomechanical considerations in cineplasty, University of California (Los Angeles), Department of Engineering, Special Technical Report 18, 1951. </td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </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>57.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Libet, Benjamin, H. J. Ralston, and Bertram Feinstein, The effect of stretch on action potential in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b> 64.</b> </td><td class="clsTextSmall">Libet, B., and E. W. Wright, Jr., Facilitation at neuromuscular functions by stretch of muscle, Fed. Proc, 11:94 (1952). </td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Blix, Magnus, Die Lange und die Spannung des Muskels, Scandinav. Arch. f. Physiol., 6:150 (1894). </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>115.</b> </td><td class="clsTextSmall">Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Inman, V. T., B. Feinstein, and H. J. Ralston, Some observations on electromyography, Am. J. Physiol., 155:445 (1948). </td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Inman, Verne T., H. J. Ralston, J. B. deC. M. Saunders, Bertram Feinstein, and Elwood W. Wright, Jr., Relation of human electromyogram lo muscular tension, University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1951. </td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Inman, V. T., H. J. Ralston, J. B. deC. M. Saunders, B. Feinstein, and E. W. Wright, Jr., Relation of human electromyogram lo muscular tension, Electroencephalog. and; Clin. Neuro-physiol., 4:187 (1952). </td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Libet, B., and B. Feinstein, Analysis of changes in electromyogram (EMG) with changing muscle length, Am. J. Physiol., 167:805 (1951). </td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Libet, Benjamin, and Bertram Feinstein, Human electromyogram, Surg. Forum, W. B. Saunders Co., Philadelphia, 1952. p. 415. </td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </td></tr><tr><td class="clsTextSmall"><b> 116.</b> </td><td class="clsTextSmall">Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (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>60.</b> </td><td class="clsTextSmall">Libet, B., Neuromuscular facilitation by stretch, and the duration of muscular activation in locomotion, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 563. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Blaschke, A. C, General energy considerations and determination of muscle forces in the mechanics of human bodies, University of California (Los Angeles), Department of Engineering [Contractor's Memorandum Report No. 9 to the Advisory Committee on Artificial Limbs, National Research Council], September 1950.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and; Joint Surg., 29:607 (1947). </td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, The pattern of muscular activity in the lower extremity during wilking, September 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall"> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Berry, F. R., Jr., Angle variation patterns of normal hip, knee and ankle in different operations, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 21, February 1952. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Close, J. R., and V. T. Inman, The action of the ankle joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1952. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Close, J. R., and V T. Inman, The action of the subtalar joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 24, May 1953. </td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components oj floor reactions during walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950. </td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of acceleration from displacement-time data, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 16, September 1951. </td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </td></tr><tr><td class="clsTextSmall"><b>104.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, |Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948. </td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </td></tr><tr><td class="clsTextSmall"><b>108.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952. </td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, 2nd ed., August 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The 1947 report contains an extensive bibliography of earlier work, mostly German, on the mechanism of human locomotion and on related matters. It is available, either in photostat form or on microfilm, from the U. S. Armed Forces Medical Library, 7th Street and Independence Ave., S. W., Washington 25, D. C.</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>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Elftman, H., A cinematic study of the distribution of pressure in the human fool, Anat. Rec, 69:481 (1934). </td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152 (1938). </td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Elftman, H., The rotation of the body in walking, Arbeitsphysiol., 10:219 (1938). </td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1938). </td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Elftman, H., Forces and energy changes in the leg during walking, Am. J. Physiol., 125:339 (1939). </td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Elftman, H., The function of muscles in locomotion, Am. J. Physiol., 125:357 (1939). </td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Elftman, H., The function of the arms in walking, Human Biol., 11:529 (1939). </td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Elftman, Herbert, The work done by muscles in running, Am. J. Physiol , 129:672 (1940). </td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Elftman, H., The action of muscles in the body, Biol. Symposia, 3:191 (1941).</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Elftman, H., Experimental studies on the dynamics of human walking, Trans. N. Y. Acad. Sci., 11:1 (1943). </td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Elftman, H., The bipedal walking of the chimpanzee, J. Mammalogy, 25:67 (1944). </td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Elftman, H., The carrying angle of the human arm as a secondary sex character, Anat. Rec, 91:49 (1945). </td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Elftman, H., The orientation of the joints of the lower extremity, Bull. Hosp. Joint Diseases, VI-.139 (1945). </td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Elftman, H., Torsion of the lower extremity, Am. J. Phys. Anthropol., N.S. 3:255 (1945). </td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John T. Manter, The axis of the human foot, Science, 80:484 (1934). </td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John Manter, Chimpanzee and human feel in bipedal walking, Am. J. Phys. Anthropol., 20:69 (1935). </td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Elftman, H., and J. T. Manter, The evolution of the human fool, with especial reference to the joints, J. Anat., 70:56 (1935). </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">Adel Precision Products Corp., Burbank, Calif.,Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947. </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Bradley, C. A, and Son, Inc., and Catranis, Inc., Syracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and foot position; toe pick up and foot providing lateral, plantar and dorsal flexion, July 1947. </td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Goodyear Tire and; Rubber Company, Akron, Ohio, Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a foot prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947. </td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Hosmer Corp., A. J., Santa Monica, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee dis-articidation amputations; work arms for wrist disarticulations, below and above elbow amputations; work tools and devices for vocational rehabilitation; hydraulic control to actuate hooks and hands used on work arms; improved design hook, 1947. </td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company, San Diego, Calif., Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947. </td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston, III., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arms, arm harnesses, hands, and hooks; mechanical testing of artificial legs, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Eberhart, Howard D., The objectives of the lower extremity prosthetics program, Artificial Limbs, May 1954. p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213 (1951). </td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951. </td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b> 112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </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>113.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </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>70.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council (Contract VAm-21223), A report on prosthesis development, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>VerneT. Inman, M.D., Ph.D., </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, School of Medicine, University of California, San Francisco; Professional Associate, Advisory Committee on Artificial Limbs, National Research Council; member, Technical Committee on Prosthetics, ACAL, NRC. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-12.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_004/table01.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-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 Lower-Extremity Clinical Study-Its Background and Objectives Creator An entity primarily responsible for making the resource VerneT. Inman, M.D., Ph.D., * Howard D. Eberhart, M.S. * https://staging.drfop.org/files/original/5d0ee93720e3cc29afeb69569f942ec3.pdf ec7d305e66c4b1672edc65546d744f4a https://staging.drfop.org/files/original/7e69b86f4f3e01170fb59ef73e47cd16.jpg 153b782803915d8c141c800756b99b14 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_02_001.pdf Text Any textual data included in the document <h2>Biomechanical Considerations in the Orthotic Management of the Knee</h2> <h5>Victor H. Frankel, M.D., Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The challenges facing the contemporary orthotist are akin to the interminable task of Sisyphus, the Greek mythic figure who was condemned to pushing a huge rock up an endless hill. Unlike Sisyphus, however, the orthotist has made and continues to make significant strides in the rational design and fabrication of prostheses and orthotic devices. Over the past decade major contributions to solving the anatomical and functional problems associated with joint replacement prostheses and orthoses have directly resulted from the growing interaction between orthopaedic surgery and biomechanics. The result of this increased interaction has been improved diagnosis and treatment of musculoskeletal disorders with prostheses and orthotic devices. The knee is certainly one of the joints that has greatly benefited from these biomechanical developments.</p> <p>Biomechanics enables the scientist to accurately describe and quantify surface joint motion of the knee and to analyze the complex forces imposed on the knee. Biomechanics also brings the motion of and the forces acting on the knee into sharp focus by analyzing the mechanical properties of the static and dynamic structures surrounding the knee: muscles, bones, ligaments, cartilage, and tendons. The biomechanical analysis of motion and force in the knee joint can be widely and successfully applied in orthotic management of the knee.</p> <p>The human knee is the largest and perhaps the most complex joint in the body. It is a two-joint structure composed of the tibiofemoral joint and the patellofemoral joint. Both joints sustain high forces and, located between the body's two longest lever arms, are particularly susceptible to injury. The knee transmits loads, participates in motion, aids in conservation of momentum, and provides a force couple for activities involving the leg.</p> <p>Although motion in the knee occurs simultaneously in three planes, the motion in one plane is so great that it accounts for most knee motion. Similarly, muscle forces on the knee are produced by several muscles, but a single muscle group (according to the activity) produces a force so large that it accounts for most of the muscle force acting on the knee. Thus, biomechanical analysis can be basically limited to motion in one plane and to the force produced by a single muscle group, and yet can still give an understanding of knee motion and an estimation of the magnitude of the main forces acting on the knee.</p> <p>To analyze motion in any joint, one must use kinematics, the branch of mechanics that deals with motion of a body without reference to force or mass. To analyze the forces imposed on a joint one must use both kinematic and kinetic data. Kinetics is the branch of mechanics which analyzes the motion of a body under the influence of given forces.</p> <h3>Kinematics</h3> <p>Kinematic data define the range of motion and describe the surface joint motion in three planes: frontal (coronal or longitudinal), sagittal, and transverse (horizontal).</p> <p>The range of motion can be measured in any joint and in any plane. Gross measurements can be made by goniometry, but more specific measurements must be made with more precise methods such as electrogoniometry, roentgenography, or photographic techniques using skeletal pins. <a></a></p> <p>The range of knee joint motion needed for performing various physical activities can be determined from kinematic analysis. A full range of knee motion is needed for performing the more vigorous activities of daily life in a normal manner. Moreover, any restriction of knee motion will be compensated for by increased motion in other joints.</p> <p>The values obtained in several studies indicate that full extension and at least 117 degrees of flexion are necessary for carrying out the activities of daily life in a normal manner (<b>Table I</b>).<a></a></p> <strong>Table I. Range of Tibiofemoral Joint Motion in the Sagittal Plane During Common Activities</strong> <img src="/files/original/7e69b86f4f3e01170fb59ef73e47cd16.jpg" h3="" width="415" height="337" /><br /> <h3>Surface Joint Motion</h3> <p>Surface joint motion, the motion between the articulating surfaces of a joint, can also be described for any joint in the sagittal and frontal planes, but not the transverse plane. The method used is called the instant center technique. This technique allows a description of the relative uniplanar motion of two adjacent segments of a body and the direction of displacement of the contact points between these segments. The instant center for motion of a planar joint can be obtained by the method of Reuleaux (1876).<a></a></p> <p>Clinically, a pathway of the instant center for a joint can be plotted by taking successive roentgenograms of the joint in different positions (usually ten degrees apart) throughout the range of motion in one plane, and applying the Reuleaux method for locating the instant center for each interval of motion. After the instant center pathway has been determined, the surface joint motion can be described. In a normal knee, the instant center pathway for the tibiofemoral joint is semicircular.</p> <p>Especially pertinent to orthotic management is data concerning knees with internal derangements. If the knee is extended and flexed about a displaced instant center, the tibiofemoral joint surfaces do not slide tangentially throughout the range of motion, but become either distracted or compressed. Such a knee is analogous to trying to close a door with a bent hinge. If the knee is continually forced to move about a displaced instant center, it will gradually adjust to this situation by either stretching the ligaments and supporting structures of the joint or by exerting abnormally high pressure on the articular surfaces.</p> <p>Such internal derangements of the tibiofemoral joint may interfere with the so-called screw-home mechanism, which is a combined motion of knee extension and external rotation of the tibia. The tibiofemoral joint is not a simple hinge joint, but has a spiral, or helicoid, motion. The spiral motion of the tibia about the femur during flexion and extension results from the anatomical configuration of the medial femoral condyle; in a normal knee this condyle is approximately 1.7cm longer than the lateral femoral condyle. As the tibia slides on the femur from the fully flexed to the fully extended position, it descends and then ascends the curves of the medial femoral condyle and simultaneously rotates externally. This motion is reversed as the tibia moves back into the fully flexed position. The screw-home mechanism gives more stability to the knee in any position than would be possible if the tibiofemoral joint were a simple hinge joint.</p> <p>The Helfet test, a simple clinical test, is used to determine if external rotation of the tibia occurs during knee extension, thus showing whether the screw-home mechanism is intact.<a></a></p> <p>In a deranged knee it may happen that no external rotation of the tibia occurs during extension. Because of the altered surface motion, the tibiofemoral joint will be abnormally compressed if the knee is forced into extension, and the joint surfaces may be damaged.</p> <h3>Kinetics</h3> <p>Kinetic data, based on static and dynamic analysis, are used to analyze the forces acting on a joint. The medical scientist can use kinetic analysis to determine the size of the forces imposed on the knee by muscles, body weight, connective tissues, or external loads in either static or dynamic situations. In particular regard to orthotic management, however, situations and movements which produce excessively high forces can be identified.</p> <p>In static analysis, the three main coplanar forces acting on a body in equilibrium are identified as: (1) the ground reaction force (equal to body weight), (2) the tensile force exerted by the quadriceps muscle through the patellar tendon, and (3) the joint reaction force acting on the tibial plateau. Since most of our activities are dynamic, however, an analysis of the forces acting on the knee during motion-dynamic analysis-must be applied to given situations. In addition to the three coplanar forces of static analysis, the medical scientist must also take into account the acceleration of the body part (the amount of torque needed to accelerate a body, for which anthropometric data-tables are used).<a></a> An orthotist might use dynamic analysis, for example, to calculate the joint reaction, muscle, or ligament forces on the tibiofemoral joint at a particular instant in time during walking, or at a particular instant in time (with a stroboscopic film) while kicking a football.</p> <p>Other biomechanical considerations in the orthotic management of the knee involve the two important functions of the patella: (1) it aids knee extension by lengthening the lever arm on the quadriceps, and (2) it allows a better distribution of stresses on the femur by increasing the area of contact between the patellar tendon and the femur. In a patellectomized knee, for example, the quadriceps muscle, now with a shorter lever arm, must produce even more force than normal to achieve the required torque about the knee during the last 45 degrees of extension. Full, active extension of a patellectomized knee may require as much as 30 percent more quadriceps force than normally required.<a></a></p> <p>During most dynamic activities, the greater the knee flexion, the higher all the muscle forces acting on the patellofemoral joint. Forces increase proportionately with knee flexion, for example, from walking to stair climbing to knee bends. Patients with patellofemoral joint derangements experience increased pain when performing activities requiring knee flexion, and orthotic management could be greatly aided by knowledge of such predictive biomechanical factors as knee flexion, and the muscle and joint reaction forces for specific situations.</p> <p>Biomechanical analysis can yield invaluable, practical data for the orthotic management of the knee. A continuing, close interaction among orthopaedic surgeons, bio-engineers, and orthotists will insure the applied efficacy of such data.</p> <p><b>References:</b></p> <ol> <li><a href="http://www.oandplibrary.org/al/1964_01_044.asp">Drillis, R., Contini, R., and Blustein, M.: "Body segment parameters: A survey of measurement techniques," <i>Artificial Limbs</i>, 8:44, 1964.</a></li> <li>Frankel, V.H., and Nordin, M.: <i>Basic Biomechanics of the Skeletal System</i>. Philadelphia, Lea &amp; Febiger, 1980.</li> <li>Helfet, A.J. : "Anatomy and mechanics of movement of the knee joint," <i>Disorders of the Knee</i>, edited by A. Helfet, Philadelphia, J.B. Lippincott, 1974.</li> <li>Kaufer, H. : "Mechanical function of the patella," <i>Journal of Bone &amp; Joint Surgery</i>, 53A:1551, 1971.</li> <li>Kettelkamp, D.B., Johnson, R.J., Smidt, G.L., Chao, E.Y.S., and Walker, M.: "An electrogoniometric study of knee motion in normal gait, <i>Journal of Bone &amp; Joint Surgery</i>, 52A:775, 1970.</li> <li>Laubenthal, K.N., Smidt, G.L., and Kettelkamp, D.B. : "A quantitative analysis of knee motion during activities of daily living," <i>Physical Therapy</i>, 52:34, 1972.</li> <li>Murray, M.P., Drought, A.B., and Kory, R.C.: "Walking patterns of normal men," <i>Journal of Bone &amp; Joint Surgery</i>, 46A:335, 1964.</li> <li>Perry, J., Norwood, L., and House, K.: "Knee posture and biceps and semimembranosis muscle action in running and cutting (an EMG study), "<i>Transactions of the 23rd Annual Meeting</i>, Orthopaedic Research Society, 2:258, 1977.</li> <li>Reuleaux, F.: <i>The Kinematics of Machinery: Outline of a Theory of Machines</i>. London, Macmillan, 1976.</li> </ol> <div style="width: 400px;"><em><b>*Victor H. Frankel, M.D., Ph.D. </b> Director of Orthopaedic Surgery, Hospital for Joint Diseases Orthopaedic Institute, 301 East 17 Street, New York, New York 10003, and, Professor of Orthopaedic Surgery, Mt. Sinai School of Medicine, New York, N.Y.<br /><br /><br /></em></div> <div style="width: 400px;"></div> Page Number(s) 1 - 3 Year 1984 Volume 8 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1984_02_001/1984_02_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Biomechanical Considerations in the Orthotic Management of the Knee Creator An entity primarily responsible for making the resource Victor H. Frankel, M.D., Ph.D. * https://staging.drfop.org/files/original/4a1d647a65001ac401d87d1ff0a502dc.pdf be21d355bbb7726b48257560f38ffcc1 https://staging.drfop.org/files/original/ade75bbe682d095fafd8dc98e0bdeebc.jpg cb33bea6982578ca9f1ac897d024b8aa https://staging.drfop.org/files/original/f53916b68ed1a9091e5b7dfd3280019f.jpg e427877188e0e0d0e8f2b3055d5f8df4 https://staging.drfop.org/files/original/1dd8550b2936a7b9cdcc9b23c89e287c.jpg 04f2643b57c264bf37196de0ec256397 https://staging.drfop.org/files/original/e6dab0edff7c7c4249c3192ca924704f.jpg c979896054406fa7bbaa56c9b9bb2d45 https://staging.drfop.org/files/original/3e28fdce00199c50876c4dea728fcd3d.jpg 5fdcfa70023ebdf6bbe368c413721e11 https://staging.drfop.org/files/original/f43c68108152e6a1e1c805a301451b93.jpg 0d3fa2972071447fad21b77828e0dde6 https://staging.drfop.org/files/original/c1607df85b443b92c33b9062283f89f9.jpg ed20251e138d78199b81805f9b773f8e https://staging.drfop.org/files/original/7c2db4f48c70105bc7bf7a49a36f693d.jpg 69d9387960fd1c5c46cf6fd1945e043b https://staging.drfop.org/files/original/a1504fa035cb6baf568bc21f4e6032ae.jpg d2ee96370904fedccfdd586158fc8106 https://staging.drfop.org/files/original/a75b7b94908e32a9a415c6af0859c4d1.jpg 4777a991370a82177c1ba45d1885294f https://staging.drfop.org/files/original/5137c3276e634e3a7a07c361d89615f6.jpg fba588d37b02c32d343d6047401bbf78 https://staging.drfop.org/files/original/2b8e10f3ccd57901d0685024fa54fe16.jpg 4993250f15bf97bab4d79615df1bcda1 https://staging.drfop.org/files/original/0de013a315001679feaee2a5fb2512ec.jpg f62d2caa4a29bf71c555be9f20eeb071 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_027.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 27 - 38 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/1966_02_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_027.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>Fitting and Training Children with Swivel Walkers</h2> <h5>W. M. Motloch <a style="text-decoration:none;">*</a><br />Jane Elliott <a style="text-decoration:none;">*</a><br /></h5> <p><i>Mobility can be provided fairly successfully for the bilateral hip-disarticulation patient when his arms can be used in connection with crutches and canes, but when the patient cannot use crutches a most difficult problem is presented to the clinic team. The most effective means of treating patients who have complete or essentially complete absence of all four limbs has been to provide them with a socket encasing the pelvic region mounted on a three- or four-wheeled platform (<b>Fig. i</b>), or to provide them with motorized carts with special controls. The unpowered vehicles permit the patient to be upright but generally they must be moved from place to place by an attendant, and the motorized carts are expensive.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. i. Three-wheeled cart built by Child Amputee Prosthetics Project, University of California, Los Angeles, for patient with congenital bilateral above-elbow amputations and bilateral lower-extremity amelias. From Blakeslee, Berton, The Limb-Deficient Child. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Experiments at the Child Amputee Prosthetics Project, University of California, Los Angeles, with pylons mounted on rockers, and hinged at a point anterior to the anatomical hip joint, proved to be very disappointing mainly because the effort required in their use exceeded the functional gain (<b>Fig. ii</b>) <a></a>.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. ii. Same child who appears in Figure i shown on pylons mounted on rockers and hinged at a point anterior to the anatomical hip joint. Although the child learned to ambulate with this device, her progress was slow and the energy expenditure extremely high. From Blakeslee, Berton, The Limb-Deficient Child. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>To overcome some of the deficiencies presented by previous approaches, Richard E. Spielrein, <a></a> Senior Engineer, Repatriation Department, Commonwealth of Australia, suggested a pylon arrangement to capitalize on side-to-side oscillations of the man-machine combination (<b>Fig. iii</b>) and built a prototype, based on mathematical computations, which was used successfully by a 16-year-old girl.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. iii. Swivel walker developed by Richard E. Spielrein, Senior Engineer, Repatriation Department, Commonwealth of Australia. From Spielrein, R. E., A Simple Walking Aid for Legless People. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Ontario Crippled Children's Centre, Toronto, Canada, has successfully utilized the principles set forth by Spielrein and presents herewith instructions for fabrication and use of the so-called swivel walker (<b>Fig. iv</b>).</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. iv. Swivel walker developed by the Ontario Crippled Children's Centre, Toronto, Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Experience has been limited to young children, but the walker should prove successful with older persons. It has been suggested that the principle of the swivel walker might also be applied in the case of paraplegia.</i></p> <p><i>A. Bennett Wilson, Jr.</i><a style="text-decoration:none;">*</a></p> <p>The swivel walker in its simplest form (<b>Fig. 1</b>) consists of two pylons attached in a vertical position to a pelvic socket, and two foot pieces which are attached to the pylons so that each may rotate about the vertical axis of the appropriate pylon. Stops are provided to limit rotation of the feet in each direction, and a spring returns the feet to a neutral position when no force is applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Principle of the swivel walker. The child can transfer his weight to one foot by leaning sideways and then swivel forward about this foot, using only the force of gravity. Stops are provided to limit forward or backward swing, with springs returning the foot to the neutral position when it has been returned to the floor. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The soles of the feet are canted in relation to the floor, and the pylons are positioned with their center lines falling posterior to the center of gravity of the patient and prosthesis so that tilting of the body on one side will cause rotation of the socket about the long axis of the pylon on the tilting side. The contralateral pylon is raised initially and swings forward due to gravity until it strikes the floor ahead. Backward motion can be obtained by tilting sideways and leaning backward so that the center of gravity falls posterior to the center lines of the pylons. Of course, to manipulate the swivel walker, the patient must have a mobile trunk.</p> <p>The type of walker suggested for initial use is shown in <b>Fig. 2</b>. Later, a more cosmetic device can be used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic dimensions of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is essentially the same as that for a conventional bilateral hip-disarticulation prosthesis <a></a> and is mounted on a platform which, in turn, is mounted on two aluminum tubes. In the bottom end of each pylon is mounted an ankle joint, or rotation unit, which in turn is attached to a foot piece mounted so that the inner edge rests on the floor when the appliance is at rest (<b>Fig. 2</b>). The foot pieces should have rubber soles to prevent slipping.</p> <h3>Measurements</h3> <ul> <li>Measurements that need to be recorded (<b>Fig. 3</b>) are:</li> <li>Crown-rump length Waist width</li> <li>Crest of ilium to ischial tuberosities</li> <li>Distance between ischial tuberosities</li> <li>Maximum distance across pelvis</li> </ul> <p>The "normal" height of the child with pylons on can be estimated by multiplying the crown-rump length by two or a little less.</p> <h3>Taking the Cast</h3> <p>Taking the cast usually requires the services of two people. A length of large-diameter stockinette is sewn closed at one end, with openings for existing limbs if present. Straps or webbing are used to suspend the stockinette from an overhead hook. This arrangement ensures firm contours and supports the child. The lower trunk, excluding the limbs, is then wrapped with plaster bandages up to the rib cage.</p> <p>If the child is not toilet trained, the cast is made over the diapers. If diapers are not worn, the ischial tuberosity, pubic tubercle, crests and anterior spine of the ilium, and the rib cage are marked as shown in <b>Fig. 4</b>. For use in alignment, vertical lines indicating the lateral and sagittal planes are drawn on the cast before it is removed from the patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Modifications of cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fabrication</h3> <h4>Socket</h4> <p>The original socket is usually made so that it extends a little higher than the waist, both front and back, for early training. As ability to balance improves and proficiency increases, the height can be reduced to approximately waist level. It is important that forward, backward, and side-to-side motions of the torso are not restricted.</p> <p>The original socket fabricated for testing the first model of the swivel walker was heat-formed out of acrylic sheet, but all later models have been of polyester laminate. Two complete layers of Dacron felt, two partial layers of Dacron felt, and two partial layers of glass cloth are used, as shown in <b>Fig. 5</b>. The lay-up is completed with four layers of nylon stockinette before impregnation with a mixture of 70 per cent rigid and 30 per cent flexible polyester resin. The laminate should be formed under a vacuum in order to prevent unnecessary bulk.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Recommended socket configuration. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After curing and removal from the plaster cast, the socket is trimmed approximately as shown in <b>Fig. 5</b> and all edges are rounded and smoothed. Ease of entry and exit is facilitated by an anterior hinge.</p> <p>A plastic hinge with the trade name of Polyhinge is satisfactory and may be fastened with flat-head wood screws. Either polyester or epoxy paste can be applied to the screw heads to prevent corrosion if necessary.</p> <p>Wooden blocks are screwed to the base of the socket to provide a level surface for mounting the socket on top of the pylon walker.</p> <p>The pylons are aluminum tubing, 2-in. outside diameter, 1/16-in. wall thickness. The top ends are fitted with wooden plugs; the bottom ends are fitted over the ankle joints.</p> <p>The dimensions of the pylon and its placement are based on the "normal" height of the child and are indicated in <b>Fig. 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Measurements required for fabrication of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An adequate method for fastening the pylons is to slit the ends and use hose clamps (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Assembly of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Ankle Joint</h4> <p>The ankle joint (<b>Fig. 7</b>), mounted between the pylon and the foot piece, permits rotation of the foot piece about a vertical axis to allow forward and backward swing. As can be seen in <b>Fig. 7</b>, the foot piece is returned to a neutral position by a spring-loaded roller. Built-in stops restrict rotation to approximately 39 deg. forward and 11 deg. backward. (It is planned that a simpler, less expensive version of the ankle joint will be available commercially in the near future.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The ankle unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Foot Pieces</h4> <p>The foot piece (<b>Fig. 2</b> and <b>Fig. 6</b>) consists of a block of wood, a platform sole, and a rubber undersole. The rubber is glued to the wooden platform, which is fastened to the block of wood with glue and screws. The block is bored to receive the lower part of the ankle unit, which is held in place with epoxy resin or paste.</p> <h3>Alignment</h3> <p>The main considerations in alignment are (<b>Fig. 2</b>):</p> <ul> <li>The center lines of the ankle joints should fall approximately 1 1/2 in. behind the center of gravity of the child's body.</li> <li>When the walker is at rest, the pylons should be vertical.</li> <li>The foot platform should tilt about 6 deg. and rest on the medial edge.</li> <li>When viewed from above, the foot pieces are rotated out about 10 deg. (This adjustment is made by reaching down inside the pylon with an extension wrench and slackening off the bolt. This releases a tapered shaft, enabling the foot piece and lower ankle housing to be rotated to the desired position.)</li> </ul> <h3>The Cosmetic Swivel Walker</h3> <p>To improve appearance and to permit the patient to assume a sitting position, the pylons can be replaced with articulated limbs (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Swivel walker equipped with articulated limbs to permit sitting, and fabricated to improve cosmesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The knee joints and hip joints are those used in a Canadian-type hip-disarticulation prosthesis, and they are aligned in a similar manner. For purposes of stability, the hip joints are placed well forward and the knee joints well back. It is imperative that the alignment between the socket and the foot pieces be identical to that used with the pylon type.</p> <p>The lateral straps are 1-in. elastic webbing installed with sufficient tension to prevent hip or knee flexion when the limb is lifted clear of the floor. Each strap is attached to the socket and to the lower limb in such a manner that in the standing position the direction of pull is behind the hip joint and in front of the knee joint. In the sitting position, the straps pass in front of the hip joint and behind the knee joint.</p> <p>The foot is carved from solid wood, bored out to receive the lower housing of the ankle joint. Foot pieces, used for training, are at-</p> <p>tached by screws through the soles of the shoes into the wooden feet. When the child has progressed to a point where foot pieces can be removed, screws are used to secure the soles of the shoes to the wooden feet. The shoe soles should be flat, with the same 6 deg. tilt from the medial edge.</p> <p>The shank sections must be hollow so that a wrench may be inserted from the top to adjust the vertical shank bolt.</p> <h3>Training</h3> <p>It is recommended that training for young children be commenced by using a lateral rocker as shown in <b>Fig. 9</b> to enable the child to establish balance, to learn and practice the sideways rocking motion, and to establish a rhythm. When the child feels secure in this arrangement, he is transferred to the swivel walker with short pylons and encouraged to go through the same rocking motion. At this point it is necessary to demonstrate to the child the forward swing by placing the hands on the trunk and guiding the child through the side-to-side motion coupled with a forward tilt. This support is gradually decreased until the child can manage unaided.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Device for training patient to use the swivel walker. The lateral rocker enables the child to establish balance, to learn and practice the sideways rocking motion, and to establish a rhythm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As proficiency in the use of the swivel walker increases, the height of the pylons is raised in 1-in. increments until a "normal" height is attained. The rate of increase will vary according to the child's capability. Experience at the Ontario Crippled Children's Centre has been that the height can be increased one inch about every two days.</p> <p>At low heights body sway above the waist is required to operate the walker. As the height is increased, the child's movement alters to a lateral displacement of the hips such that the body moves sideways while remaining vertical.</p> <p>When patients become proficient in the use of the walker, they do not swing the walker to the limits of the stops.</p> <p>The ability to walk backward is attained with little more difficulty than walking forward, but smaller steps are generally used. One child was able to walk very well in either direction within a period of two weeks. Walking backward is important because it permits the child to back out of corners or similar situations.</p> <p>Great care must be taken with the child during training, since it is possible that a few falls will occur until his sense of balance is perfected. Falls from being pushed by other children are likely to be far greater in number than those resulting from overbalancing. It is recommended that some form of protective head covering (such as an ice hockey head guard) be worn during this stage of training.</p> <p>One child was fitted with the swivel walker shown in <b>Fig. 8</b> after she became proficient with the pylon type. Initially, the foot pieces were larger than the shoes. As proficiency developed, they were gradually trimmed in size and finally removed, leaving the shoes tilted at the same angle.</p> <p>With both types of walker it was found that the children averaged approximately 120 steps per minute, each step being approximately three inches when walking forward.</p> <p>Each child had to be treated individually according to his own temperament. One child was extremely nervous and frightened, and so training had to be carried on more slowly than with another child who accepted alterations readily.</p> <p>From experience gained so far, it is suggested that a child who is nervous and cautious be given a period of at least one week to become used to major adjustments and alignment changes.</p> <p><b>References:</b></p> <ol> <li>Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</li> <li>McLaurin, Colin A., The evolution of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 22-28.</li> <li>Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, Colin A., The evolution of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 22-28.</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">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., Washington, D. C. 20418.</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">Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jane Elliott </b></td></tr><tr><td class="clsTextSmall">Physiotherapist, Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Rd., Toronto 17, Canada.</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>W. M. Motloch </b></td></tr><tr><td class="clsTextSmall">Prosthetist, Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Rd., Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-09.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-07.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-13.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 Fitting and Training Children with Swivel Walkers Creator An entity primarily responsible for making the resource W. M. Motloch * Jane Elliott * https://staging.drfop.org/files/original/9278e2810ea9f78e2de4c8bba8abbd72.pdf a774a49fa86c90712363d0801131e532 https://staging.drfop.org/files/original/08588a42be997361ba8f0142b7823983.jpg bee92071ff1c11bb2d2ceb61ca93b3df https://staging.drfop.org/files/original/9c17baf3b9691a8d9a37cdce7212e703.jpg feecd87d738ea94d1b39cc924df85985 https://staging.drfop.org/files/original/3d034d5f3443f358031dab6eba679d06.jpg 1f5e08192e9e7ef11a3299d1f9749209 https://staging.drfop.org/files/original/451f37e9c36d349733b74e0af0e323d3.jpg 232044070b13d5921ba696566e6e560e https://staging.drfop.org/files/original/efaaeec0404c6bfdb706ef31a7cc8773.jpg 31daf4bc27bde9e0a78a2d1ffc3a261f https://staging.drfop.org/files/original/11ccde34591e33f4bf94ae477a409147.jpg 32fd97e2284084e280a5a3c40bc68e12 https://staging.drfop.org/files/original/b9380eca06f68f68dc024f24e35ce0fa.jpg bf40832a2704e549a6292d2e59bc98bb https://staging.drfop.org/files/original/c7b17c455f05352581a7c7a67769c333.jpg 7c8cbab28c7a54a0495778bcbf11af86 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_036.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 36 - 41 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_02_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_036.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Toronto Orthosis for Legg-Perthes Disease</h2> <h5>W. P. Bobechko, M.D., F.R.C.S.(C.) <a style="text-decoration:none;">*</a><br />C. A. McLaurin, B.A.Sc, P.Eng <a style="text-decoration:none;">*</a><br />W. M. Motloch <a style="text-decoration:none;">*</a><br /></h5> <p>The treatment of Legg-Perthes disease has been given considerable attention at the Hospital for Sick Children in Toronto during the last few years. It is now known that certain types of Legg-Perthes disease have a good prognosis regardless of the type of treatment used, whereas other types tend to have a poor prognosis. Proper prescription of treatment must, therefore, recognize this difference in prognosis.</p> <p>Attempts have been made to assess the outcome of the disease on the basis of age at onset and the degree of involvement of the ossific nucleus of the femoral head.</p> <p>In children who develop Legg-Perthes disease prior to the age of five years, the prognosis tends to be better than in a child who develops the condition at an older age. This difference is probably related to the total mass of bone that has to be re-ossified, since it has been noted that in a smaller femoral head the time for re-ossification is often shorter, being in the vicinity of 12 to 18 months compared to several years for an older child.</p> <p>The degree of involvement also plays a most important part, and attempts have been made here to differentiate between cases where the entire femoral head is involved, with avascular necrosis of the entire ossific nucleus, and those where merely a portion is involved. The partial-head-type of Legg-Perthes disease carries a much better prognosis and is less liable to deformity, since a part of the femoral head remains uninvolved.</p> <p>If there is any tendency towards the formation of a metaphyseal cyst, the possibility of a poor long-term result is increased.</p> <p>The stage at which the patient is first seen is of the utmost importance. If the child is seen early in the course of the disease, before joint deformity has occurred, proper management, if instituted quickly, can often result in a congruous joint. If, however, there is already considerable flattening and subluxation when the child is first seen, then the result, of course, cannot be as good. If the entire process of reossification has already occurred by the time the child is first seen, the golden opportunity has passed, and at this stage only secondary reconstructive procedures can be carried out, with even less satisfactory results.</p> <p>Certain selected cases are suitable for innominate osteotomy, in which the femoral head is covered and seated just as if the hip were held in abduction and internal rotation. At present, innominate osteotomy is restricted to the child who carries an unusually bad prognosis; that is, a child over the age of six years with total involvement of the femoral head. In addition, an arthrogram must be made to be certain that a significant joint deformity is not already present. If a deformity is present, innominate osteotomy is contraindicated. In addition, prior to the use of an innominate osteotomy, full joint movement must be obtained, which sometimes will require traction or soft tissue release of contracted structures, such as the psoas tendon.</p> <p>In the very young child with only a part of the head of the femur involved, often no treatment is indicated, provided that no soft tissue contractures have occurred. If soft tissue contractures are present, then soft tissue release may suffice, with or without a short period of traction.</p> <p>This leaves a small group of children for whom bracing may be used to advantage. These children would typically be in the under-six age group, with partial or total head involvement and with free joint movement, before deformity has set in.</p> <p>In the past, ischial weight-bearing braces have been used in the treatment of Legg-Perthes disease with little regard for the various forms and severity of the disease process. Cineradiography has revealed that as the patient walks with an ischial-bearing brace the involved hip tends to move medially and laterally, a condition which may contribute to subluxation and further flattening in the form of a coxa plana; therefore, use of such braces has been discontinued at the Hospital for Sick Children.</p> <p>In 1957, Dr. William Craig<a style="text-decoration:none;">*</a> of Los Angeles first reported <a></a> the use of the abduction and internal rotation method of treatment of Legg-Perthes disease, a procedure which has been modified by Dr. Gordon Petrie<a style="text-decoration:none;">*</a> of Montreal. <a></a> When a child was allowed to bear weight on the legs in the abducted cast, it was found that a remodeled femoral head would, in fact, develop in a spherical fashion in its round and uninvolved acetabulum. This method has proved satisfactory in many instances, but there are certain disadvantages. Because the child's legs must be kept in abduction for a period of several years, cast changes must be made at 8-to 12-week intervals. Considerable stiffness develops about the knees and ankles and, in some instances, there has been a suggestion of flattening of the femoral condyles because of the continuous pressure that is applied to the knee as it is held in one position over a prolonged period of time. In addition, prolonged plaster immobilization encourages the development of osteoporosis, atrophy of muscle, pressure sores, and other problems.</p> <p>To eliminate some of the problems encountered with the use of abduction casts, a new type of articulated experimental brace has been designed. Known as the "Toronto Legg-Perthes Brace," it provides for 90-deg. abduction and slight internal rotation, yet allows hip and knee movements so that the child may ambulate and sit (<b>Fig. 1</b> and <b>Fig. 2</b>). With the brace, the child is encouraged to walk as much as possible, for it is the weight-bearing movement with the hips centered in a safe position that encourages successful remodeling of the femoral head during growth. The brace is removed easily, but the child, of course, must not be allowed to walk without the brace. It is emphasized that at present (1968) this brace has been used on an experimental basis for the past 18 months, and we do not yet have any indications as to whether any problems will develop, such as those that were produced by ischial weight-bearing braces which, in fact, produced a coxa plana and probably did more harm than good. Cineradiography on one patient has indicated that the femoral head does stay within the acetabulum during loading and unloading of the joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Front and rear views of the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The Toronto brace for Legg-Perthes disease in use. <i>Left, </i>Three-quarter view in the standing position; <i>Right, </i>side view in the sitting position. Note that the thighs are maintained in the abducted position at all times. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Sixteen patients are presently using the Toronto brace and, in our present state of knowledge, this new type of brace appears to fulfill all the criteria set forth.</p> <h3>Biomechanics</h3> <p>The Toronto brace holds the legs in 90-deg. abduction with respect to each other, with the feet rotated internally. The body weight, when the patient stands erect, is distributed axially through each leg to each foot. The shoes are fastened to blocks of wood with the plantar surface at an angle of 45 deg. to the floor. The foot blocks are tied together by rods which are rigidly attached to the blocks but articulated at the sagittal plane. The force diagram is shown in <b>Fig. 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Resolution of forces being applied to patient using the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Each tie rod is connected by a ball joint to a rigid frame that supports the two thigh cuffs. The thigh cuffs take no load when the patient stands with knees extended, yet the hips are held in abduction as the knees are flexed. The geometry permits each knee to flex independently of the other (<b>Fig. 4</b>) and, because ball joints are used, accurate alignment is not necessary. The ball joints also allow dorsi-plantar flexion of the foot block (<b>Fig. 5</b>). Because the plantar surface of the shoe and foot is at 45 deg. to the floor, plantar flexion of the foot itself is accompanied by toe-in and dorsiflexion of the foot is accompanied by toe-out. Otherwise, toe-in and toe-out are securely held to the appropriate angle (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Schematic view from the front of the Toronto brace for Legg-Perthes disease to show the geometry of the system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Location of the shoe with respect to the foot block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Schematic view from the top of the Toronto brace, showing angular position of the sole of the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fitting and Fabrication</h3> <p>The first step in fitting and fabrication of the Toronto orthosis is to make a tracing of the patient's legs and pelvis when he is supine with each leg abducted 45 deg. from the center line of the body. (If this cannot be accomplished, traction or soft tissue release is indicated before fitting can proceed.) The shoes are put on the patient's feet so that the edge of the sole is traced rather than the edge of the foot itself, because the shoes are a part of the total structure. The following information should be indicated on the tracing (<b>Fig. 7</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Typical tracing needed for fabrication of the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The position of the thigh cuffs, which should be 1 in. above the patella and 2 in. below the groin.</li><li>The position of the shoe, when the sole of the shoe is placed at a 90-deg. angle to the long axis of the leg.</li><li>The position of the knee axis.</li><li> Measurements of the lower (LC) and upper (UC) circumferences of the thigh cuffs.</li></ol> <p>The frame, joint block, tie rods, foot blocks, and thigh cuffs are outlined on the tracing to facilitate fabrication.</p> <h3>Frame</h3> <p>The frame, which supports the thigh cuffs and joint block, is made from 1 in. X 1/4<i> </i>in. 24ST-4 aluminum bar, bent cold into a more or less diamond shape to conform to the tracing, and attached to the upper sides. The joint block is attached to the lower apex.</p> <h3>Joint Block</h3> <p>The purpose of the joint block is to provide a firm mounting for the ball joints to which the tie rods are attached. The block is assembled from five sections cut from 3 in. X 3 in. X 1/2 in. 65 ST (or equivalent) aluminum angle. Two automotive-type tie rods and joints are used for the ball joints,<a style="text-decoration:none;">*</a> which are located in the block so that they are in line with the knee axis. The threaded shank of the socket is bent to a 45-deg. angle before being brazed to the tie rod (<b>Fig. 8</b>). The tapered shank (Morse taper no. 1) on the ball of the joint is fitted to a hole in the joint block when the Chevy II part is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Method of bending threaded shank of the ball joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Tie Rods</h3> <p>The tie rods which connect the joint block with the foot blocks are made from chrome molybdenum tubing, 3/4 in. O.D. X .056 in. wall thickness. Tubing of this strength is required to resist damage that may be encountered with curbs, steps, etc. One end of the tie rod is brazed to a foot-block plate and the other end to the threaded shank of the joint.</p> <h3>Foot Blocks</h3> <p>The foot blocks are used to secure the shoes to the rods and support the shoes at the correct angle. Each foot block consists of a metal plate and a triangular block of wood. The metal plate is brazed to the distal end of the tie rod, and the wooden block is fastened to the plate with epoxy resin and wood screws. The shoes are fastened to the sloping surface of the wood block with rubber cement and wood screws. Note that the shoes are aligned on the block with approximately 15 deg. to 20 deg. internal rotation, as shown in <b>Fig. 6</b>. The bottom surface of the blocks should be covered with a tough soling material. A section of automobile tire is very serviceable, but tends to mark floors. It can be fastened on with rubber cement and wood screws. Frequent replacement is usually necessary.</p> <h3>Thigh Cuffs</h3> <p>The thigh cuffs should fit from 2 in. below the groin to 1 in. above the proximal border of the patella. The distal posterior edge should be flared to minimize discomfort in the popliteal area when the knees are flexed. The cuffs should be made to fit (not too tightly) over the trousers. They should be made from a semi-flexible material with a lateral opening so that the brace can be put on and taken off readily. Velcro straps provide a convenient method of adjustment. Cuffs made at the Centre were formed from a thermoplastic material from Smith and Nephew called "San Splint." A similar material, "Orthoplast," is marketed by Johnson and Johnson. The thigh cuffs and Velcro straps have required frequent replacement in active patients.</p> <h3>Gait Training</h3> <p>Usually about three days of intensive training by a physiotherapist are required for the child to learn to walk in the brace. Two crutches are used. They are usually held in front of the body, although the occasional child keeps one crutch behind. Stairs and curbs can be negotiated with little difficulty, and some patients learn to walk without crutches for short distances.</p> <p>The braces are removed for bathing, swimming, and sleeping, but the child must never be allowed to stand, kneel, crawl, or walk without the brace.</p> <p><b>References:</b></p> <ol> <li>Craig, William, Personal communication, 1967.</li> <li>Petrie, Gordon, Personal communication, 1968.</li> <li>Salter, Robert B., <i>Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip</i>, J. Bone Joint Surg. (Brit.), 43B:3:5l8-539, August 1961.</li> <li>Salter, Robert B., Personal communication, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Joints from a 1965 Chevy II have been used satisfactorily.</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">Petrie, Gordon, Personal communication, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Dr. James A. Petrie, Orthopaedic Surgeon, Royal Victoria Hospital, Montreal, P.Q., Canada.</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">Craig, William, Personal communication, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Dr. William Craig, 328 W. 23rd St., Los Angeles, Calif. 90007.</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>W. M. Motloch </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>C. A. McLaurin, B.A.Sc, P.Eng </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</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>W. P. Bobechko, M.D., F.R.C.S.(C.) </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-08.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 Toronto Orthosis for Legg-Perthes Disease Creator An entity primarily responsible for making the resource W. P. Bobechko, M.D., F.R.C.S.(C.) * C. A. McLaurin, B.A.Sc, P.Eng * W. M. Motloch * https://staging.drfop.org/files/original/16eacc2e24fa11ba24117d1fb85c931c.pdf de0c0a58e9193f24569f1c879ad120b2 https://staging.drfop.org/files/original/606a6c31866c4d006f77d0445e543cae.jpg f4ab710fe6f916f4722e405866dc107d https://staging.drfop.org/files/original/91cd0ddfaca05e2bdc88e8aef7411353.jpg 7a64b2419fe01ec7ad868c5979c7bfa3 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_009.pdf Text Any textual data included in the document <h2>Orthotic Philosophies of Treatment</h2> <h5>Wallace Motloch, CO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In situations when a medical condition places a physical limitation on a growing child, the orthotic treatment and devices are aimed at minimizing that limitation. Through the combined knowledge and skills of the orthotist, medical team, and family, as well as the child, the orthotic program maximizes that child's assets.</p> <p>To illustrate how the various aids and braces work within the orthotic program, one can compare the developmental milestones of a child with normal body to that of a child with spina bifida (<a href="/files/original/606a6c31866c4d006f77d0445e543cae.jpg"><b>Fig. 1</b></a>). As the developmental need for sitting, crawling, and ambulating is encountered, an orthotic device is introduced to the spina bifida child who cannot accomplish these tasks well. Depending on the availability of funds and clinical resources, the orthotic care may start at infancy with the fabrication of devices for safe handling of the newborn, modifying equipment for play, bathing, and safe transportation. The orthotic involvement continues for the rest of that person's life as various braces for ambulation, support of the spine, contracture management, and general development of a lifestyle are designed and manufactured.</p> <strong><a href="/files/original/606a6c31866c4d006f77d0445e543cae.jpg">Figure 1</a>. Comparison of the developmental milestones of a normal child to a spina bifida child.</strong><br /> <p>As the children progress from one developmental milestone to another and their needs change, so must orthotic devices. Often these needs overlap, calling for a "wardrobe" of devices (<a href="/files/original/91cd0ddfaca05e2bdc88e8aef7411353.jpg"><b>Fig. 2</b></a>). To illustrate this point let's imagine a person developmentally ready to crawl. To accomplish such exploration safely one will best be served by a wheeled device called a Caster Cart. While the Caster Cart is not a brace per se, it provides a vital part of the program by helping in a way that no brace or wheelchair can. It allows the child to move around safely, positions him close to the floor, allows for retrieving playthings from the floor, and it aids in "hand-free" sitting.</p> <strong><a href="/files/original/91cd0ddfaca05e2bdc88e8aef7411353.jpg">Figure 2</a>. Wardrobe of devices for a child who is ready to stand and ambulate (brace and walker). At the same time, the child retains a Caster Cart for exploration and Body Jacket for support of collapsing spine.</strong><br /> <p>Even though the Caster Cart has so many advantages, many parents are hesitant at this juncture, primarily because they imagine braces or some other bionic devices as restoring greater normalcy to their children. The orthotist must be very aware of the great pressure that drives the parents. They are desperate to do something! They are anxious to get the child into the best braces. They want to see the child up and ambulating. They want to see what it will be like—and that is the most normal behavior of any person. The orthotist must be compassionate at this point. He must know the dynamics of this situation. This is the most crucial moment in the parent-orthotist relationship; it will set the stage for many future meetings and achievements.</p> <p>Having seen several hundred Spina Bifida children and their parents go through this stage, personally I believe that not one but three devices are in order: a Caster Cart, Standing Brace (It should be pointed out here that the name "Standing Brace" is a misnomer as the device facilitates much more than standing), and Parallel Walker. The reason that this combination works the best is that crawling is very quickly followed by standing and ambulation. Oftentimes these are not demarcated clearly, and as the functions are accomplished, the devices continue to be used in an overlapping fashion—so why not have all three at once and let the child dictate the progress. While the actual design of braces can vary at this stage, as long as the child is upright safely and can stand "hand-free," the purpose is achieved.</p> <p>As the child gets older (two to three years), another crucial bracing decision has to be made. It has to be decided if the child is capable of ambulating with a reciprocal gait (one leg in front of the other) or whether he/she must ambulate by swing-to, swing-thru, or pivoting. It has been my experience that whenever possible the Reciprocal Gait Brace (Dual cable type) should be considered, as it has particular importance for the Spina Bifida person. The Reciprocating Gait Brace (RGB) is a dynamic orthosis unlike any conventional device made. It provides:</p> <ul> <li> <p><b>Standing Balance and Support</b>: Wearers can have their hands free for activities of function while standing.</p> </li> <li> <p><b>Automatic Hip Joint Locking</b>: This provides for ease of locking the brace with hands on crutches or walkers.</p> </li> <li> <p><b>Efficient Ambulation</b>: Compared to conventional orthosis, RGB was tested (distance walked with same increase in heart rate) to be two to three times more efficient. This saves energy for people with muscle weakness, and for people likely to gain weight, it encourages more physical activity.</p> </li> <li> <p><b>Dynamic Hip Reciprocating</b>: The special hip mechanism couples the hip joint motion so that flexing of one side causes forced extension of the opposite side (a mechanical hip extensor). This function facilitates walking, but in people prone to hip flexion contractures it also stretches the hip contractures with every step.</p> </li> </ul> <p>Around the age of ten another crucial decision comes up: the use of the wheelchair. There are many reasons for this. A few are: lack of physical strength for ambulation, cosmetic appearance and peer pressure, ease of assistance from others and general convenience of getting around. Many people with Spina Bifida find that ambulation in braces becomes quite energy consuming and that in the school setting in particular, it makes the carrying of books inconvenient. Many slowly, but surely, drift to greater use of the wheelchair. They find that their shorter stature in braces doesn't serve them as well as the sitting posture in a wheelchair. Also, it is harder for them to get help from others now that they are bigger and heavier. When need for assistance arises, say to go up ten steps, it is harder to help a brace wearer than a wheelchair rider. In any case, because many people choose a wheelchair in addition to, or instead of, braces, the orthotist stays involved in design and fabrication of special pressure sore prevention aids like contoured seat cushions and Suspension Body Jackets.</p> <p>Unfortunately, for many spinal cord injured teenagers and adults we do not have braces that can compete effectively with the wheelchair's efficiency and convenience. As things are, while there are a fair number of devices to choose from for the under-ten-years-old group, the choice is very limited for the older group. Much more ingenuity and research is needed to develop designs that will prove useful to the latter group.</p> <p><b>References:</b></p> <ol> <li>W. Motloch, "Human Needs and Orthotic Goals for Spina Bifida Patients," <i>Canadian Ortho-Pros.</i>, Summer 1975.</li> <li>W. Motloch, "Wardrobe Devices," <i>Inter-Clinic Information Bulletin</i>, January 1974.</li> <li>W. Motloch, "Crutchless Standing," <i>Canadian Ortho-Pros.</i>, Spring 1973.</li> <li>W. Motloch, "New Items for Spina Bifida Programs," <i>Inter-Clinic Bulletin</i>, July 1970.</li> <li><a href="http://www.oandplibrary.org/al/1971_02_036.asp">W. Motloch, "Parapodium: an Orthotic Device for Neuro-Muscular Disorders," <i>Artificial Limbs</i>, Autumn 1971.</a></li> <li>W. Motloch, "Analysis of Medical Costs Associated with Healing of Pressure Sores in Adolescent Paraplegic," B.S. Thesis, University of San Francisco, February 1978.</li> <li>W. Motloch, "Seating and Positioning for the Physically Impaired," <i>Orthotics and Prosthetics</i>, June 1977.</li> <li>Personal communication with E. Hamilton, S. Walder, C. McLaurin, Dr. N. Carrol, and others from Ontario Crippled Children's Centre.</li> </ol> <em><b>*Wallace Motloch, CO </b> Wallace Motloch, CO is the Director of the Center for Orthotic Design, Inc.<br /><br /><br /></em> Page Number(s) 9 - 11 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_009/1984_04_009-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_009/1984_04_009-2.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 Orthotic Philosophies of Treatment Creator An entity primarily responsible for making the resource Wallace Motloch, CO * https://staging.drfop.org/files/original/caebe3f12ffbae3736dc0772ee55ae46.pdf 2c2ad2a01e8a4dc8c3905be963fdf48c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_001.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Syme's Amputation</h2> <h5>Walter Mercer <a style="text-decoration:none;">*</a><br /></h5> <p>This issue of Artificial Limbs is, and always will be, a classical contribution to everything pertaining to Syme's amputation, including, as it does, the most detailed and accurate description extant of the proper method of doing the amputation.</p> <p>It has to be remembered that Syme was the greatest of the pre-Listerian surgeons and, indeed, his operation was developed to combat the disastrous septic complications that so often beset the surgeon who dealt with compound fractures, especially where the bone was divided, in contrast to cases that were disarticulated. The fear of sepsis was no longer a real one after Lister's discovery, but that there were other and great advantages in this operation is proved by the fact that Syme's operation is still recognised by competent surgeons as a method of choice in the suitable case. But there have been criticisms of the operation. Harris has stated the reasons for this difference of opinion. He believes that these lie in the method of the operation and in the after-treatment. Various imperfections of the end-results and the methods of their avoidance are described. Most of these can be avoided by a careful technique, and if this were generally practised there would be fewer complications about this excellent operation.</p> <p>Harris reminds us of an important feature of anatomy not generally recognised. This is the specialised form of elastic adipose tissue developed between the calcaneum and the plantar aponeurosis which is resistant to pressure. There are here pockets of fat enclosed by dense septa of fibrous tissue. These fibrous tissue strands are in the form of the letter "U," with the open end of the "U" pointing towards the calcaneum. If this concept is true, it is obvious why the dissection of the heel flap should be close to the calcaneum, because if these little loculi are opened, as will happen if the dissection is through the subcutaneous layer, the fat content is extruded and an important weight-bearing mechanism rendered useless.</p> <p>All modifications, apart from Syme's own one, have detracted from the good qualities of the Syme stump and, indeed, have often ruined its weight-bearing qualities and brought the modified Syme's operation into disrepute. Kelham and Perkins, of the British Ministry of Pensions, are often quoted for their strong objection to this operation, and they concluded their article by expressing the hope that the modified operations would soon be as dead as the original Syme. But their remarks were not based on the original Syme, and so it is not remarkable that they hoped that their modified operation would become obsolete.</p> <p>Modifications like that of Elmslie only lead to failure by reducing the weight-bearing area and making the positioning and fixation of the heel flap more difficult. The plane of transection of the tibia should be so placed that the minimum of bone is removed and the largest possible cross-section of the tibia remains, and that, of course, should be parallel to the ground.</p> <p>It is good to know that the opinions of the British Ministry of Pensions at Roehampton are now very different. The Chief Medical Officer there believes that a Syme amputation is the operation of choice and he adds that "nobody would persuade me to have a below-knee amputation if I could have a Syme."</p> <p>Opinion on durability, too, seems to have changed. Many of the cases seen at Roehampton have had little or no trouble over 30 and 40 years. Shellswell quotes a case who had no trouble in 74 years of limbwearing and in his investigation of 305 Syme's amputations with an average follow-up of 29.6 years he found that 66 percent had satisfactory stumps.</p> <p>Harris points out that an imperfection that is commonly overlooked is the misplaced heel flap. So often after the operation the patient is sent out of the theatre to have the bandaging and the dressing completed. A little too much pull inwards or outwards produces-and permanently-a flap which is not exactly beneath the centre of the cut lower end of the tibia. Harris secured this correct position by strips of adhesive plaster. A plaster-of-Paris support has also been suggested, and a very secure method is to fix the stump by a nail or pin driven up through the lower end of the tibia.</p> <p>Gordon Dale, who has had an immense experience when in charge of all amputations for the Canadian Department of Veterans Affairs, discusses the use of the Syme amputation in peripheral vascular disease. This is an interesting review of the subject with a detailed description of typical cases. The first Syme amputation for thromboangiitis obliterans was done as far back as 1925, and since then it has been used in such cases whenever it seemed warranted. By 1940 this amputation had been used successfully for a wide variety of conditions, including perforating ulcers, in unrecovered sciatic lesions, cauda-equina lesions, frostbite, arterial occlusion, and gangrene from peripheral arterial disease. Dale showed by demonstration of actual cases the great value and durability of these amputations in active life, and in so doing was able to refute the views on durability expressed by the British Ministry of Pensions.</p> <p>The biomechanics of the Syme prosthesis are reviewed by Radcliffe and particularly the locomotion pattern and the manner of weight-bearing for a Syme amputee. In an analysis of the process of human locomotion, the walking cycle is divided into two phases-the stance phase and the swing phase-and these are reviewed. The energy curves are most interesting and give some insight into the complexity of knee-ankle interaction in normal human locomotion. Because of the inherent limitations in available space in the Syme prosthesis, attempts to introduce ankle action have been for the most part unsuccessful. Because in this limited space the Syme amputee cannot achieve the same degree of function as the above-knee or below-knee amputee wearing a SACH foot, the function will in general represent an improvement over the result to be had with the usual articulated joint. This is perhaps an understatement, for when the knee joint on the prosthetic side assumes a greater proportion of the shock-absorption function as evidenced by increased knee flexion under load just after heel contact there is much less deviation from the normal gait.</p> <p>The actual prosthesis is described in a further article. In a review of the history it is apparent that there has been a gradual improvement since the beginning of the century, though even in 1940 the device was bulky, uncomfortable, and generally subject to mechanical failure. With the introduction of plastic laminates into the practise of prosthetics, research workers have been able to alleviate to a great extent the shortcomings of the designs then currently in use, and now excellent and enduring results have been obtained in a large number of Syme amputations observed in Canada. There seems to be little doubt but that the results in Canada, superior apparently to those in Great Britain, have been due chiefly to adherence to the classical procedure of Syme. In this connection, it is said that "Syme was seldom if ever meticulous as to detail," which is hardly consistent with the views of a famous assistant of Syme's, Joseph Bell, in expressing the special character of Syme's method of operating, nor indeed with his reputation in Edinburgh.</p> <p>The present prosthesis is the result of research undertaken by the National Research Council of Canada, an activity initiated by Dr. Harris in 1944, though it was not till ten years later that the device had sufficient merit to warrant its general adoption. This is known as the "Canadian-Type Syme Prosthesis," or more simply, in Canada, as the "Plastic Syme." Among the essential features is a socket made of laminations of Fiberglas applied to a plastic mould of the stump and bonded with a rigid epoxy resin. It is lined with foam rubber, and the stump is inserted posteriorly. There is no ankle joint, and the foot is of the SACH type. This prosthesis is stronger, lighter, and much neater than anything produced before and is now in general use, and we have in the last two articles the considered opinion on it from Canada and America. It is stated in the first of these that its chief advantages lie in its improved appearance with reduced weight, its improved durability by virtue of a stronger structure, its freedom from mechanical troubles, and its reduced cost.</p> <p>This issue of Artificial Limbs leads one to the conclusion that the Syme's amputation is a very good one when properly carried out and properly cared for afterwards. The limb, too, that is in common use as described is a vast improvement on the older types and permits a gait that is not much short of normal.</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>Walter Mercer </b></td></tr><tr><td class="clsTextSmall">'Bidston,' 7 Easter Belmont Road, Edinburgh 12, Scotland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Syme's Amputation Creator An entity primarily responsible for making the resource Walter Mercer * https://staging.drfop.org/files/original/eb7af921f4b32f8e97132e548f88898b.pdf b3171ca328eee50b5195df04b2d0c788 https://staging.drfop.org/files/original/8b668143ca8ff4ec00d38bdaca0e8295.jpeg 8099103e73990942586441d921a16c1c https://staging.drfop.org/files/original/3bb0ef66a8d97b487e2406e04dfe528a.jpg 657f28db4b18efbba8fdf19ced12aefc https://staging.drfop.org/files/original/c874cf9cf5f6cd93cbfd7caefebfdb17.jpg 3a422d3bde70187bd6eacbad0b5b61bd https://staging.drfop.org/files/original/8ae5ce0e382f544320be566569a2f206.jpg e3914b13228afa24f44648b12154099a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_007.pdf Text Any textual data included in the document <h2>Feedback For Electrically Powered Prostheses And Orthoses</h2> <h5>Warren Frisina, B.E. (in M.E.)&nbsp;<a style="text-decoration: none;">*</a><br />James A. Reeve, B.S. (in E.E.)&nbsp;<a style="text-decoration: none;">*</a></h5> <p style="font-size: 60%;"><i>All rights reserved © Warren Frisina 1981</i></p> <p><i>This research was supported by the National Institute of Handicapped Research under the designation of New York University Medical Center as a Research and Training Center.</i></p> <p>Basically, pressure feedback systems for upper limb electrically powered prostheses consist of sensors about the prehensile area, electronic processing circuits, and actuators that contact the body. Sensors require careful installation and tend to be vulnerable to damage. Processing circuits leave that much more delicate equipment to coordinate. Actuators sometimes unduly complicate construction and fitting.</p> <p>The system to be described here makes use of the characteristic current response of an electric motor encountering a load—current increases in proportion to the load. This response is directly employed as the combined feedback/actuating signal. It is sent to a miniature direct current electric motor⁴ (<a href="/files/original/8b668143ca8ff4ec00d38bdaca0e8295.jpeg"><b>Fig. 1</b></a>). The top of <b>Fig. 1</b> shows three Micromo motors and the bottom of the figure, the assembled unit. On the shaft of the motor an eccentric mass is mounted. (Several such masses are shown on the right of <b>Fig. 1</b>). This causes the motor to vibrate in proportion to the motor speed (motor speed is proportional to current). When this motor is rigidly mounted to virtually any portion of a prosthesis, the entire prosthesis will vibrate in turn (<a href="/files/original/3bb0ef66a8d97b487e2406e04dfe528a.jpg"><b>Fig. 2</b></a>). Thus, the entire surface of the skin in contact with the prosthesis receives feedback information. The units installed thus far in patients' below-elbow myoelectric prostheses have been fixed at the distal end of the socket with a hose clamp which has been laminated to the socket (<a href="/files/original/c874cf9cf5f6cd93cbfd7caefebfdb17.jpg"><b>Fig. 3</b></a>).</p> <p>The feedback motor can be installed in virtually any electrically powered prosthesis by putting it in series with the drive motor(s). So that most of the current flows to the drive motor(s) and to avoid overloading the small feedback motor, a resistor of approximately three ohms is placed in parallel with the feedback motor. In order to fine tune the system, it would be convenient to have this resistor be of the variable type.</p> <p>This system has been applied to myoelectric prostheses for seven patients at the Institute of Rehabilitation Medicine, New York University Medical Center. It is being applied explicitly for force feedback. But it appears to serve for position feedback as well, since the prosthetic hand unit and glove offer resistance to the drive motor as the hand opens, i.e., the greater the opening, the higher the vibration frequency. The hardness or, more importantly, brittleness, of objects could also possibly be determined by the sensing of rate of change of vibrations, i.e., vibration rate of change for a hard object like an egg is greater than that for a soft object like a paper cup. There have been no controlled studies as yet to verify these possible benefits.</p> <p>A variation of the principle has been applied in the laboratory to an electric arm orthosis tried by a C-4 lesion quadruplegic patient. The feedback motor is either clipped to the user's lapel (<a href="/files/original/8ae5ce0e382f544320be566569a2f206.jpg"><b>Fig. 4</b></a>) or to the back of his wheelchair.</p> <p>Another orthotic variation of the principle was tried in the laboratory by replacing the feedback motor with a flashlight-type light bulb to provide proportional visual feedback. Brightness of the bulb is proportional to pressure at the desensitized finger tips when used with an electrically-driven prehension orthosis.</p> <em><b>*James A. Reeve, B.S. (in E.E.) </b> Project Engineer, Orthotics &amp;Prosthetics, IRM, NYU Medical Center.</em><br /><br /><em><b>*Warren Frisina, B.E. (in M.E.) </b> Formerly Associate Research Scientist, Orthotics &amp;Prosthetics, Institute of Rehabilitation Medicine, NYU Medical Center</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 7 - 8 Year 1981 Volume 5 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Feedback For Electrically Powered Prostheses And Orthoses Creator An entity primarily responsible for making the resource Warren Frisina, B.E. (in M.E.) * James A. Reeve, B.S. (in E.E.) * https://staging.drfop.org/files/original/3ed6e858fb0862d7d2be1b23db392979.pdf 341e77544bf40d3db543a912bb5f0a44 https://staging.drfop.org/files/original/5bc396e4cedef13cf16a253eff163040.jpg ec592855cdba2557e088f78921c41388 https://staging.drfop.org/files/original/fdb6f406a2d352fb47a3cee9e8f38369.jpg 231b76d1408171ad64fae7742ecb2080 https://staging.drfop.org/files/original/7c0842c290468ef1fba4f4843d047f6e.jpg f826d6e153080c737808def1263cdd8b https://staging.drfop.org/files/original/e8a75b8ff67cee7bfa961096b4546fc2.jpg 1b87a973e8f3e3194184030a5e733712 https://staging.drfop.org/files/original/e9b74a814d560aa381bdccc572202d18.jpg 7e4403cff18523ddfb3120463a4be570 https://staging.drfop.org/files/original/ef75d0139e58c59e14d6dd35acdb17a2.jpg 70501d19f818f8d17d3b4ab798b5c8e3 https://staging.drfop.org/files/original/db9be3d7b4042ee252c02a83e44410f6.jpg 811f62d0d758421359d9516a636cc7f9 https://staging.drfop.org/files/original/9d40c9562a0fa9212368f1e2168e0414.jpg 2a71a8f8ae7d5478f89c2d59c2fd982b https://staging.drfop.org/files/original/79520afc4856b97de75b65ceca55ed6d.jpg c56d209e3cc0b131ddf0552ec40728ef https://staging.drfop.org/files/original/11938c318c7cf07237c990a66332d5e6.jpg e3023baa4d85b0b47a1f48737de7838c https://staging.drfop.org/files/original/b7f3d4881f3418405d87e322dad4c534.jpg 2d3c7a9b149b79c2b05043f12da68c06 https://staging.drfop.org/files/original/7f2f89a25a05551ade1e71a258885300.jpg 1c7361b6419e0d308961d5e58f72b6a2 https://staging.drfop.org/files/original/d8559825156298574f27b394d24be4e6.jpg 9c4e998131de15aafcc55e58721cf377 https://staging.drfop.org/files/original/251a6125624f21d3c3f26d9da96c3938.jpg 13d793d6f5c11a23a6232ac42f78aec2 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_073.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 73 - 87 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_073.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_073.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 III. The Treatment Process</h2> <h5>Warren P. Springer, M.A. <br /></h5> <p>The amputees who took part in the NYU Upper-Extremity Field Studies obtained their new prostheses through a treatment process characterized by seven clear-cut steps. These were preprescription examination, prescription, preprosthetic therapy (if indicated), fabrication of the prosthesis, initial checkout, training, and final checkout.</p> <p>The preprescription examination was conducted at the beginning of the treatment process in order to obtain information that would be useful in formulating the prescription and planning the entire treatment program for the patient.</p> <p>As for prescription, the research and educational program strongly encouraged the clinic-team approach, wherein the physician, as clinic chief, involved the prosthetist, the therapist, the patient, and frequently other individuals, such as the social worker or the vocational counselor, in the prescription process. The resulting prescription not only covered the strictly medicosurgical aspects of management but also specified the type of prosthesis and components that were to be used and the training the patient was to receive.</p> <p>The preprosthetic phase of treatment, when indicated, was directed toward providing the patient with the necessary strength and range of motion to operate his prosthesis and toward conditioning his stump for wearing it.</p> <p>In the fabrication process, the prosthetist, working with the patient, carried out the construction and fitting of the prosthesis in accordance with the specifications of the prescription.</p> <p>Initial checkout, which was done on a team basis, consisted of a systematic inspection and evaluation of the prosthesis to ensure that accepted standards of construction and function were achieved. This step was accomplished before the amputee received training and before he was permitted to wear his prosthesis for any extended period.</p> <p>Training consisted essentially of two parts—controls training and use training. The purpose of controls training was to develop the ability to open and close the terminal device, control prehension force, operate the wrist unit, interchange terminal devices, and, in the above-elbow cases, flex the prosthetic elbow and operate the elbow lock. Use training was designed to develop the ability to utilize the prosthesis in practical tasks related to daily-living activities and to occupational requirements.</p> <p>Final checkout was performed after the completion of training or after an initial period of wear. It paralleled initial checkout in that many biomechanical evaluation procedures were repeated to determine if wear had given rise to any difficulties or deficiencies. But in addition to the evaluation of the prosthesis itself final checkout also included an evaluation of training and of the amputee's ability to use the prosthesis at a practical level.</p> <p>This paper is primarily an account of the experiences and opinions pertaining to the treatment process as obtained from interviews with 359 adult, male amputees both at the beginning and at the end of their participation in the studies. The information concerning checkout and training is supplemented by clinical data from records of an additional 410 amputees who participated in clinical aspects of the study.</p> <p>The general characteristics of the research group of 359 amputees closely parallel those of the 1630 amputees in the survey group (Section II). Between the two groups there were no significant differences with respect to age, height, weight, marital status, cause of amputation, or strength and range of motion on the side of the amputation, although there were slight differences in educational level, in experience with arm prostheses, and in the relative frequency of below- and above-elbow types.</p> <p>In interpreting the data in this section, certain considerations should be kept in mind. First of all, a considerable portion of the information is based on the amputees' recollections of past events. The differences that may exist between the recollection of events and the events as they actually happened constitute a possible source of error. A second consideration has to do with the amputees' interpretations of the questions asked during the interviews, especially at the beginning of the study. Terms such as "clinic," "prescription," "checkout," "physical therapy," and "training" may have had widely varying meanings for different subjects. For example, a subject might have said that the prosthesis he was wearing at the beginning of the study had been subjected to a checkout when in reality it had been given only a cursory inspection instead of the systematic examination and evaluation that constituted a "checkout" in our meaning of the term.</p> <p>A third factor has to do with the number of amputees who were able to give meaningful responses to these questions. In some instances and for various reasons usable responses were not obtained from the entire group. In some cases questions were not answered. In most instances, however, classifiable responses were obtained from at least 80 percent of the group, and it seems reasonable that these responses are representative of the attitudes of the entire group.</p> <p>On the positive side, there is good reason to assign a considerable degree of importance to the opinions and reactions expressed by the subjects, since, in the last analysis, the amputee is the final judge of his prosthesis. The extent to which he accepts and approves of the process through which he obtains his prosthesis may have considerable bearing on the extent to which he accepts and uses the device.</p> <h3>Prescription</h3> <p>Prior to their participation in the research studies, only 17 percent of the amputees had ever received an arm that was prescribed by a clinic team (physician, limbfitter, and therapist). In the great majority of cases, decisions as to the type of limb and components had been made either on an individual basis by the limbfitter or the amputee or jointly by both limbfitter and amputee. Fifty-six percent of the amputees approved of this procedure, the most frequent reason (21 percent) given for approval being that they were consulted concerning their choice.</p> <p>In the group (44 percent) that did not approve of the preprogram procedure through which they had received a limb, 14 percent reacted negatively to the fact that they were not consulted. It was somewhat surprising to find that an additional 18 percent expressed the opinion that the amputee should not be consulted. Of the total group, 12 percent felt that the doctor should prescribe the prosthesis. Apparently a significant number of amputees prefer to trust the judgment of others in the matter of prosthetic replacement. Others (and the number probably increases with their prosthetic experience) prefer to become personally involved in the selection of components best suited to their needs.</p> <p>Since all of the prescriptions for the new prostheses and related treatments were arrived at on a clinic-team basis, the amputees were asked the following question to obtain their reactions to the team method of prescription: Do you think that prescription of a new arm by a clinic consisting of a doctor, limbfitter, and therapist is a good procedure? Ninety-four percent of the amputees answered in the affirmative. Compared to the mixed reactions concerning the preprogram procedures, the figure of 94 percent clearly indicates that the amputees preferred the new procedure. By far the most frequent reason given for this response was that the combined experience which could be obtained through the clinic procedure was useful. Typical comments were:</p> <blockquote><p>". . . more heads are better than one."</p> </blockquote> <blockquote><p>". . . experience of several people is helpful."</p> </blockquote> <blockquote><p>". . . no aspect is overlooked."</p> </blockquote> <p>Other reasons that were mentioned relatively frequently can be classified under these headings:</p> <blockquote><p>". . . prevents errors."</p> </blockquote> <blockquote><p>". . . team members act as a check on each other."</p> </blockquote> <blockquote><p>". . . amputee becomes involved in the prescription."</p> </blockquote> <p>Among the 6 percent who did not approve of the procedure, the most common reason offered was that:</p> <blockquote><p>"An old wearer knows what he needs."</p> </blockquote> <p>To obtain information on the parts the various clinic members played in prescription, the amputees were asked: Who was most influential in deciding the kind of arm you should havef The replies are summarized in the accompanying chart.</p> <h4>Terminal Devices</h4> <p>The next two charts show the relative frequency with which the various types of terminal devices were prescribed in the research study. For purposes of comparison, data on the hands and hooks that were being worn at the beginning of the study are included under the heading "Old Prosthesis."</p> <p>In interpreting the prescription data on hands and hooks, consideration should be given to the fact that it was a policy of the research program to encourage the prescription of APRL hands and hooks in order to obtain additional data for evaluation of these devices. This accounts for part, but by no means all, of the changes in terminal components of the old and the new prostheses. Other factors involved in the changes were related to an increasing tendency on the part of clinic groups to prescribe aluminum hooks and hooks with rubber or neoprene facings and to a natural interest in the possibilities of voluntary-closing terminal devices with their wide range of grasp forces. In the case of the APRL hand, the wide range of grasp forces was combined with improved appearance. This natural curiosity and interest in new devices is reflected in the increased use of the Sierra two-load hook also.</p> <h4>Wrist Units</h4> <p>The new prostheses showed a marked increase in the prescription of positive-locking wrist units with the "quick-change" disconnect. The chief reasons for this increase related to:</p> <ol> <li>Specific vocational or avocational indications for a positive lock to control rotation.</li><li>Prescription of both hand and hook for approximately four out of five subjects. A substantial majority of these cases required a wrist unit with a "quick-change" feature to facilitate interchange of hand and hook. (<b>Fig. 1</b>)</li></ol> <h4>Wrist-Flexion Units</h4> <p>There were only two wrist-flexion units on the old prostheses. Both cases were bilateral amputees. Twenty-two wrist-flexion units were prescribed in the research group. Ten were for bilateral amputees; six were for above-elbow, four for shoulder-disarticulation, and two for below-elbow amputees. (<b>Fig. 2</b>, <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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Below-elbow Hinges</h4> <p>A marked increase in the number of flexible hinges prescribed reflects the increased awareness of the value of utilizing residual rotation of the forearm stump whenever possible so that the need for pre-positioning the terminal device with the sound hand can be reduced or eliminated entirely. An additional advantage of flexible hinges is that they are less likely to damage the sleeves of the wearer's clothes.</p> <h4>Below-elbow Cuffs</h4> <p>Prescription for below-elbow cuffs showed a marked change toward smaller cuffs and elimination of straps. This change is a result of increased recognition of the desirability of providing a cuff large enough to give adequate stability and suspension but which would also have minimum bulk, would restrict motion as little as possible, and would give greater comfort.</p> <h4>Elbow Units</h4> <p>A guiding principle in the prescription of prosthetic elbow units for above-elbow and shoulder-disarticulation prostheses was that locking should be accomplished independently by controls attached to the harness, without recourse to operation of controls by the sound hand. The extent to which this principle was applied can be seen from the data, which show that all elbow units prescribed were harness-operated. This is a highly significant change from the data relating to the old prosthesis, which show that only 46 percent of the old elbow units were harness-operated.</p> <h4>Sockets</h4> <p>Practically all of the prescriptions for the new prostheses specified plastic laminate as the material to be used in fabricating the socket. The data on the socket material used in the old prostheses show that 37 percent were made of plastic, 28 percent were made of leather with a steel frame, and the remainder were made of fiber and metal, wood, or leather. Approximately four out of five of the new prostheses had double-wall sockets, as compared to less than one out of five of the old prostheses. Twelve percent of the old and 14 percent of the new below-elbow sockets were of the split-socket, step-up type in both the old and the new prostheses. (<b>Fig. 4</b>, <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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harnesses</h4> <p>The data on harnesses show a highly significant increase in the number of figure-eight harnesses prescribed for below-elbow and above-elbow cases with the new prostheses as compared with the old. The reasons for this increase are related to the favorable attitude of the program toward this simple type of harnessing, except for cases wherein heavy lifting was expected. Practically all of the shoulder-disarticulation amputees had chest-strap harnesses on both the old and the new prostheses.</p> <p>Vinyon tape was specified in 96 percent of the prescriptions for new prostheses, and cotton webbing or nylon or dacron tape were prescribed in the remaining 4 percent. (<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>In the old prostheses, 83 percent of the harnesses were made of cotton webbing, 8 percent were of leather, and the remaining 9 percent were made of vinyon or nylon tape. The marked shift to the use of vinyon tape was due primarily to the presumably superior characteristics attributed to vinyon with respect to dimensional stability, washability, fraying, and resistance to bacteria and fungi.</p> <h4>Control Systems</h4> <p>All of the prescriptions for new prostheses called for the use of the Bowden cable in the control system. In the old prostheses, 58 percent utilized Bowden cable; the remainder utilized nylon cord, leather, or steel cable without a housing. The change to Bowden cable was effected to take advantage of its higher efficiency in transmitting forces.</p> <h3>Preprosthetic Therapy</h3> <p>Four out of ten subjects said they had received treatment by some form of exercise or other physical therapy prior to their entrance into the study. The same proportion of the group indicated that their stumps had been bandaged to bring about shrinkage.</p> <p>In response to the question, Do you think these [preprosthetic] treatments were helpful?, 79 percent replied in the affirmative and offered the following reasons (in order of decreasing frequency): increased strength, increased range of motion, helped stump shrinkage, reduced pain, improved function, reduced flabbiness.</p> <p>During the course of the research studies, preprosthetic exercise or other physical therapy was prescribed for 13 percent of the amputees treated. That only a relatively small proportion of the subjects received preprosthetic treatment is accounted for by the fact that most of the amputations occurred quite some time before the amputees participated in the program. In most cases, treatment consisted primarily of exercise to increase strength and range of motion of the stump. Other physical-therapy measures, such as diathermy, massage, and hydrotherapy, accounted for a relatively small proportion of treatments. Almost all of the subjects indicated that treatment was received daily. (<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>Seven percent of the amputees had their stumps bandaged to cause shrinkage. About two thirds of this small group indicated that bandaging had been continued over a period of 4 to 12 weeks; the remainder of the group said that bandaging had been continued for more than 12 weeks.</p> <p>Of those who did receive preprosthetic treatment, 88 percent considered the treatments helpful. The reason given most frequently was that the treatments increased strength and range of motion. About one out of five subjects mentioned stump shrinkage as the chief beneficial effect.</p> <h3>Initial Checkout</h3> <p>With reference to arms worn prior to entrance into the program, the subjects were asked: Was your arm checked for fit, comfort, and function before it was delivered to youf Four out of five indicated that their prostheses had been subjected to some form of initial checkout or evaluation, even though this was not done on a formal basis. One third of this group said that the limbfitter had made the check. Thirteen percent designated the physician as having made the check, and 9 percent said the check was made at the hospital. The others did not provide specific information as to who performed the checkout or evaluation.</p> <p>A basic principle guiding operations in the Field Studies was that the amputee would not be permitted to wear his new prosthesis or proceed to training until initial checkout had been passed successfully. If deficiencies were encountered that would interfere with wear or training, recommendations for correction were made, and the amputee was scheduled to appear again so that initial checkout could be completed.</p> <p>Several factors serve to explain why a relatively large proportion of amputees had to appear before the clinic two or more times in order to pass initial checkout. One is that the checkout procedure proved to be highly effective in directing attention to the necessary corrections and adjustments in individual components and to the prosthesis as a whole. A second related to the relatively high and rigid standards established by the checkout procedure. A period of time was generally required before the prosthetic experience necessary to meet these standards was gained. The relatively greater frequency with which above-elbow and shoul-der-disarticulation amputees failed to pass initial checkout on the first appearance, as compared to below-elbow amputees, was for the most part due to difficulties in harnessing. In addition, the relatively small number of shoulder disarticulations seen meant that it took correspondingly longer to obtain substantial experience in their fitting and harnessing. (<b>Fig. 10</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>While a majority of prostheses passed initial checkout on the first presentation, this does not mean that no deficiencies were found at initial checkout in these cases. More often than not, a number of minor deficiencies were found, which resulted in a "provisional pass" rather than a "pass." When a provisional pass was given, recommendations were made for correction of the minor deficiencies found. When the amputee reported for his first training period, a check was made to see that the recommended changes had been effected.</p> <p>Among the below-elbow subjects, the most frequent deficiencies found at initial checkout were in connection with sockets. With above-elbow amputees, the deficiencies found most frequently were in connection with harnessing. The fewest deficiencies were encountered with wrist units. The charts show the order in which the various components ranked according to the number of deficiencies found.</p> <p>The amputees taking part in the study were asked: Do you think it was worth while that the new arm was checked for fit, comfort, and function before it was delivered to you? Ninety-four percent of the replies were yes. The most common reasons given for these replies were:</p> <blockquote><p>". . . to correct and prevent problems."</p> </blockquote> <blockquote><p>". . . provides a check on fit."</p> </blockquote> <blockquote><p>". . . provides a check on comfort."</p> </blockquote> <blockquote><p>". . . provides a check on prescription."</p> </blockquote> <p>Some of the comments of those few who did not think it was a good procedure were:</p> <blockquote><p>". . . made no necessary changes to arm."</p> </blockquote> <p>". . . am intelligent enough to decide for myself if it is comfortable."</p> <blockquote><p>". . . could be checked out at limbshop."</p> </blockquote> <blockquote><p>". . . had to wear it first to see if anything was wrong."</p> </blockquote> <h3>Training</h3> <p>The data pertaining to previous training showed that 42 percent of the amputees had received prosthetic training sometime prior to the beginning of the study. Eighty-nine percent of this group expressed the opinion that this training was helpful. Three fourths of the amputees who received no previous training said they thought training would have been helpful, while the remaining fourth thought it would have been of no use.</p> <p>Data obtained from the clinical studies showed that 81 percent of the subjects received training, that 14 percent received no training, and that owing to incomplete records the training status was indefinite for the remaining 5 percent. Among the amputees who received no training, the most common reasons offered were: the amputee had worn a prosthesis before and previous training was considered adequate; the amputee passed the prosthetic-use test without training; the amputee declined training. (<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 /> <p>In response to a query concerning the value of prosthetic training, four out of five amputees replied in the affirmative. Among the most frequent reasons given for the affirmative answer were:</p> <blockquote><p>". . . training gives an idea of what can be done with the prosthesis."</p> </blockquote> <blockquote><p>". . . learned mechanical operation of components."</p> </blockquote> <blockquote><p>". . . expedited use of arm."</p> </blockquote> <p>Of the group who did not believe that training was valuable, there were proportionately twice as many below-elbow as above-elbow amputees. They offered such comments as:</p> <blockquote><p>". . . using an arm is easy."</p> </blockquote> <blockquote><p>". . . training was not well organized."</p> </blockquote> <blockquote><p>". . . I would rather learn my own way."</p> </blockquote> <blockquote><p>". . . amputee was left on his own too much."</p> </blockquote> <blockquote><p>". . . training helped very little."</p> </blockquote> <blockquote><p>". . . training was not long enough "</p> </blockquote> <p>In response to the question, Do you believe the training you were given in the use of your new prosthesis could be improved?, 41 percent answered in the affirmative. About one fourth of those who answered in the affirmative expressed the opinion that there should be more training in activities of daily living. An equal number thought that more time was needed. Among the group that expressed the opinion that more time was needed there were more than three times as many above-elbow amputees as there were below-elbow amputees.</p> <p>Other suggestions for improvement of training were:</p> <blockquote><p>". . . there should be more enforced training."</p> </blockquote> <blockquote><p>". . . provide a training manual which would allow the amputee to practice at home."</p> </blockquote> <blockquote><p>". . . adapt training to occupational needs."</p> </blockquote> <blockquote><p>". . . there is not enough supervision of training."</p> </blockquote> <p>The total training time for an individual amputee ranged from half an hour to 99 hours, but more than nine out of every ten amputees received less than 20 hours of training. Except for bilateral amputees, more than eight out of every ten amputees received 10 hours or less of training. The average number of hours of training for each amputee type is based on the great majority of amputees (94 percent) who required less than 20 hours of training. Of the small remaining group of amputees (6 percent), one half received from 21 to 30 hours of training; the other half received from 30 to 99 hours. It must, however, be emphasized again that the larger part of this group had had previous prosthetic experience. (<b>Fig. 12</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>The average length of individual training sessions for the amputees in the clinical studies was one hour and forty minutes. There was no significant difference in the figures for below-elbow, above-elbow, shoulder-disarticulation, and bilateral amputees. For almost 50 percent of the amputees, the length of the individual sessions was one hour.</p> <p>In reply to the question, Did any difficulties arise in connection with the operation or comfort of your new prosthesis during training or the initial period of use?, 54 percent of the amputees replied in the affirmative. Among the below-elbow subjects, the socket was the most frequent source of difficulties relating to fit and comfort, while among the above-elbow group the harness constituted the major source of trouble. With respect to function, operation of terminal devices and the control system were the most troublesome. The control system was the most common source of difficulty with respect to maintenance.</p> <h3>Final Checkout</h3> <p>Prior to participation in the Field Studies, less than 30 percent of the amputees had had their prostheses rechecked for fit, comfort, and function after the period of initial wear or training. In accordance with the procedures</p> <p>described in Section I, all prostheses in the Field Studies were subjected to final checkout after the completion of training or the initial period of wear. At this time not only was the prosthesis given a systematic and thorough inspection and evaluation but, in addition, an appraisal was made of the patient's ability to use the prosthesis, and a careful examination was made to see if there were any medical or surgical problems that might interfere with successful wear and use. Clinics considered that an amputee had "passed" final checkout only when there were no further surgical, medical, or prosthetic problems of any kind that required attention.</p> <p>Sixty percent of the prostheses passed final checkout on first presentation, 26 percent passed on second presentation, and 14 percent required more than two appearances to pass final checkout. This compares with 69 percent, 24 percent, and 7 percent, respectively, for initial checkout.</p> <p>The decrease in the number of prostheses that passed final checkout on first presentation, as compared with initial checkout, was due chiefly to the results of wear of the prosthesis, the emphasis on the amputee's ability to use the prosthesis, the apparent need for additional training, and the need for modifications which had been overlooked at the initial checkout or on which judgment had been withheld until the effect of wear could be determined. The actual number of deficiencies found at final checkout was, however, smaller by far than the number at initial checkout. Among the below-elbow amputees, the total number of deficiencies recorded at final checkout was only 339 as compared with 801 at initial checkout. The corresponding figures for above-elbow amputees were 358 at final checkout and 970 at initial checkout. These figures show clearly that the prostheses were far better at final checkout than they were at initial checkout, even though it took a little longer to get through the checkout procedure. (<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 /> <p>As was the case at initial checkout, the difficulties found most frequently at final checkout were related to socket fit for the below-elbow amputee and to harnessing for the above-elbow amputee. The fewest difficulties were encountered in relation to wrist units. The order in which various components ranked according to the number of deficiencies found is to be seen in the combined data for initial and final checkout.</p> <p>The effects of wear and use were to be seen in the continued difficulties with fit and comfort of the below-elbow socket at final checkout and also in the relative increase in deficiencies encountered with terminal devices. The more common deficiencies in the latter case were related to malfunctions of hand or hook, staining of or damage to the cosmetic glove, and excessive backlash with voluntary-closing devices.</p> <p>At both checkouts, deficiencies of the elbow unit rank fairly high on the list. Analysis indicates, however, that most of these difficulties were not with the internal mechanism but rather with other factors such as adjustment of the harness and control attachments that activate the elbow lock.</p> <p>In response to the question, Do you think it was worth while that your arm was rechecked for fit, comfort, and function after training and initial period of wear?, 90 percent of the replies were in the affirmative. The most frequent reason for this reply was that the recheck permitted problems to be corrected. Typical comments were:</p> <blockquote><p>". . . gives an opportunity to correct problems after wear."</p> </blockquote> <blockquote><p>". . . experts can see difficulties better."</p> </blockquote> <blockquote><p>". . . it is important to find out if arm still functions properly."</p> </blockquote> <blockquote><p>". . . it provides a general check."</p> </blockquote> <h3>Summary</h3> <p>The amputees' experience in the field-studies program differed quite markedly from their previous prosthetic experience with respect to prescription and final checkout. Prior to their participation in the study, less than one out of five had ever had a prosthesis that was prescribed by a clinic team, and less than one third had had their previous prostheses subjected to a final comprehensive checkout. (<b>Fig. 14</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>The differences with respect to preprosthetic treatment, initial checkout, and training were less marked. Relatively fewer amputees received preprosthetic treatment in connection with the new prostheses than was the case in connection with the prostheses that were being worn at the beginning of the study. This, of course, can be accounted for by the lessened need for these services with increased prosthetic wear.</p> <p>Although a substantial majority of the amputees said that their previous prostheses had been subjected to some form of initial checkout or evaluation, these had not been done on any formal or systematic basis and had in general not involved the application of standards of acceptance.</p> <p>Forty-two percent of the amputees who had worn a prosthesis prior to the beginning of the study had received training in its use, although the nature or extent of this training is not clear from the data. More than eight out of ten subjects received training with the prostheses obtained in the research program.</p> <p>Amputee opinion pertaining to the treatment process, as indicated by the data gathered, was for the most part strongly in favor of the new procedures. Ninety-four percent of the amputees approved of the team method of prescription. Eighty-eight percent of those who received preprosthetic treatment said the treatments were helpful. Ninety-four percent were of the opinion that initial checkout was worth while.</p> <p>Four out of five amputees were of the opinion that the training they received in the use of their prostheses was valuable. But 41 percent of the group thought that training could be improved. The most frequent suggestions for improvement were to increase the amount of training time and the amount of training in meaningful activities of daily living.</p> <p>The final checkout to which all of the prostheses in the research studies were subjected was particularly comprehensive and designed to uncover any medicosurgical, prosthetic, training, or other factors that might interfere with successful wear and use. Nine out of ten amputees were of the opinion that this procedure was worth while.</p> <p>All in all, the treatment process inaugurated as part of the studies was considered valuable and achieved a high degree of amputee acceptance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <br /> Figure 1 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-46.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-47.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-48.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-49.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-50.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-51.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-52.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-53.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-54.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-55.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-56.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-57.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-58.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-45.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 III. The Treatment Process Creator An entity primarily responsible for making the resource Warren P. Springer, M.A.  https://staging.drfop.org/files/original/593a03bd32e0a38628a533eb480e570b.pdf 7b1c18e73ced8fe84e9ce8c8c1551759 https://staging.drfop.org/files/original/7abfc3f82f27d4cae4864fbc83eaa7ca.jpg 51ff09f2f28f7f856979e6a6880eb923 https://staging.drfop.org/files/original/38ff763dad0b8d9e9954644067509495.jpg bd3bf6528c0085cc6aec3c8e955cb979 https://staging.drfop.org/files/original/f8e2a31c0bd3f95b729300ee8c9879cc.jpg 28b176e97650c170308ba1a969fc1571 https://staging.drfop.org/files/original/f562a9fa3c3f94727515c29bd75cc559.jpg ef14a7b5fad4b0c30065f491fcc01227 https://staging.drfop.org/files/original/6952f83ebe300a2539999786a8831c6a.jpg 3a2eea97c038487eeb84b84f6f4c61c8 https://staging.drfop.org/files/original/a314d14c2a1d04870c0d8d62a4925f3e.jpg fa6737f21ac8c44366271c5a592814ec https://staging.drfop.org/files/original/32544d213596bd32eea634e714494839.jpg 41c5aef37e93e2a99658b953ffde267b https://staging.drfop.org/files/original/95627bf9ee488969ba0a0130899f6d6b.jpg 5ca5658e1c297471c234c6713c8746de https://staging.drfop.org/files/original/e48666013dc08eecebb3d1cb7fe5473f.jpg 3d05ef9c7dd1ba2645c171d070eb7714 https://staging.drfop.org/files/original/45a501b0f715878b320272e655015f75.jpg 93ea84bf6b4d4429ef22f77912316288 https://staging.drfop.org/files/original/5ee12f7068fd98808db19c82e6b00c57.jpg 930d382e602d78a03a66fab3ed2e7f66 https://staging.drfop.org/files/original/313f5c71cdce0cf79795463dcc4a01e4.jpg b50b7f4e4974f517055a27ac650ed7d3 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_201.pdf Text Any textual data included in the document <h2>The Team Approach to Orthotic Management in Quadriplegia</h2> <h5>Wayne R. Rosen, CO.&nbsp;<a style="text-decoration: none;">*</a><br />Janie J. McColey, O.T.R.&nbsp;<a style="text-decoration: none;">*</a><br />John H. Bowker, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This article presents the approach to orthotic intervention in quadriplegia taken at the University of Miami/Jackson Memorial Rehabilitation Center. To begin, it must be emphasized that quadriplegia implies not only loss of walking, but also loss of normal use of the hands. Since our hands are the tools with which we sustain life, a major goal of rehabilitation must be to restore the ability to independently carry out common activities of daily living such as feeding, grooming, and manipulation of devices which may allow resumption of educational and vocational goals.<a></a> As health care professionals in the rehabilitation field, we must be aware of advances in technique and equipment which can enhance the ever-increasing life span of this young population whose educational, economic, and social progress has been so severely curtailed.<a></a> The role of the orthotist and occupational therapist as members of the rehabilitation team is to address this very underemphasized problem of upper limb management.</p> <p>When the spinal cord team is first asked to evaluate and treat a newly injured quadriplegic patient, they must take into consideration all aspects of care, not just those in their individual areas of specialization. During the acute medical phase, the emphasis is on preserving life and preventing further neurological damage. At this stage, there is little concern for joint positioning or splinting. After life-threatening problems have been addressed, however, prompt management of the upper limbs is of primary importance if we are to avoid joint stiffness and/or deformity which would interfere with the progression of rehabilitation.<a></a> This approach to the upper limbs involves a number of basic methods: frequent joint range of motion, limb positioning with and without positioning devices (temporary and permanent), dynamic orthoses (temporary and permanent), and externally powered orthoses. In our facility, spinal cord injured patients are initially placed on Roto-Rest beds. These beds, with their continuously alternating side-to-side motion, have proven to have a positive effect on the respiratory, renal and circulatory systems, as well as providing skin protection for the S.C.I. patient.<a></a> There is, however, potential for loss of glenohumeral and scapular mobility with its use for extended periods. We have currently adapted the bed so as to allow positioning of the shoulders in abduction and external rotation, alternating with the usual adduction and internal rotation. This change of shoulder position has been included in our regular routine of joint range of motion and should reduce the pain and stiffness that often interferes with arm placement and coordination.<a></a> Elbow flexion-forearm supination deformity is another potential problem, especially in C5 quadriplegics.<a></a> This may be managed by positioning the elbow in extension and pronation between range of motion sessions. The use of thermoplastic elbow-extension splints (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg"><b>Fig. 1</b></a>), bivalved casts (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg"><b>Fig. 2</b></a>), or serial casting (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg"><b>Fig. 3</b></a>), will assist the therapist in maintaining proper position. Functional hand position should be maintained with the use of a resting hand splint (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg"><b>Fig. 4</b></a>) or a functional long opponens splint with C-bar and lumbrical bar (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg"><b>Fig. 5</b></a>), to avoid the development of a flat "simian" hand.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg"><strong>Figure 1. Elbow Control Orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg"><strong>Figure 2. Bivalved plaster cast.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg"><strong>Figure 3. Serial casting (Plaster of Paris).</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg"><strong>Figure 4. Thermoplastic resting splint.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg"><strong>Figure 5. Long opponens with MCP extension stop.</strong></a><br /> <p>Once the patient is medically stable, he is able to begin a more active phase of rehabilitation, including the use of functional orthoses, if appropriate. His response to this whole process depends largely on the success of the first few days, which in turn depends on how the treatment team constructs the patient's first experiences of sitting, trunk balancing, and functional arm placement. Only when control of these factors is satisfactory will it be appropriate to introduce orthoses for function. This becomes a critical point in time for the patient and therapist, because two possible approaches to future functional activities exist. The first approach is based on the use of adaptive devices which will allow some patients to perform specific functions such as self-feeding and oral-facial hygiene. However, it is our feeling that even at this early stage, multipurpose temporary functional orthoses must be introduced if definitive orthoses are to play a useful part in the patient's life. Therapists should be prepared to fabricate and properly fit a training orthosis, which will allow the patient reasonable options in developing his functional goals.<a></a></p> <p>The following chart provides guidelines for management techniques according to the level of remaining neurologic function. Many of the orthotic options listed in the "Recommended Management" column are from the N.Y.U. Upper Extremity Orthotics Manual.<a></a></p> <p><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-07.jpg"><b>Chart</b>, <b>Chart (cont'd)</b></a></p> <p>The guidelines listed above have been generally accepted throughout the world as the rational basis for orthotic intervention. The following variables, however, must receive equal consideration before an orthosis can be successfully fit to a patient.</p> <p><i>Locality</i></p> <p>The patient should reside not only reasonably close to a facility capable of adjusting his orthosis, but should have accessible transportation available if a problem arises.</p> <p><i>Cost</i></p> <p>Sufficient funds must be allocated to cover not only the initial cost of the orthosis prescribed but also maintenance and replacement as necessary.<a></a></p> <p><i>Gadget Tolerance</i></p> <p>The patient must have the patience to don and doff the orthosis or he will discard it because it "takes too long to apply." He may then actually prefer to sacrifice his independent performance of intricate manual tasks by either choosing a less effective piece of adaptive equipment or relying on another person for assistance. We, as practitioners, must monitor the attitude of a candidate to be sure that the function of the orthosis will be greater than the perceived inconvenience of wearing it.<a></a></p> <p><i>Dominance</i></p> <p>The hand preferred prior to injury for writing and activities of daily living will usually be maintained as the dominant hand. This hand should be fit initially and the patient's progress monitored with specific activities before fitting the nondominant hand. Specific activity usage will determine whether or not the second orthosis is indicated.<a></a></p> <p><i>Vocation/Avocation</i></p> <p>The patient's ability to perform fundamental activities of daily living is basic to maximum restoration, but it is equally important to determine additional intended uses of the orthosis, both vocationally and avocationally (i.e., manual work, desk work, telephone answering services). These data will help determine the type of materials suitable for fabrication or even the type of orthosis that would best suit the individual's needs.<a></a></p> <p><i>Psychological/Familial Roles</i></p> <p>Assessment of the patient's psychological status is vital in establishing a treatment plan. Psychological make-up of the individual can play a very large role as to whether or not the patient will accept an orthosis. In this regard, cosmesis may play as important a role as function when dealing with a person's already altered body image. Psychological intervention is necessary to assist the patient through the stages of denial, anger, and depression to final adaptation. Indeed, the team members may need help in dealing with their own value systems regarding quality of life in relation to long term disability.</p> <p>The personalities of the patient and family members, as well as those of the orthotist and occupational therapist, play important roles in rehabilitation after a spinal cord injury. An air of confidence emanates from professionals who are comfortable and confident with the task at hand. This confidence can be passed on to the patient, who will in turn become comfortable and confident with the orthosis being fitted. Too often, however, therapists and orthotists are not comfortable with the intricacies of fabricating upper limb orthoses, leaving the patient at a disadvantage as he begins his rehabilitation process, in that he may not be made aware of all the options available, but rather only those preferred by the professionals. Therefore, it is necessary to assemble a team of practitioners who are well versed in all aspects of their respective specialties so as to not hinder the patient in an already stressful situation. Family support is also extremely important as a reinforcement of professional recommendations. Clear, concise instructions should be given to the patient and family members in order to increase the effective use of the orthosis.<a></a></p> <p><i>Economics</i></p> <p>Since most orthotists in private practice cannot afford the luxury of skill maintenance for the small part of orthotic practice represented by upper limb orthotics, the majority of these devices are being made in an institutional setting, where an orthotist and occupational therapist on staff service the needs of quadriplegics. More time and energy can then be devoted, with less concern for monetary return, to fabrication and fitting of a complex device such as a wrist-driven prehension orthosis. Being on-site means quicker response time to the patient with no travel time for the practitioner, which also means that more time can be spent actually working with the patient as the need for adjustment arises. The expertise afforded by a qualified and skilled team of practitioners to the patient can only help an already trying and difficult situation.<a></a></p> <p>Through a team approach to orthotic evaluation of the spinal cord injured patient, the best orthosis for that individual should be provided. That does not necessarily mean the most complex or expensive orthosis. It means that, given a specific clinical picture, an orthosis is chosen based on all the factors previously discussed. The purpose of setting standards and guidelines is to increase the success rate of our patients, in allowing them every opportunity to return to a meaningful lifestyle. When this occurs, we as practitioners have done our job and can consider the input of our specialty a success. Conversely, our failures have a negative effect on both the patient and the practitioner. For the patient, it becomes a setback in that his hospital stay may be extended or, more importantly, the potential for independence may be lost because of rejection of the orthosis. For the practitioner, it may be not only a time of second-guessing, but a learning experience at the patient's expense.</p> <p>Our approach to fitting of functional orthoses is as follows. All candidates for wrist driven prehension orthoses are initially fitted by the occupational therapist with a temporary training orthosis, namely the Rehabilitation Institute of Chicago (R.I.C.) tenodesis splint (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg"><b>Fig. 6</b></a>). The patient then trains for a period of time determined by the therapist. Once he has mastered this device, he can be fit by the orthotist with a definitive orthosis. The choice at our facility is the Engen wrist-driven prehension orthosis (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg"><b>Figure 7</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg"><b>Fig. 8</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg"><b>Fig. 9</b></a>). We feel this device best suits our needs because of ease of fit, adjustability, and cosmesis.<a></a> The occupational therapist trains the patient to use his orthosis for activities of daily living, including the important function of self-catheterization of the bladder.<a></a> By virtue of thorough training, we feel the acceptance rate of orthoses is increased.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg"><strong>Figure 6. R.I.C., Tenodesis (temporary) splint with wrist extended and fingers apposed.</strong></a><br /><strong><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg">Figure 7. Wrist-driven prehension orthosis with wrist in neutral position and fingers open-Ranchos Los Amigos type.</a></strong><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg"><strong>Figure 8. Wrist-driven prehension orthosis with wrist extended and fingers apposed-Engen type.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg"><strong>Figure 9. Wrist-driven prehension orthosis (Modified N.Y.U.-I.R.M. system).</strong></a><br /> <p>Unfortunately, our success rate with the Externally Powered Prehension Orthosis (EPPO) has not been as favorable as that of the wrist driven type (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg"><b>Fig. 10</b></a>). Two-thirds of all EPPOs that have been fit at our institution have not been used long-term. The feedback from our patients is that they were trained throughout the long rehabilitation process to adapt with the aid of special equipment and then, just prior to discharge, given a brace to replace the adaptive equipment. The patient who spent four to six months in the rehabilitation facility would have perhaps a week to learn to function with his new orthosis. It is hardly surprising that, in most cases, the orthosis was discarded in favor of the adapted equipment with which they were familiar. The problem has been, that for high cervical injuries, a training version of an externally powered prehension orthosis does not exist. This problem could be solved by development of a training EPPO in which the components could be reused on different patients. The only parts of the orthosis that would need to be custom-made would be the hand shells. The cost to the patient for these would be minimal and in the long run we could save the patient the cost of a very expensive "closet trophy" if he proved to be a poor candidate. We have initiated this project as a joint effort of the Occupational Therapy Department and the Department of Orthotics.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg">Figure 10. Externally powered prehension orthosis.</a><br /></strong><br /> <h3>Summary</h3> <p>The fabrication and fitting of functional upper limb orthoses in quadriplegia requires close team work, especially between the orthotist and occupational therapist if the ultimate goal of acceptance of the orthosis as a useful aid to activities of daily living is to be achieved. We feel strongly that quadriplegics with wrist extensors should be fitted early with a functional training orthosis rather than supplied with activity-specific adaptive equipment. A confident, caring attitude on the part of the occupational therapist and orthotist can also do much toward achieving this goal. For quadriplegics with shoulder and elbow motion but no wrist extension, a training version of an externally powered prehension orthosis is badly needed for evaluation prior to ordering a definitive device. Success in the fitting of complex orthoses such as these requires almost unlimited "gadget-tolerance" on the part of the practitioner, if not the patient. The ultimate professional responsibility is to be equipped with both the manual skills and the objectivity to introduce all available options to our patients for their acceptance or rejection.</p> <p><b>References:</b></p> <ol> <li>Abrahams, D., R.D. Shrosbree, and A.G. Key, "A Functional Splint for the C5 Tetraplegic Arm," <i>Paraplegia</i>, 17:2, July, 1979, pp. 198-203.</li> <li>Allen, V.R., "Follow-up Study of Wrist-Driven Flexor-Hinge-Splint Use," <i>The American Journal of Occupational Therapy</i>, 25:8, 1971, pp. 420-422.</li> <li>Becker, D., M. Gonzalez, G. Amilcare, F. Eismont, and B. Green, "Prevention of Deep Venous Thrombosis in Patients with Acute Spinal Cord Injuries: Use of Rotating Treatment Tables," <i>Neurosurgery</i>, 20:5, 1987, pp. 675-677.</li> <li>Berard, E., J. Depassio, N. Pangaud, and J. Landi, "Self Catheterization: Urinary Complications and the Social Resettlement of Spinal Cord Injured Patients," <i>Paraplegia</i>, 23, 1985, p. 386.</li> <li>DeVivo, M.J., P.R. Fine, H.M. Maetz, and S.L. Stover, "Prevalence of Spinal Cord Injury: A Re-estimation Employing Life Table Techniques," <i>Archives of Neurology</i>, 37, 1980, pp. 707-708.</li> <li>Eisenberg, M.G. and D.O. Tierney, "Changing Demographic Profile of the Spinal Cord Injury Population: Implications for Health Care Support Systems," <i>Paraplegia</i>, 23, 1985, pp. 335-343.</li> <li>Fishman, S., et al., <i>The Upper Extremity Orthotics Manual</i>, New York University Post-graduate Medical School.</li> <li>Lamb, Jr., C.R., A.J. Booth, and M.E. Godfrey, "Flexor Hinge Splint: Modification to Allow Radial Deviation," <i>Archives of Physical Medicine and Rehabilitation</i>, 55, July, 1974, pp. 322-323.</li> <li>Meyer, C.M.H., R.D. Shrosbree, and D.L. Abrahams, "A Method of Rehabilitating the C6 Tetraplegic Hand," <i>Paraplegia</i>, 17, 1979-80, pp. 170-175.</li> <li>Nichols, P.J.R., S.L. Peach, R.J. Haworth, and J. Ennis, "The Value of Flexor Hand Splints," <i>Prosthetics and Orthotics International</i>, 2, 1978, pp. 86-94.</li> <li>Patterson, R.P., D. Halpern, and W.G. Kubicek, "A Proportionally Controlled Externally Powered Hand Splint," <i>Archives of Physical Medicine and Rehabilitation</i>, 52:9, September, 1971, pp. 434-438.</li> <li>Spieker, J.L. and B.J. Lethcoe, "Upper Extremity Functional Bracing: A Follow-Up Study," <i>The American Journal of Occupational Therapy</i>, 25:8, 1971, pp. 398-401.</li> <li>Stauffer, E.S. and V.L. Nickel, "Control Systems for Upper Extremity Function in Traumatic Quadriplegia," <i>Paraplegia</i>, 10, 1972, pp. 3-10.</li> <li>Yarkony, G.M., L.M. Bass, V. Keenan, III, and P.R. Meyer, Jr., "Contractures Complicating Spinal Cord Injury: Incidence and Comparison Between Spinal Cord Centre and General Hospital Acute Care," <i>Paraplegia</i>, 23, 1985, pp. 265-271.</li> <li>Zrubecky, G. and M. Stoger, "The Orthosis for Restoration of Prehensile Function in Tetraplegics," <i>Paraplegia</i>, 11, 1973, pp. 228-237.</li> </ol> <em><b>*John H. Bowker, M.D. </b> John H. Bowker, M.D., is Professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami School of Medicine and Medical Director of the University of Miami/Jackson Memorial Rehabilitation Center in Miami, Florida.</em><br /><br /><em><strong>*Janie J. McColey, O.T.R.,</strong> is the Supervisor of Occupational Therapy, Spinal Cord Unit at the University of Miami/Jackson Memorial Rehabilitation Center in Miami.</em><br /><br /><em><b>*Wayne R. Rosen, CO. </b> Wayne R. Rosen, CO., C.P.E.D., is Chief Orthotist, Department of Prosthetics and Orthotics at the University of Miami/Jackson Memorial Rehabilitation Center, 1611 N.W. 12th Avenue, Miami, Florida 33136.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 201 - 209 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg Figure 6 CHART http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-07.jpg CHART CONT. http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-08.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg Figure 9 FIGURE 8 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg Figure 10 FIGURE 9 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg Figure 11 FIGURE 10 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Team Approach to Orthotic Management in Quadriplegia Creator An entity primarily responsible for making the resource Wayne R. Rosen, CO. * Janie J. McColey, O.T.R. * John H. Bowker, M.D. * https://staging.drfop.org/files/original/0833619f5e725925cd800c92714e217a.pdf f8cc7a22aa74728474f8dd18a422e13a https://staging.drfop.org/files/original/93b6e8e78d28f3a4b19219d5d0780629.jpg 04cc15ee28e53828d5d326dd88090b20 https://staging.drfop.org/files/original/345e28e78e61de9956f328db53407a53.jpg cc7d3094bd8e533f530e57c763d89156 https://staging.drfop.org/files/original/912b1afa69cacdf58a67897a83dcb315.jpg 7d3276d165a85f49bcaa170b6d63d8c2 https://staging.drfop.org/files/original/a336421d18e76b67aa3f15362a01a722.jpg 5424cf6316a027878c7cc16d28562dcd https://staging.drfop.org/files/original/ed019ac44a487f5a4d063bc3257f6613.jpg e0c695cdd2bdf121fba9bca5e8ec4b72 https://staging.drfop.org/files/original/6f79e7026b83de4890fedbf81936bf61.jpg 8829aadb1e7bf6c1a2f5b7ef81380d25 https://staging.drfop.org/files/original/f12ba0f6a5db975123a05a0ecc61bf8c.jpg d49c7e19a6ae87c07570043983a8154b https://staging.drfop.org/files/original/8111a6f2f5c9866102adc00d9369ba3a.jpg b550bebd56a8d3d8b5c4622eb2bfb636 https://staging.drfop.org/files/original/6f66c873f335c178a868bb081b408a99.jpg fee6486ffc1b68ab2e75eb9e394bfca2 https://staging.drfop.org/files/original/1e33291187b5f81e97bd34ef54e5ea18.jpg 0b0317c0877ceedfc4841a2f6b45464d https://staging.drfop.org/files/original/6d31a1a5146ef36443a7083f8fe0dce2.jpg 0e19dfad8f02ba4aba2378536fcc1854 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_067.pdf Text Any textual data included in the document <h2>Soft Molded Sandals for Insensitive Foot Care</h2> <h5>William C. Coleman, D.P.M.&nbsp;<a style="text-decoration: none;">*</a><br />Arthur Plaia, M.A.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In the United States, the most common cause of sensory loss on the foot is diabetes. Fifty to seventy percent of all non-traumatic amputations in this country are performed on diabetics.<a></a> In Atlanta, Georgia, the amputation rate was lower by half after a program of foot inspection, footcare, and shoe-fitting was instituted.</p> <p>A person with loss of sense of touch and pain in the feet should never walk barefoot. A single step on a sharp object or hot surface with bare feet often results in permanent loss of foot function or eventual amputation of the foot.</p> <p>A comprehensive program of medically-prescribed, therapeutic footware should address the patient's need for appropriate shoes at all times. Once the need for prescribed footwear has been identified, there is a period between the time the prescription is written and time when the definitive shoes are dispensed to the patient. During that period, the feet still need protection. A form of protective, temporary footwear, needs to be worn by the patient until those shoes are ready. There are a wide variety of devices used for this purpose around the country. The form of these devices is largely dependent on the available facilities and footwear expertise.</p> <p>A person with a plantar ulcer on an insensitive foot should never walk in shoes or sandals. The most important therapeutic consideration for a person with no sense of pain is to control the mechanical stresses during the healing of these wounds.<a></a> Shoes and sandals do not provide enough control over these forces.</p> <p>After a wound has been covered completely by skin, the healing and repair of the injury is not complete. A person with sensory loss needs very careful monitoring during this period immediately after closure, because they are at very high risk of reulcerating the area.<a></a> Temporary footwear, which provides a high level of protection, should be worn during this time.</p> <p>Usually, unmodified Plastazote®<a style="text-decoration: none;">*</a> shoes or postoperative wooden soled shoes are used as the temporary protection. Once they have served this temporary function, the shoes are discarded and only the definitive shoes are worn from then on. There are many other times, however, when protection of the insensitive foot is needed and custom molded footwear would be the best form of protection.</p> <p>Other times when protective footwear is needed are listed here.</p> <ol> <li> <p>Many people do not want to wear their street shoes around the house until bedtime. Since a person with insensitive feet should never walk barefoot, protective footwear, for use in the house, should be worn. Most commercial house slippers have thin soles which are not intended for walking on rough surfaces and do not provide any significant protection from sharp objects on the floor.</p> </li> <li> <p>Plantar foot deformity is often present when prescribed footwear is a necessity. With bony prominences or loss of plantar fat-pads, a person should never walk or stand barefoot on hard surfaces. This is a problem, particularly when this person showers and they stand on porcelain, concrete, or tile.</p> </li> <li> <p>A person who needs prescribed footwear should always have at least two pairs. Most people, who need them, do not. This is important during periods of time when these shoes are being repaired or the prescription is changed.</p> </li> </ol> <p>Plastazote® was first used for orthopedic purposes by William Tuck, in England, in 1967.<a></a> He notified Dr. Paul Brand in Carville, Louisiana and the first Plastazote® sandals were constructed soon after. Plastazote® provided a material which was easily molded directly on the foot so protective, interim footware could be quickly constructed.</p> <p>Prior to the introduction of Plastazote®, sandals at Carville were constructed of 5/8" thick microcellular rubber. Microcellular rubber is not a moldable material and foot conformity had to be accommodated by constructing microcellular pads and wedges.<a></a> This was imprecise and time consuming.</p> <p>Over the years, several people have contributed modifications to the design and construction techniques of the "Carville" sandal.<a></a> It has become an integral part of the total foot program.</p> <h3>Materials and Equipment Used to Construct the Sandal</h3> <p>The following is a list of the materials used to build the sandal.</p> <p><i>Materials for the Plastazote® Foot Bed</i></p> <ul> <li> <p>2 pieces of 1/2" x 6" X 12" Plastazote® #1 (medium)<a style="text-decoration: none;">*</a></p> </li> <li> <p>2 pieces of 1/2" x 6" x 12" Plastazote® #2 (firm)<a style="text-decoration: none;">*</a></p> </li> <li> <p>2 pieces of 1/4" x 5" x 12" Plastazote® #3 (rigid)<a style="text-decoration: none;">*</a></p> </li> <li> <p>2 pieces of Plastazote® #2, 5" x 10" X 1/2" thick to provide heel lift</p> </li> <li> <p>2 pieces of 1/4" x 3" x 33" Plastazote® #3 for wrapping the sides of the sandals</p> </li> </ul> <p><i>Additional Materials</i></p> <ul> <li> <p>Neoprene crepe soling (12 iron = 1/4") (24 iron = 1/2") (1" x 9") Spring steel cut to the full length of the sandal's length.</p> </li> </ul> <p><i>Webbing for Straps</i></p> <ul> <li> <p>2 pieces of cotton webbing 1" x 9"</p> </li> <li> <p>2 pieces of cotton webbing 1" X 8 1/2"</p> </li> <li> <p>2 pieces of cotton webbing 1 1/2" x 9"</p> </li> <li> <p>2 pieces of cotton webbing 1 1/2" x 8 1/2"</p> </li> <li> <p>2 pieces of cotton webbing 1" x 12"</p> </li> </ul> <p><i>Velcro® to be sewn to webbing</i></p> <ul> <li> <p>2 pieces of 1" x 2 1/2" Velcro® hook</p> </li> <li> <p>2 pieces of 1 1/2" x 2 1/2" Velcro® hook</p> </li> <li> <p>2 pieces of 1" x 2 1/2" Velcro® pile</p> </li> <li> <p>2 pieces of 1 1/2" x 2 1/2" Velcro® pile</p> </li> </ul> <p><i>Glue</i></p> <ul> <li> <p>Contact Cement or other adhesive</p> </li> </ul> <h3>Tools</h3> <ul> <li> <p>Skiving knife</p> </li> <li> <p>Ruler</p> </li> <li> <p>Scissors</p> </li> <li> <p>Polyfoam block (size 8" high x 12" wide x 18" long) cut at approximately 45° from the top to the base at the front of the block.</p> </li> </ul> <h3>Equipment</h3> <ul> <li> <p>Sewing machine or Patcher machine</p> </li> <li> <p>Finishing sander or grinding wheel</p> </li> <li> <p>Oven</p> </li> </ul> <h3>Pieces of the Sandal Prepared in Advance</h3> <p>Most of the materials used in the construction of a sandal are pre-cut and pre-sewn in the shop to speed the construction process.</p> <p>All pieces of Plastazote® are cut from large sheets into the rectangular sizes listed above. The cotton webbing and Velcro® are purchased on large rolls and cut to the sizes above in advance.</p> <p>A 1 1/2" x 2 1/2" patch of hook Velcro® is sewn to one end of a 1 1/2" x 9" piece of webbing. Approximately 1/2" of cotton webbing is left exposed on the very end so the end can be grasped by the patient to release the strap. A 1 1/2" x 2 1/2" piece of pile Velcro® is sewn to the end of a 1 1/2" x 8 1/2" piece of webbing. This procedure is repeated on the 1" x 8 1/2" and 1" x 9" pieces of cotton webbing.</p> <p>The oven should be preheated to a temperature of 140° Celsius (285° Fahrenheit). This is the temperature at which all polyethylene materials should be heated.</p> <p>Plastazote® is a closed-cell polyethylene foam material. If polyethylene foam materials are overheated, the cell structure is weakened and the material shrinks in all directions. To determine the amount of time a polyethylene foam should be heated, measure the thickness of the material in millimeters and multiply the thickness by twelve (10 mm x 12 = 120 seconds). The answer will be the time of heating in seconds.</p> <p>To mold the Plastazote® directly on the foot, the heated Plastazote® is placed between the foot and a thick foam rubber block. The foot is pressed into the foam and Plastazote®. The foam presses the polyethylene foam up around the sides of the foot and into every plantar hollow and the material cools and remains in this shape.</p> <p>The top/front of the foam a block is cut at a 45° angle to prevent obtaining a deep mold of the toes (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg"><b>Fig. 1</b>)</a>. A deep mold would create a ridge distal to the ends of the toes. During gait, the medial foot enlongates with pronation. This elongation could result in distal toe damage on an insensitive foot if this ridge were present.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg">Figure 1. The open-celled foam block used to mold the Plastazote® footbed is cut on the top/ front to prevent deep-molding the toes into the Plastazote®.</a><br /></strong><br /> <h3>Construction of the Sandal</h3> <p>Patients are seated in an adjustable chair to insure the knee and ankle can be maintained at right angles as the Plastazote® is molded to their foot. Patients with insensitive feet are asked to wear socks for heat insulation from the warm polyethylene foam.</p> <p>To begin the sandal, a piece of 6" x 12" x 1/2" thick, medium, Plastazote® #1 is heated according to the above formula. After the Plastazote® has been heated, it is placed on the foam block with the toe region hanging over the 45° cut of the foam block. The foot is aligned over the Plastazote® with the metatarsal heads positioned over the top edge of the cutoff section of the foam block. The patient's foot is then pressed into the Plastazote®.</p> <p>After the Plastazote® foot bed has cooled, but before the patient is asked to lift their foot, an outline is drawn to mark a reference for what will become the outer sides of the sandal (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg"><b>Fig. 2</b></a>). Hold the pen marking this line in a vertical position. Purposely draw the toe area distal to the foot further distal to the toes than needed. Mark the toe of the sandal about 1" distal than the toes of the foot. Material used to wrap the sides of the sandal will pull the distal end of the sandal back.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg"><strong>Figure 2. As the first Plastazote® layer is cooling, a line is drawn to mark the outer edge of the sandal.</strong></a><br /> <p>Cut the molded piece of Plastazote® around the outside of the molded portion to remove excess material. Make this cut approximately 1/2" outside the drawn line. This will allow for better control of shaping the sandal during a later grinding process.</p> <p>Apply adhesive to the bottom (convex side) of the molded material and to one side of a 6" x 12" x 1/2" firm, #2 Plastazote® piece. Then heat the #2 Plastazote®. Set the heated #2 piece on the foam block and the molded #1 Plastazote® piece on top of it (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg"><b>Fig. 3</b></a>). Place the foot back into the molded #1 piece and then press down to mold the #2 Plastazote® piece to the bottom of the #1 piece. Plastazote® #1 and #2 are autoadhesive, but this characteristic of the material has not proven to form a dependable bond in these sandals.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg"><strong>Figure 3. The molded #1 Plastazote® is set on the glued surface of the heated #2 prior to molding the two together.</strong></a><br /> <p>Then cut the #2 piece to the edge of the # 1 piece and ground both pieces vertically to meet the line drawn earlier. At this time, ground flat some of the roundness on the plantar surface of the molded #2 piece and flatten by grinding the area under the metatarsal heads and toes.</p> <p>Use the 1 1/2" wide webbing to build the strap which will cross over the midfoot region just in front of the ankle. Use the 1" webbing for the strap which will cross over the top of the metatarsals just proximal to the metatarsal heads. Also use 1" strapping behind the heel.</p> <p>Place the patient's foot in the foot bed and "velcro" the straps together and hold them in place over the foot. Align the straps over the foot and mark the Plastazote® and straps (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg"><b>Fig. 4</b></a>). Glue together the Plastazote® footbed and straps, using the marks as a reference. Cut the straps under the sandal so they don't overlap (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg"><strong>Figure 4. The cotton-webbing straps are held in place while the sandal and straps are marked for later gluing.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg"><strong>Figure 5. The straps are cut so they do not overlap under the footbed.</strong></a><br /> <p>Coat with glue the 5" x 10" x 1/2" scrap piece of #2 Plastazote® and the bottom of the molded footbed and heat the #2 piece. Glue the #2 piece under the heel arch and metatarsal heads. Ground down the bottom to form a 1/2" high wedge heel which tapers down to the metatarsal heads (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg"><b>Fig. 6</b></a>). This heel lift also serves to fill any remaining arch and curvature under the sides of the molded footbed.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg"><strong>Figure 6. The bottom of the sandal is ground flat under heel, arch, and metatarsal heads after the heel wedge is glued on. The area under the toe is ground up to form the rocker.</strong></a><br /> <p>The sole of these sandals should be absolutely rigid. On smaller patients the rigid Plastazote®, which will be added later, will be sufficient to accomplish this. But in larger, heavier patients, it may be necessary to include a rigid steel shank from the heel to the toe. For those patients, glue a piece of leather to the bottom of the footbed to prevent penetration of the steel through the footbed. Bend up the steel from the metatarsal heads to the end of the toe of the sandal in the form of a rocker. Glue the steel shank to the bottom of the leather, and shape and grind flat a filler material around the shank so bumps will not form in the outer sole of the sandal.</p> <p>If the steel shank is not used, coat with glue a piece of 5" x 12" x 1/4" rigid #3 Plastazote® and the bottom of the footbed. Heat the #3 piece and then attach it to the bottom of the footbed. This is done by adhering the heel of the sandal to the #3 piece first and then, in a rolling motion, elevate the heel of the sandal as the toe is pressed down onto the material piece<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg"> (<b>Fig. 7</b></a>). This creates a rocker sole with increased toe spring under the toes.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg"><strong>Figure 7. The heel of the sandal is lifted before the front of the heated #3 Plastazote® is glued to the footbed to help form the rocker sole.</strong></a><br /> <p>Skive back one end of a piece of rigid Plastazote® 3" wide by 33" long and 1/4" thick to a distance of 2" and at a shallow angle. Then apply glue over the 2" skived portion and the entire other side of the rigid Plastazote® piece. Coat the sides of the footbed with glue. Heat the rigid Plastazote® and glue it vertically around the perimeter of the sandal (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg"><b>Fig. 8</b></a>). Glue the skived end to the medial arch area of the footbed first. This leaves the glue coated skived area facing out from the sandal. Completely wrap the #3 strip around it, overlapping onto the skived area, and cut off the excess. Trim the bottom flat and round the upper edge level with the top of the footbed by grinding. Then glue neoprene crepe soling to the bottom.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg"><strong>Figure 8. The sandal is made more rigid by gluing 1/4" #3 Plastazote® vertically around the footbed.</strong></a><br /> <p>Place the patient's foot into the sandal to fit a heel strap. The strap is 1" cotton webbing. Mark the location of the strap. Remove the sandal and sew the strap into place (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg"><b>Fig. 9</b></a>). Rivets can also be used to attach the strap.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg"><strong>Figure 9. The completed sandal with neoprene crepe soling and heel strap attached.</strong></a><br /> <p>For shortened feet, use only a single vertical, instep strap of 1 1/2" to 2" width and attach the heel strap to this single strap (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg"><b>Fig. 10</b></a>). For more long-term use, construct the straps and sides of leather (<b>Fig. 11</b>). If the patient's skin is thin and atrophied, softer materials such as beta-pile can be used as straps.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg"><strong>Figure 10. For shortened feet a single, broad strap can be used across the instep.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-11.jpg">Figure 11. Leather can be used for sandals intended for long-term or outdoor wear.</a><br /></strong><br /> <h3>Considerations for Insensitive Feet</h3> <p>In a series of 41 diabetic patients with sensory neuropathy in their feet, when measured with pedobarograph, 51% had abnormally high pressure under their metatarsal heads.<a></a> This is compared to only 7% of non-diabetic patients displaying higher pressures. The skin under the metatarsal heads has been shown in many studies to be the most frequently ulcerated part of the insensitive foot.<a></a> The forefoot region of insensitive feet needs a higher level of protection than the rest of the foot. This can be accomplished in the Plastazote® sandal by making the sole rigid and creating a rocker effect in the sole design.<a></a> A rigid sole minimizes shear between the sandal and skin. It also eliminates flexion and extension at the metatarsal-phalangeal joints.<a></a> If the toes of the foot are rigid, a flexible soled shoe will press up into the toes during gait.</p> <p>Rocker soles have been shown to greatly reduce foot pressure during gait. The point on the sole where rocking begins should always be posterior to the metatarsal heads, but ideally would be placed near the middle of the sandal. These rocker styles of sole are also helpful in the rehabilitation of patients with fused ankles.<a></a></p> <h3>Conclusion</h3> <p>For 20 years at the Gillis W. Long Hansen's Disease Center in Carville, Louisiana, Plastazote® sandals have proven to be an effective form of interim footwear for insensitive patients. The technique is simple and highly adaptable to many types of foot therapy.</p> <p><b>References:</b></p> <ol> <li>"A Report of the National Diabetes Advisory Board," <i>NIH Publication No. 81-2284</i>, Bethesda, Maryland, November, 1980. p. 25.</li> <li>Boulton, A.J.M., M.D., C.A. Hardisty, M.D., R.P. Betts, Ph.D., C.I. Franks, Ph.D., R.C. Worth, MD., J.D. Ward, M.D., and T. Duckworth, M.D., "Dynamic Foot Pressure and Other Studies as Diagnostic and Management Aids in Diabetic Neuropathy," <i>Diabetes Care</i>, 6, June, 1983, pp. 26-33.</li> <li>Duckworth, T., M.D., A.J. Boulton, M.D., R.P. Betts, Ph.D.. C.I. Franks, M.D. and J.E. Ward, M.D., "Plantar Pressure Measurements and the Prevention of Ucleration; in the Diabetic Foot," <i>The Journal of Bone and Joint Surgery</i>, 67, January, 1985, pp. 79-85.</li> <li>Karat, S., M.D., "The Role of Microcellular Rubber in the Preservation of Anaesthetic Feet in Leprosy," <i>Leprosy Review</i>, 40, July, 1969, pp. 165-170.</li> <li>Milgram, JE., M.D., "Office Measures for Relief of the Painful Foot," <i>Journal of Bone and Joint Surgery</i>, 46, July, 1964, pp. 1095-1116.</li> <li>Pati, L., M.D. and F. Behera, M.D., "Metatarsal Head Pressure (M.H.P.) Sores in Leprosy Patients," <i>Leprosy in India</i>. 53, October, 1981. pp. 588-593.</li> <li>Price, E.W., M.D., "Studies on Plantar Ulceration In Leprosy VI, The Management of Plantar Ulcers," <i>Leprosy Review</i>, 31:3, July, 1960, pp. 159-171.</li> <li>Reed, J.K., RPT, "Plastazote® Insoles, Sandals, and Shoes for Insensitive Feet," <i>Surgical Rehabilitation in Leprosy</i>, Editors F. McDowell and CD. Enna, Williams and Wilkins, 1974, pp. 323-329.</li> <li>Ross, W.F., M.D., "Footwear and the Prevention of Ulcers in Leprosy," <i>Leprosy Review</i>, 33, February, 1962, pp. 202-206.</li> <li>"Selected Statistics on Health and Medical Care of Diabetics," The National Diabetes Data Group, 1980, pp. A-3.</li> <li>Tuck, W.H., C.P.O., "The Use of Plastazote® to Accommodate Deformities in Hansen's Disease," <i>Leprosy Review</i>, 40, July, 1969, pp. 171-173.</li> </ol> <p><em><b>*Footnote</b> The numerical identifications of the different densities of Plastazote® correspond with the designations assigned for these densities by Alimed Inc., 297 High Street, Dedham, Massachusetts 02026.</em></p> <p><em><b>*Footnote</b> Plastazote® is a trademark of BXL Plastics Limited, 675 Mitcham Road, Croydon CR9 3AL England.</em></p> <p><em><b>*Arthur Plaia, M.A. </b> Arthur Plaia, M.S., is Chief of the Orthotic Department, Gillis W. Long Hansen's Disease Center.</em></p> <p><em><b>*William C. Coleman, D.P.M. </b> William C. Coleman, D.P.M., is Chief of the Podiatry Department at the Gillis W. Long Hansen's Disease Center, Carville, Louisiana 70721.<br /><br /><br /></em></p> <div style="width: 400px;"></div> Page Number(s) 67 - 73 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-11.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 Soft Molded Sandals for Insensitive Foot Care Creator An entity primarily responsible for making the resource William C. Coleman, D.P.M. * Arthur Plaia, M.A. * https://staging.drfop.org/files/original/6c0a91f3e6ca48a7d6eb71da9b638ef1.pdf 053df77f111f816175d9cd9b8a12a789 https://staging.drfop.org/files/original/56827526320afb7bc3726a24ed19a2e1.jpg 548798c301947254e31ac1fd04ba5be2 https://staging.drfop.org/files/original/3e0affd56b0e765df6a7a25041d5dc38.jpg 20141917fda2ff9c21dc4cd7f4f9579d 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/1982_02_008.pdf Text Any textual data included in the document <h2>Post Operative Management of Lower Extremity Amputees Using Tubular Elastic Compression Bandaging</h2> <h5>William M. Brady, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3><br />Introduction</h3> <p>Edema is inevitable in a postoperative limb and is a matter of concern to all who are involved in the postoperative care and rehabilitation of amputees. Persistent edema, that is edema that fails to subside over a period of weeks following amputation surgery, delays the rehabilitation process including the fitting of the definitive prosthesis<a></a>.</p> <p>Several systems of compression bandaging have been investigated and reported in various medical journals. These include soft dressings, pneumatic pressure sleeves, stump shrinkers, semirigid dressings, and rigid dressings with or without a program of early ambulation<a></a>. Of all of these systems, the most common one is the elastic wrap bandage<a></a>. It is readily available inexpensive, comes in a range of sizes and is washable. In spite of its advantages, however, its users are also aware that it is difficult to apply, doesn't maintain continuous pressure, must be reapplied frequently, cannot be reapplied the same way each time, and loses its compressibility after a few washings.</p> <p>Since the amount of external compression applied to the limbs seems to be a key factor in reducing edema, studies have been undertaken to define the "ideal" pressure. Some of the findings reported are as follows:</p> <ol> <li> <p>less than 5 to 10 mmHg of mercury is undersirable<a></a>;</p> </li> <li> <p>external pressure of 30 mmHg or greater decreased the venous flow rate of the leg<a></a>;</p> </li> <li> <p>external pressures above 25 to 30 mmHg, if sustained, may be potentially harmful<a></a>;</p> </li> <li> <p>pressures obtained from elastic wrap applied by skilled professionals ranged typically from 23 to 72 mmHg<a></a>;</p> </li> <li> <p>elastic compression to the lower limb markedly reduced the volume of the limb<a></a>.</p> </li> </ol> <h3>Development of a Product</h3> <p>Early in 1980 Knit-Rite, Inc.,<a style="text-decoration: none;">*</a> a manufacturer of prosthetic socks and stockinette tubing, initiated the development of a tubular elastic compression material that would be equal or superior to any compression bandage currently available on the market. Believing that such a product would have medical applications in the control of edema but uncertain of how it could be made to achieve the desired pressures and other characteristics, they contacted the Physical Medicine Department, University of Kansas Medical Center, for recommendations. Out of this inquiry evolved an amputee study involving 41 amputees, 35 below knee (B.K.) and 6 above knee (A.K.) and resulted in a paper entitled "Pressure Applied by Stump Bandages: A Comparative Study," by G. Varghese et al.<a style="text-decoration: none;">*</a> This study compared the elastic wrap, the Knit-Rite tubular elastic bandage and stump shrinker, and another brand of tubular elastic bandage. It supported some beliefs and established others:</p> <ol> <li> <p>Elastic wrap was the most difficult to apply.</p> </li> <li> <p>Pressures exerted by elastic wrap varied widely and the results were significantly different when applied by skilled and unskilled people.</p> </li> <li> <p>Elastic wrap failed to sustain constant pressures over a prolonged period of time and had a tendency to loosen with usage.</p> </li> <li> <p>Both tubular compression bandage products were more easily applied by patients and/or family members.</p> </li> <li> <p>More consistent pressure over a prolonged period of usage could be obtained with tubular elastic bandages.</p> </li> <li> <p>The Knit-Rite tubular compression bandage, when doubled, exerted a pressure which was in the "ideal" range, between 15 to 30 mmHg as measured by a solid state pressure transducer.</p> </li> </ol> <p>Actually, many changes in the product occurred during the course of this study.<a style="text-decoration: none;">*</a> Finally the acceptable tubular compression bandage was made available as a 10 meter Compressogrip® roll in a range of widths and lengths and as a stump shrinker item in a range of widths and lengths. The stump shrinker item is individually packaged and labeled with care instructions.</p> <h3>Field Testing</h3> <p>At the same time that the Kansas University Medical Center was conducting their research and continuing through the present time, Isle Orthotic-Prosthetic Services, of Kansas City, Missouri, was using the tubular compression bandage in the postoperative management of its referred amputee patients. Field testing was also conducted at a private prosthetics facility in the Kansas City area and at the V.A. Hospital.</p> <p>These findings, while empirical do confirm the results of the scientific researchers. The earlier a program of tubular compression bandaging is begun post-operatively, the sooner swelling will subside and tissues can be properly supported and correctly molded to a shape acceptable for prosthetic fitting. The correct size of bandage must be selected and patients or responsible family members instructed concerning the proper method of applying the tubular compression bandage and maintaining a controlled, total-contact fit throughout the period of wear. The recommendation, with the permission of the managing physician, is to wear the bandage 24 hours per day, except for bathing or during periods of muscle spasm, cramping or persistent pain. At least 2 to 3 bandages need to be supplied to the patient to allow for laundering.</p> <h3>Selecting the Proper Size Bandage</h3> <p>Care needs to be taken in fitting to insure that the width selected achieves adequate compression without overstretching the material (<a href="/files/original/56827526320afb7bc3726a24ed19a2e1.jpg"><b>Fig. 1</b></a>) and that the length selected allows for a double layer (<a href="/files/original/3e0affd56b0e765df6a7a25041d5dc38.jpg"><b>Fig. 2</b></a>). Optimum compression occurs when the tubular compression bandage is stretched at least 50% but not more than 100% of the original width. For a B. K. amputee it is recommended that a circumference measurement be taken 2" below the medial tibial tubercle, and for an A. K. amputee, 2" proximal to the distal end.<br /><strong><br /><a href="/files/original/56827526320afb7bc3726a24ed19a2e1.jpg">Fig. 1</a> Sizing Chart for Tubular Elastic Stump Shrinkers.<br /><br /><a href="/files/original/3e0affd56b0e765df6a7a25041d5dc38.jpg">Fig. 2.</a> Application Technique.<br /></strong></p> <p><br />Example: The measured circumference is 11 inches. From the chart (<a href="/files/original/56827526320afb7bc3726a24ed19a2e1.jpg"><b>Fig. 1</b></a>) we see that Size #3 is the correct size. The sizes #2 through #5 are approximately 2" through 5" in flat width. Thus Size #3 is approximately 6" in circumference and would best accommodate measurements from 9" to 12" in circumference. If the differential between distal and proximal circumferences, as in extremely tapered A. K.'s, is greater than 5", then the next size larger bandage should be selected to avoid overstretching the material and to insure ease of application.</p> <h3>Applying the Bandage</h3> <p>On a below knee amputee, apply the first layer so that the material extends approximately 3" proximal to mid-patella. Slide the nylon ring (supplied with and surrounding the bandage) forward until firm distal pressure occurs, then reflect the second layer over the first to no more than 1/2" proximal to the superior border of the patella (<a href="/files/original/3e0affd56b0e765df6a7a25041d5dc38.jpg"><b>Fig. 2</b></a>). In this way, greater pressure is maintained distally than proximally. If necessary, excess material may be marked and cut off, folding inside the cut ends of the second layer to achieve a smooth edge; however, the cut edge may ravel. Different lengths are available to eliminate cutting as much as possible (<a href="/files/original/56827526320afb7bc3726a24ed19a2e1.jpg"><b>Fig. 1</b></a>).</p> <p>Have the patient flex and extend the knee to check the security of the bandage. Then have the patient remove and re-apply the bandage several times until you are confident that the technique is mastered. Good follow-up is an important part of patient management. We recommend that the patient be rescheduled at 2 to 3 week intervals to check the progress of the shrinkage. Remeasuring and recording all pertinent circumference and diameter readings can then be done. When measurements have stabilized and no appreciable changes are noted from the last visit, casting for the definitive prosthesis can be initiated.</p> <p>The same basic procedure can be followed with A. K. amputees, except that some A. K. amputees will require the addition of a modified garter belt or webbing suspension to minimize the tendency of the bandage to roll proximally.</p> <h3>Summary</h3> <p>Our observations concur with recent research which suggests that the process of controlling and reducing edema is accelerated by using the Compressogrip® tubular compression bandage versus the conventional elastic wrap. Further, our experience indicates that the shaping of soft tissues is enhanced and that the post-operative period required to prepare the patient's residual limb for the definitive prosthesis is somewhat shortened when a tubular compression bandage is used. We project that patients managed in this fashion will have fewer post-fitting problems that are related to additional shrinkage occurring in the first few weeks of prosthetic wear and that the incidence and/or severity of phantom sensation will be reduced as a result of the controlled compression of the Compressogrip® tubular compression bandage.</p> <p><b>References:</b></p> <ol> <li>Mooney, V.; Harvey, J.P.; McBride, E.; and Nelson, R.S., "Comparison of Post-Operative Stump Management: Plaster vs. Soft Dressings", <i>Journal Bone and Joint Surg</i>., 53-A, March 1971.</li> <li>Sher, M.H., "The Air Splint: An Alternative to the Immediate Postoperative Prosthesis", <i>Arch Surg</i>., 108: 746-747,1974.</li> <li>Puddifoot, P.C.; Weaver, P.C.; Marshall, S., "A Method of Supportive Bandaging for Amputation Stumps", <i>Br. J. Surg.</i>, 60: 729-731.1973.</li> <li>Islerwood, PA; Robertson, J.C.; Rossi, A., "Pressure Measurements beneath Below Knee amputation stump bandages: Elastic Bandaging, the Puddifoot dressing, and pneumatic bandaging technique compared", <i>Br. J. Surg.</i>, 62: 982-986,1975.</li> <li>Manella, K.J., "Comparing the Effectiveness of Elastic Bandages and Stump Socks for Lower Extremity Amputees", <i>Physical Therapy</i>, 61, March 1981.</li> <li>Holloway, G.A., Jr.; Daly, Colin H.; Kennedy,D.; Chemosky, J., "Effects of External Pressure Loading on Human Skin Blood Flow Measured by 133 Xe Clearance", <i>Journal of Applied Physiology</i>, 40 April 1976.</li> </ol> <b>Footnote</b> Field, M., Manager, Textile Research and Development, Knit-Rite, Inc., Kansas City, MO 64141.<br /><br /><b>Footnote</b> Varghese, G.; Hindle, P.; Zilber, S.; Perry, J.; Redford, J.B., 'Pressure Applied by Stump Bandages: A Comparative Study', American Congress of Rehabilitation Medicine, Oct. 1980.<br /><br /><b>Footnote</b> Kansas City, Missouri 64141.<br /><b><br /><em>*William M. Brady, C.P.O. </em></b><em> President, Isle Orthotic-Prosthetic Services, Kansas City, MO</em><br /><br /> <div style="width: 400px;"></div> Page Number(s) 8 - 10 Year 1982 Volume 6 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1982_02_008/1982_02_008-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1982_02_008/1982_02_008-2.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 Post Operative Management of Lower Extremity Amputees Using Tubular Elastic Compression Bandaging Creator An entity primarily responsible for making the resource William M. Brady, C.P.O. * https://staging.drfop.org/files/original/78bf6788488bdf97bc8b5683d42a6f70.pdf 28499b5aee932356ff3db57649d54f41 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_03_005.pdf Text Any textual data included in the document <h2>Editorial: The Driving Force in Rehabilitation</h2> <h5>William M. Susman, M.A., R.P.T.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>By design, and in daily clinical practice, rehabilitation is a multi-disciplinary effort. The patient is best served by professionals addressing the psychosocial and vocational aspects of disability as well as the various aspects of physical impairment in a specialized manner. The driving force behind the effective functioning of this approach is communication among the professionals comprising the rehabilitation team. This communication may occur within the structured format of professional publications, the formal yet often spontaneous settings of team clinics and rounds, or the many informal daily contacts between colleagues involved in the treatment of any one patient.</p> <p>Such communication enhances patient management in numerous ways. Consistent definitions and coordination of treatment approaches and goals can be achieved. Different perspectives regarding the same clinical situation can be shared, perspectives tempered by the different relationship each team member has with the patient, the expertise each member brings to the clinical problem, and the priority of concerns each establishes according to his or her functional role. Perhaps most importantly, the team is able to bring its collective clinical experience to bear upon the problem at hand. No one clinician, regardless of depth or breadth of experience, should fail to search out and use this collective experience for it can only serve to broaden the range of possible solutions.</p> <p>An excellent example of such an opportunity is provided in the lead article by Dr. Alexander in this issue of the Newsletter. This is not to say that executive decisions should not be made in the rehabilitation setting, but that if they are based upon the communicated experience and viewpoints of all team members, such decisions will not be autocratic.</p> <p>It should not be forgotten that the clinician also benefits from such communication. The most stimulating workplace is one in which a free exchange of ideas can take place without the fear that image or role is being threatened. In an imperfect world with personality differences and professional pressures, this can be hard to achieve, but must be actively sought. The stimulation of thought through this collective process also leads to clinical innovation and new research ideas and, ultimately, improvement in the professional's level of expertise and advancement of the state of the art of rehabilitation as a whole.</p> <p>Clinical professions involved in rehabilitation are currently undergoing rapid growth in knowledge base, upgrading of standards for entry into practice, and increasing professional responsibility. The fields of orthotics and prosthetics and physical therapy may be the best examples of these trends. It is imperative that no one clinical field, regardless of increased training, authority, or specialization becomes more isolated in clinical practice. Obviously, a given level of clinical skill cannot be replaced by input from another discipline, but the effective use of that skill can be channeled by communication within the clinic team towards better patient treatment, our foremost concern.</p> <b>*<em>William M. Susman, M.A., R.P.T. </em></b><em> Assistant Professor, Ithaca College, Division of Physical Therapy, Albert Einstein College of Medicine, Jacobi Hospital, Bronx, New York.</em><br /> <div style="width: 400px;"></div> Page Number(s) 5 - 6 Year 1980 Volume 4 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: The Driving Force in Rehabilitation Creator An entity primarily responsible for making the resource William M. Susman, M.A., R.P.T. * https://staging.drfop.org/files/original/7821ac6162abe595c2139897f396fecc.pdf 0bcce967fcfd627030a029c02594ff9c https://staging.drfop.org/files/original/a66e029293ca734565f6b91200071432.jpg e0ab811142f0169b690b4e8859ef14b6 https://staging.drfop.org/files/original/345a8f6d88787fb5569177c99ca4d7f7.jpg d29c0ac6eb59475dc22409206e69c298 https://staging.drfop.org/files/original/12ca9adaacb8c06c5eb20427ab64f46d.jpg 8363fe5120fc99ac33a0eb179ae273ed https://staging.drfop.org/files/original/e9d94ea851ebdbb5e0a81ae9d61b845f.jpg a108f96e990025c40ff36607bc770296 https://staging.drfop.org/files/original/27ad3e7aadc5e665c134b448e33340c5.jpg ce9577ae574f7e521bf0a6dee646d735 https://staging.drfop.org/files/original/5bc094ab41ace0120e8ba8896408edb8.jpg 8d8a73eceb72ffa43d8d319a3dfd8f8d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_03_005.pdf Text Any textual data included in the document <h2>Bilateral Knee Disarticulation, Immediate Post-Surgical Fitting: An Unusual Case Study</h2> <h5>William Susman&nbsp;</h5> <p>There are certain specific indications for utilizing immediate Post-Surgical Fitting (IPSF) in the postoperative management of the amputee. Clinical observations have substantiated that the constant even pressure provided by the immediate application of a rigid dressing to the residual limb helps control edema, supports circulation, and immobilizes tissue, subsequently minimizing the inflammatory process within the traumatized tissues, promoting wound healing, aiding good shaping of the limb and decreasing intrinsic pain and phantom sensations.</p> <p>The attachment of a pylon and prosthetic foot to the rigid dressing either immediately after the residual limb is wrapped or within a short post-operative period has been shown to enhance the positive effects of the rigid dressing and provide additional functional and psychological benefits. The gentle compression of residual limb tissue provided by closely monitored weight-bearing promotes wound healing by further decreasing edema. Ambulation resumes with a prosthesis sooner than with more conventional post-operative management approaches. Hospital stay is shortened, resulting in a more rapid return to previous personal, social and vocational activities. The amputee experiences an almost immediate resumption of function and although he or she will most likely undergo mourning for the lost limb, the actual commencement of rehabilitation is also experienced. In addition, the patient may be told pre-surgically the sequence of post-operative events so that the immediate introduction of functional prosthetic restoration can be hopefully, although cautiously, anticipated.</p> <p>It is readily acknowledged that IPSF is not appropriate for all circumstances. Cooperation among the rehabilitation team members from prosthetics, physical therapy, surgery, physiatry, and nursing, and a shared understanding of the technical aspects and goals of treatment, as well as individual proficiency in treatment procedures are necessary. The patient's understanding of the treatment approach and a willingness to adhere to treatment protocol are also essential. Lowered standards in any one of these areas may lead to injury of residual limb tissue, pressure sores, wound infection, hematoma, or necrosis and ultimately failure of the procedure and a real physical and psychological set-back for the patient. In addition, such complications are more difficult to perceive since the wound cannot be directly observed without disruption of the rigid dressing.</p> <h3>Patient History</h3> <p>With the above general review of the clinical advantages and precautions of IPSF in mind, it may be illustrative to present a case which is representative of these aspects of this treatment approach and yet extraordinary in view of the history and personal motivation for seeking treatment. The patient was a 28 year old woman who had contracted anterior poliomyelitis at the age of 16 months. She presented with stunted lower limbs, and muscle power at both hips was below functional levels except for the ability of the Sartorious muscle to withstand moderate resistance bilaterally. The knees and ankles were essentially flaccid. Sensation throughout the lower limbs was within normal limits. No contractures were evident and upper body strength was above normal.</p> <p>The patient wore bilateral, conventional KAFO's with knee locks and both ankles set in plantarflexion. Her feet rested on approximately nine-inch cork lifts set inside the calf sections of tall leather boots. (See <a href="/files/original/a66e029293ca734565f6b91200071432.jpg"><b>Fig. 1</b></a>) The patient related that as an adolescent she increased the lift height periodically to compensate for the lack of normal lower limb growth. She displayed excellent balance and body awareness, ambulated and climbed stairs and curbs independently with axillary crutches, and was able to negotiate sitting and rising from most types of seating. She led an active life as a college instructor and graduate student.</p> <p>The patient had a history of multiple surgical procedures during her teen-age years including a spinal fusion for scoliosis, subtalar arthrodeses, transplantation of hamstring tendons to the quadriceps mechanisms, and Achille's tendon releases bilaterally. She also had a history of left patella and right tibial fractures because of falls.</p> <p>The patient had been interested in seeking elective amputation of her legs for some time. Her chief reasons were of both a physical and a psychological nature. Pain in her feet resulting from the prolonged standing teaching required, and concern over the vulnerability of her legs to fractures from falling were related. Nevertheless, her foremost concern was for her appearance. Due to the devices she used to provide height and function she always felt compelled to wear floor-length dresses and was unable to interchange footwear (see <a href="/files/original/a66e029293ca734565f6b91200071432.jpg"><b>Fig. 1</b></a> &amp; <a href="/files/original/345a8f6d88787fb5569177c99ca4d7f7.jpg"><b>Fig. 2</b></a>). She wanted greater freedom in dress and to be able to have her legs seen without embarrassment over their appearance. She also found the braces and boots cumbersome and loose on her legs. Therefore, the patient came to the clinic seeking amputation primarily for reasons of cos-mesis and self-image.</p> <h3>Pre-Surgical Management</h3> <p>The rehabilitation team's decision to recommend bilateral knee disarticulation amputations was based upon the less traumatic nature of the surgical procedure, the good weight-bearing tolerance that has been demonstrated at this level, and another factor unique to this case. Due to the diminished growth of the patient's femurs, knee disarticulations would leave the amputation level proportional in length to long above-knee amputations. This level would provide a long lever arm for prosthetic control, yet not disturb anthropometric placement of the prosthetic knee and, consequently, proportional thigh and shank length.</p> <p>The IPSF approach was selected due to the patient's psychosocial background and to avoid the abrupt prolonged change in function that can result from bilateral surgery. With IPSF the patient would have a shorter period of disruption of her social and vocational success and her proud independence in activities of daily living. It would limit her experience as a wheelchair-dependent individual since two-legged function would never be completely interrupted.</p> <p>To determine whether or not knee disarticulation prostheses would provide function comparable to her presenting situation, temporary prostheses were fabricated to simulate post-surgical restoration. Plaster quadrilateral sockets with polyvinyl chloride (PVC) thermoplastic pylons, SACH feet and shoes were used. A cut-out in the posterior wall of each socket allowed the patient's shanks to protrude in the flexed-knee position, thus mimicking knee-disarticulation amputations (see <a href="/files/original/12ca9adaacb8c06c5eb20427ab64f46d.jpg"><b>Fig. 3</b></a>). A full functional evaluation showed no deficit in the patient's function from that previously demonstrated. Her ambulation pattern remained unchanged.</p> <p>From a psychological standpoint the patient was instructed to seek psychiatric consultation to closely examine her motivations for electing this treatment and to investigate her feelings regarding the possible failure of adequate functional prosthetic restoration. In addition, the patient discussed at length with team members the pros and cons of her decision and the possible sequela of amputation surgery such as wound-healing difficulty, residual limb pain, phantom sensations, less than optimal function, and prosthetic maintenance.</p> <h3>Post-Surgical Management</h3> <p>After closure of the amputation wounds and placement of drains, stump socks were applied over the surgical dressings on both limbs. A distal pad was held in place while a plaster wrap of each residual limb was done. Each plaster socket was hand-molded to provide a quadrilateral shape and ischial seat. Supracondylar purchase and belts over the iliac crests provided suspension. Pylons were not added at this time since the PVC tubing to be used requires heating before application.</p> <p>On post-operative day (POD) #2 the surgical drains were removed. On POD #5, PVC pylons and SACH feet with shoes were applied. To control and monitor the degree of weight-bearing, a tilt table and two scales were used (see <a href="/files/original/e9d94ea851ebdbb5e0a81ae9d61b845f.jpg"><b>Fig. 4</b></a>). Two five minute-periods at ten pounds of weight-bearing were allowed initially. On POD #6 the patient was seen twice during the day and stood on scales in the parallel bars (see <a href="/files/original/27ad3e7aadc5e665c134b448e33340c5.jpg"><b>Fig. 5</b></a>). Two daily sessions were continued and weight-bearing was increased to 20 pounds on the right limb and 15 pounds on the left, being limited due to pain. Throughout this period the patient complained of phantom sensations and residual limb pain which increased markedly at night. The first cast change was done on POD #12 at which time the stitches were removed. The following day the patient began ambulation in the parallel bars with weight-bearing to tolerance. On POD #15 the patient was given a walker for bedside use and on the following day was able to ambulate independently outside the parallel bars with axillary crutches and a four-point gait, testimony to her longstanding adaptation to her physical deficits and her determination to succeed. At this time the patient was transferred from the acute care setting to an inpatient rehabilitation bed.</p> <p>Four weeks after surgery the patient was casted for her definitive prostheses. At five weeks she was fitted with the sockets and locked knees and returned to the parallel bars for ambulation training. During the sixth week, first one and then both prostheses had safety knees added. By the ninth post-operative week the patient had returned to the use of crutches and had received training in elevation activities and ambulation on different terrains.</p> <p>The prostheses were delivered at the end of the ninth post-operative week and consisted of quadrilateral total contact sockets with semi-suction and supracondylar suspension. Windows were not cut in the sockets for donning but rather a soft insert was fabricated which was compressed during donning and re-expanded within the socket to grip the femoral condyles. The patient rejected the use of any suspension belts as uncosmetic. Otto-Bock's modular endoskeletal safety knees and components, and SACH feet were used. (See <a href="/files/original/5bc094ab41ace0120e8ba8896408edb8.jpg"><b>Fig. 6</b></a>).</p> <h3>Follow-Up</h3> <p>The patient returned to her former daily interests and activities and maintained her ambulatory status. Having worn the prostheses for approximately a year and a half she returned for re-evaluation. Changes in residual limb shape due to shrinkage necessitated the fabrication of a second pair of prostheses which she currently uses.</p> <h3>Summary</h3> <p>This case well illustrates the advantages and appropriate application of the IPSF approach to amputee management. The patient was able to have both limbs amputated at once and yet hasten the rehabilitation process. The physical debilitation and psychological shock associated with such a radical intervention was minimized by her youth, determination, and cooperation with the rehabilitation team. A deeply felt desire to improve her quality of life was satisfied with minimal disruption of what was an already successful life style in the face of life-long physical difficulties.</p> Page Number(s) 5 - 7 Year 1979 Volume 3 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-6.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 Bilateral Knee Disarticulation, Immediate Post-Surgical Fitting: An Unusual Case Study Creator An entity primarily responsible for making the resource William Susman  https://staging.drfop.org/files/original/d49da90fa9f0c0ee8147b96e291908d3.pdf 7f08e42eea8bbbd23d3d4d6b91d0a0d2 https://staging.drfop.org/files/original/943afc173437b395a3f94b4ff2659a5e.jpg aa7edcef18db620b1fa2f490e5abf250 https://staging.drfop.org/files/original/e5efcf538172dab88f36c526b06a5f91.jpg aba531f72f2e4837c3a0a0b0996a73b8 https://staging.drfop.org/files/original/4ccde9a701dd6d5771ce107d46ac1bc2.jpg 5982b814b207265768b8e8750f90685f https://staging.drfop.org/files/original/aa05931a1d684780719bffdfc3498e7a.jpg b880cef406760c7ee2e1a038abc28149 https://staging.drfop.org/files/original/421de63be1138b2062533ad526050cd9.jpg 88152a35fb9192cc5d5b0a5e982bf642 https://staging.drfop.org/files/original/f4ec3d7373a8b0783fac25fe09b090b3.jpg 3f7eebb64f66e1965cf88142303178ed https://staging.drfop.org/files/original/f65c0df2d21adfa0a03a47a88fbf4c89.jpg d1a7c7c76a17d4b01701aa2a3b301a19 https://staging.drfop.org/files/original/4d3edf70ddb64346ebd926f557b44423.jpg df371f26240fe9a9af112a646a920e90 https://staging.drfop.org/files/original/130be2ed482165f3c83e4db139d76775.jpg 1e67cc03d90ff9c36c754e076e4cf71d https://staging.drfop.org/files/original/7559e1b4fd16d73a7c5698a4499dd5a7.jpg 225d1d21859fd91c9ebad5bc7191a4ed https://staging.drfop.org/files/original/08cd8d811779f982414986d31a527e19.jpg d3771dbd56799b33182af35d1c92d2ae https://staging.drfop.org/files/original/0939223082872fe05d76f44303b19cca.jpg 93a3a96df839aeb10aef4f65b4baf868 https://staging.drfop.org/files/original/df210d8c1bc8a0526c3cc9c380a65f3b.jpg ab58e114ecbeb9a449d2ccc395937275 https://staging.drfop.org/files/original/95e5e807e78ed5211798f516f1166caa.jpg 788a7ede4aa0a25137bd4a58b820245d https://staging.drfop.org/files/original/a0b47ea6e200a0bd2d2c28ae25937015.jpg 866795b24cb4c9e1f5970dc549e5e4dc Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_033.pdf Text Any textual data included in the document <h2>Removable Rigid Dressing for Below-knee Amputees</h2> <h5>Yeongchi Wu, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Harold Krick, CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Background</h3> <p>According to the National Center For Health Statistics, there were 274,000 patients with amputations of major limbs in 1971 in the United States. This number rose to 358,000 in 1977. Kay in 1975 reported 53.8 percent of the 6,000 reviewed new patients had had amputations at the below-knee level.<a></a> If the percentage and the number of amputees remained unchanged, there would be at least 200,000 below-knee amputees in this country at any given time. It is possible that this number could have been doubled in the past ten years. The most recent information regarding amputation available to the authors was the Vital and Health Statistics published by the U.S. Department of Health and Human Services in April, 1986. A review of 192,000 medical records from the 407 hospitals that participated in the 1984 National Hospital Discharge Survey showed an estimated 32,000 below-knee amputations alone. Therefore, improvement in the management of below-knee amputees will certainly benefit a significant number of patients.</p> <p>At the V.A. Lakeside Medical Center (VALMC) and Rehabilitation Institute of Chicago (R.I.C.), members of Northwestern University-McGraw Medical Center, Chicago, three techniques have been developed for treatment of below-knee amputees. These include the Removal Rigid Dressing (R.R.D.), Scotch-cast™ preparatory prosthesis, and the "one-step socket lamination definitive prosthesis." These approaches have been invaluable in the management of below-knee amputees.</p> <p>This paper describes the Removal Rigid Dressing for postoperative management of the below-knee amputee. Clinical experiences since 1977 have shown the benefits of the R.R.D. to be the following:</p> <ol> <li> <p>Rapid residual limb shrinkage</p> </li> <li> <p>Prevention of edema</p> </li> <li> <p>Possibility of frequent residual limb observations</p> </li> <li> <p>Soft tissue immobilization to facilitate wound healing</p> </li> <li> <p>Elimination of skin breakdown commonly seen in elastic bandaging</p> </li> <li> <p>Simplicity of donning and doffing</p> </li> <li> <p>Development of tolerance to weight bearing</p> </li> <li> <p>Prevention of residual limb trauma</p> </li> <li> <p>Reduction of wound pain</p> </li> </ol> <p>With nine years clinical experience at this university medical center and dissemination through the Northwestern University Prosthetic School, it appears to us that this technique has its merits in the postoperative and pre-pros-thetic management of the below-knee amputee.</p> <p>In a study done in 1977, the average hospital stay for amputees at VALMC was reduced by 90 days after the development of the R.R.D.<a></a> This was achieved primarily by complete elimination of skin breakdown seen previously from elastic bandaging and by speeding stump shrinkage with the R.R.D.<a></a></p> <p>In the 1970s, at the VALMC in Chicago, there were many problems in postoperative below-knee residual limb care. For many years, the below-knee amputees were managed with a soft dressing or thigh high cast, i.e. Immediate Post-Surgical Fitting (IPSF) without pylon, followed by elastic bandaging, as many hospitals did at that time. The technique was done by the therapists, nurses, and patients, following the procedure learned directly or indirectly from the Northwestern University Prosthetic/Orthotic School. There was no special team or particular therapists assigned to amputee care. Inevitably, many techniques differing from the original were used by different individuals. For a long time, the staff was puzzled by the very high frequency of skin breakdown and distal edema (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg"><b>Fig. 1</b></a>). At times, it was a surprise at the V.A. Prosthetic Clinic when a patient presented who was free of any residual limb complications.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg"><strong>Figure 1. A typical pressure sore over the tibial tubercle and distal edema from conventional elastic bandaging.</strong></a><br /> <p>It was apparent that inconsistent limb care techniques by the staff and the patient himself was a contributing factor (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg"><b>Fig. 2</b></a>). Many thoughts came to mind and many attempts were made to remedy this problem, such as using a protective covering made of thermoplastic or a donut shaped sponge over the tibial tubercle to prevent skin breakdown. Nothing was promising until one afternoon in early 1977 when the idea of the R.R.D. came to light.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg"><strong>Figure 2. A conventional elastic bandage is an unreliable technique in a patient's hand.</strong></a><br /> <p>This happened after seeing a 90 year old man develop a tibial pressure sore on his well healed limb only three hours following the change from a thigh high plaster cast to an elastic bandage. We decided that the elastic bandage was guilty and should never be used for below-knee amputees again, and the thigh high cast could be modified to continue the excellent results. We analyzed the principles behind the thigh high plaster cast and incorporated them into the R.R.D. system.</p> <p>The design was completed on the same day and the same principles have been kept until this date without any further modifications. This system is a below-knee plaster cast suspended by a stockinette to a supracondylar suspension cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg"><b>Fig. 7</b></a> (a, b, c) and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg"><b>Fig. 7</b></a> (d, e, f)). Underneath the below-knee plaster cast, sport tube socks are added to provide-continuous controlled compression.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg"><strong>Figure 7 d, e, and f. Application of the Removable Rigid Dressing: d) the supracondylar cuff, e) pull the stockinette, and f) fold the suspension stockinette to make sure the cast is secured over the supracondylar cuff.</strong></a><br /> <h3>Why Does R.R.D. Work?</h3> <p>No matter how successful this method has been, we certainly were inspired by the important pioneer work by Dr. Weiss in Poland, and later by Dr. Burgess<a></a> in this country. A few of the principles that made the R.R.D. an effective procedure were originally utilized in the IPSF system:</p> <ol> <li> <p>Use of a non-expandable dressing prevents the development of edema following amputation.</p> </li> <li> <p>Use of supracondylar suspension keeps the cast in place.</p> </li> <li> <p>Rigid dressing is effective in immobilization of soft tissue, which is essential for wound healing and pain control as well as trauma prevention.</p> </li> <li> <p>Controlled compression of the residual limb avoids skin breakdown and facilitates shrinkage.</p> </li> </ol> <h3>Fabricating The R.R.D.</h3> <p>The R.R.D. consists of four components: a) tube socks, b) below knee plaster cast, c) suspension stockinette, and d) supracondylar cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><strong>Figure 3. Components of the Removable Rigid Dressing: a) athletic tube socks with the elastic band removed, b) below-the-knee cast, c) suspension stockinette, and d) thermoplastic supracondylar suspension cuff.</strong></a><br /> <p><i>Tube Socks</i></p> <p>The idea of using tube socks arose because of the difficulty in obtaining wool socks from the V.A. supply center in early 1977 and the necessity of hand care of wool socks. By replacing the elastic bandaging with R.R.D., we noted that below-knee residual limbs changed from their previous conical shapes to cylindrical contours. The measurements of properly fitted wool socks for our patients differed from those supplied by the V.A. supply center. For a while there was a shortage of socks for our patients. This led to the need for alternatives. One day, we tried a large size tube sock on sale at the V.A. canteen store.</p> <p>To this date, we still use tube socks routinely at the V.A. hospital and R.I.C. They can be changed daily by the patient and are machine washable. They also provide excellent sock marks on the skin for determining the degree of pressure over the residual limb. They are cheaper and available at most department stores (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b><strong>A</strong></a>). We simply cut off the elastic tops and use them as nice fitting #2 size, 2 ply socks.</p> <p>Tube socks are cut in long and short lengths. Short tube socks are effective for localized compression with a bulbous limb so that progressively diminishing shrinkage can be achieved from the distal to proximal area.</p> <p>For the large residual limb, when the tube socks may not be long or wide enough, Soft-socks (Knit-Rite, Inc.) can be used.</p> <p><i>Plaster Cast</i></p> <p>The cast for a R.R.D. (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b><strong>B</strong></a>) is shorter than that of the IPSF. It extends only up to the knee level for easy removal. The casting procedure also differs slightly for pressure relief. In the IPSF, felt paddings are used to bridge the bony areas. In the R.R.D., cotton paddings, six layers at the center and tapered to the margins, are used as "spacers" over the bony prominences of the tibial tubercle, tibial crest, fibular head and any pressure sensitive areas. Once the cast is made, the spacers are discarded. An empty space between the cast and the skin is formed to provide a controlled pressure relief (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg"><strong>Figure 4. Cotton paddings are used as spacer for pressure relief.</strong></a><br /> <p>The trim line of the plaster cast is up to mid-patellar level anteriorly and lower posteriorly to allow knee flexion. It is wider proximally in order to ensure easy removal and reapplication of the cast. This is especially true with a bulbous limb where the concave side needs additional padding to avoid a cast that is too tight at the top (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg"><b>Fig. 5</b></a>). In case of a narrow proximal opening, a longitudinal cut on the back of the cast can be used to widen the proximal part and allow reapplication (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg"><strong>Figure 5. Adequate medial padding is needed to assure a wider proximal opening for easier cast re-application (a). A narrow opening makes cast reapplication impossible (b).</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg"><strong>Figure 6. If cast opening is too narrow, a longitudinal cut on the back of cast allows widening of the cast proximally while still maintaining distal compression.</strong></a><br /> <p><i>Suspension Stockinette</i></p> <p>The suspension stockinette, made of 4-inch casting stockinette with one end tied, secures the cast to the suspension cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b><strong>C</strong></a>).</p> <p><i>Supracondylar Suspension Cuff</i></p> <p>The suspension cuff is made of thermoplastic material. It has a Velcro® closure to keep the cuff in place and a strip of Velcro® hook along the upper edge to secure the suspension stockinette (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3D</b></a>). For the obese patient who has very limited purchase over the femoral condyles because of tissue bulk, a fork strap with a waist belt can be used.</p> <h3>Application Of The Removable Rigid Dressing</h3> <p>After the surgical wound is properly dressed, the proper number of tube socks are applied layer by layer to avoid possible wrinkles. Then the plaster cast is applied and followed by the suspension stockinette and the supracondylar cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg"><b>Fig. 7</b> (a, b, c)</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg"><b>Fig. 7</b> (d, e, f)</a>). To make the application easier, a semi-circular mark is made on the cast and another on the supracondylar cuff so that the patient can match both marks to form a circle over the patella.</p> <h3>When To Apply The R.R.D.</h3> <p>The R.R.D. can be applied at the completion of surgery or when the first thigh-high rigid dressing is removed for wound inspection. It can be used whenever there is a need for limb shrinkage in any new or old amputee.</p> <h3>Adding Socks</h3> <p>When possible, additional socks are applied to maintain a comfortable snug fit and to facilitate progressive shrinkage. Sometimes short socks distally are preferred to provide localized distal compression without building up the thickness proximally (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg"><strong>Figure 9. Short tube socks provide localized compression in bulbous stump.</strong></a><br /> <h3>Weight Bearing Exercise</h3> <p>It is not possible to say how many days after amputation one can start weight bearing. In general, initiation of weight bearing exercise is determined by the state of wound healing, usually seven to 14 days after surgery. Immediate postoperative weight bearing is likely to cause mechanical shearing from movement and delay wound healing during the first two weeks after amputation, as reported by Mooney.4 However, steady pressure without mechanical shearing on the residual limb using a wheelchair strap can be very beneficial (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg"><b>Fig. 8</b></a>). We have found this can be used even within the first week after surgery. While in the wheelchair, the patient is encouraged to push frequently with the R.R.D. against resistance of the strap.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg"><strong>Figure 8. A strap is attached to the arm rests for the patient to exert partial weight bearing exercise while in the wheelchair (left). A car jack mounted onto plywood becomes an inexpensive adjustable stool for weight bearing and balance exercise (right).</strong></a><br /> <p>Because it is removable, one can decide the time to start body weight bearing exercise based on the wound condition. The R.R.D. allows observation of the limb after each graded weight bearing exercise. By doing so, one can plan both the amount and duration of the next weight exercise.</p> <p>For unilateral amputees, the weight bearing exercise can be done by standing on a padded car jack (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg"><b>Fig. 8</b></a>).</p> <p>For bilateral amputees, the tilt-table is used for weight bearing. The degree of weight stress is controlled by the inclination of the tilt table and the duration of standing. This proceeds progressively to the upright position and is followed by ambulation with walking heels attached to the casts (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg"><b>Fig. 10</b></a>). Walking with Rigid Dressings helps bilateral amputees develop balance and sometimes is preferred by the obese and cardiac patients at home (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg"><b>Fig. 10</b></a>). Walking with the R.R.D. also assists the evaluation of questionable candidates for prosthetic fitting. Ambulatory use of the R.R.D. produces simulation of prosthetic stress, allowing the amputee to quickly adapt to the actual prosthesis, an impossible step when using the conventional elastic bandaging method.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg"><strong>Figure 10. A) For bilateral amputees, weight bearing exercise is done on the tilt table. B) The stump is examined to modify the amount of weight bearing, i.e. the degree of inclination and duration of weight bearing. C) Weight bearing continues to the upright position in the parallel bars, and D) eventually to ambulation with walking heels attached to the casts or with a preparatory prosthetic fitting.</strong></a><br /> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg"><b>Fig. 11</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg"><b>Fig. 12</b></a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg"><strong>Figure 11. A stump with bony prominence and scars cannot tolerate the elastic bandage, but has no difficulty with Removable Rigid Dressing.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg"><strong>Figure 12. A one handed patient, either due to hemiplegia or upper limb amputation, can use the system easily.</strong></a><br /> <h3>Making A New Cast</h3> <p>The below-knee cast is changed whenever the residual limb has shrunk to the point at which too many tube socks are being used, usually about 10-14 ply of socks. The total number of casts needed depends on the speed of progressive shrinkage. Frequently three or four casts are required before the patient is ready to be fitted for a preparatory prosthesis.</p> <h3>R.R.D. Compared To IPSF</h3> <p>Both the R.R.D. and the thigh high rigid dressing provide immobilization of soft tissue, prevention of trauma, and prevention of edema. However, being removable, the R.R.D. allows frequent limb observation without a need for cast-cutting and cast-reapplication as needed in a thigh high rigid dressing. More importantly, it permits frequent addition of tube socks for fast shrinkage.</p> <p>Because space is provided between bony prominences and the plaster, adding tube socks will produce compression force to soft tissues, but will not cause pressure sores (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg"><b>Fig. 4</b></a>). If there is excessive pressure over an area, the cast can be softened from outside with a hammer, then pushed from inside for relief.</p> <p>Being removable, the R.R.D. has been very useful in monitoring the limb's response to weight bearing exercise. This facilitates progressive weight bearing within the safe tolerance range. Both undesirable skin breakdown from excessive weight bearing activity and hesitation in application of early graded weight bearing stress are minimized.</p> <h3>R.R.D. Compared To The Shrinker</h3> <p>The residual limb shrinker is an effective method for shrinkage, except for the danger of excessive pressure over bony areas or thin grafted skin. It does not protect the limb from unexpected falling, nor does it allow weight bearing exercise. The compression force can be adjusted by sewing the shrinker periodically rather than by adding socks as with the R.R.D.</p> <h3>R.R.D. Compared To The Elastic Bandage</h3> <p>The elastic bandage is not only difficult to apply for the staff and the elderly below-knee amputees,<a></a> but also is so unreliable that it frequently causes skin breakdown and distal edema (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg"><b>Fig. 2</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg"><b>Fig. 3</b></a>). It cannot protect the limb from trauma due to accidental falling. With the R.R.D., it is much easier for the patient to don and doff as well as adjust the compression, accommodate progressive shrinkage,<a></a> and perform weight bearing exercise.</p> <p>Since the adoption of the R.R.D. at this medical center, the problems of skin breakdown and distal edema, commonly seen in the past from elastic bandaging, have been completely eliminated (<b>Fig. 13</b>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-14.jpg"><strong>Figure 13. One of the first patients achieved 15-ply shrinkage in 7 days and spontaneous healing of the right pretibial sore caused by an elastic bandage.</strong></a><br /> <h3>R.R.D. For Delayed Wound Healing</h3> <p>Delayed wound healing is not a contraindication for using the R.R.D. or a preparatory prosthesis. The R.R.D. is a useful means to facilitate wound healing, because the system reduces edema and tissue tension. The size of the open wound can be reduced and the edges of the wound can be brought closer together. With frequent debridement of the necrotic tissue and adding socks for shrinkage, often a big open wound can be healed without surgery (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg"><b>Fig. 14</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg">Figure 14. Removable Rigid Dressing facilitated shrinkage of the limb (upper left) and the open wound. By frequent debridement and prosthetic fitting (upper right), the wound completely healed without skin graft (lower left).</a><br /></strong><br /> <h3>Scotchcast™ Preparatory Prosthesis</h3> <p>When the patient is able to tolerate full weight bearing in the R.R.D. and the residual limb is no longer bulbous, a Scotchcast™ preparatory prosthesis can be fit for early gait training and further shrinkage.<a></a> The advantages of the Scotchcast™ preparatory prosthesis are its moderately light weight, comfortable fitting, rare need for realignment, and reduction of fabricating time. This is achieved by, 1) direct formation of the socket on the residual limb with special pressure relief techniques, 2) use of a wool sock lining as the soft interface, and 3) precise semi-dynamic alignment of the prosthesis. Since the Scotchcast™ prosthesis can be fabricated within 1 1/2 hours during the patient's initial visit, the delivery of this prosthetic service is very efficient and cost effective.</p> <h3>Conclusion</h3> <p>The Removable Rigid Dressing has proved to be a very reliable means of preprosthetic management of the below knee amputee at this institution and others for the past nine years. It has proven to shorten the time from amputation to the initial preparatory prosthesis; is shown to be equal to or superior to all other means of preprosthetic stump management; features easy application; simple donning and doffing by the patient; progressive stump shrinkage by adding socks under the cast; gives protection through its rigidity for the not yet healed stump; ease in wound inspection; and allows early weight or pressure bearing to be started, thus conditioning the soft tissues for the first prosthesis. The R.R.D. has no contraindications other than application to a residual limb with a deep wound infection that requires surgical intervention.</p> <h3>Acknowledgments</h3> <p>The authors wish to express their appreciation to Henry B. Betts, M.D., Robert Keagy, M.D., Nasim Rana, M.D. and Dudley Childress, Ph.D., for their support in the development and demonstration of this technique.</p> <p><b>References:</b></p> <ol> <li>Burgess, E.M. and Romano, R.L., "The Management of Lower Extremity Amputees Using Immediate Postsurgical Prostheses," <i>Clin. Orthop.</i>, 57, 1968, pp. 137-146.</li> <li>Burgess, E.M., Romano, R.L., and Zettl, J.H., "The Management of Lower Extremity Amputations," <i>Technical Report TR10-6</i>, Prosthetic and Sensory Aids Service, Departments of Medicine and Surgery, Veterans Administration, Washington, D.C., 1969.</li> <li>Kay, H.W. and Newman, J.D., "Relative Incidence of New Amputations: Statistical Comparisons of 6,000 New Amputations," <i>Orthotics and Prosthetics</i>, Vol. 29, No. 3, 1975.</li> <li>Mooney, V., Harvey, J.P., Jr., Mcbride, E., and Snelson, R., "Comparison of Postoperative Stump Management: Plaster vs. Soft Dressings," <i>Journal of Bone and Joint Surgery</i>, 53-A, March, 1971, pp. 241-249.</li> <li>Mueller, M.J., "Comparison of Removable Rigid Dressing and Elastic Bandages in Preprosthetic Management of Patients with Below-knee Amputations," <i>Physical Therapy</i>, 62, 1982, pp. 1438-1441.</li> <li>Wu, Y. and Flanigan, D.P., "Rehabilitation of the Lower-Extremity Amputee with Emphasis on a Removable Below-Knee Rigid Dressing," pp. 435-453, and "Gangrene and Severe Ischemia of the Lower Extremities," edited by John J. Bergan, M.D. and S.T. James Yao, M.D., Grune and Stratton, New York, 1978.</li> <li>Wu, Y., Keagy, R.D., Krick, H.J., Stratigos, J.S., and Betts, H.B., "An Innovative Removable Rigid Dressing Technique for Below-the knee Amputation," <i>Journal of Bone Joint Surgery</i>, 61A, 1979, pp. 724-729.</li> <li>Wu, Y., Brncick, M.D., Krick, H.J., Putnam, T.D., and Stratigos, J.S., "Scotchcast™ P.V.C. Interim Prosthesis for Below-knee Amputees," <i>Bulletin of Prosthetics Research</i>, BPR 10-36, Fall, 1981.</li> <li>Parhad, A., Gervis, B., and Wu, Y., "From The Clinic: The Rigid Dressing; Pre-prosthetic Ambulation for the Below-knee Amputee, A<i>mer. Corr. Ther. J.</i>, 37, 1983, pp. 66-89.</li> <li>Gervis, B., Parhad, A., and Wu, Y., "From The Clinic: Fabrication of the Removable Rigid Dressing and Supracondylar Cuff for the Below-knee Amputee," <i>Amer. Corr. Ther. J.</i>, 35, 1982, pp. 126-133.</li> <li>Wu, Y., Krick, H.J., and Sankey, J.A., "Postoperative and Prosthetic Management of Below-knee Amputee with Removable Rigid Dressing and Scotchcast™ Preparatory Prosthesis." <i>Proceedings of 8th annual Conference of Rehabilitation Engineering Society of North America</i>, 1985, pp. 370-372.</li> </ol> <b>Harold Krick, CP. </b> Rehabilitation Institute of Chicago, 345 E. Superior Avenue, Chicago, Illinois 60611.<br /><br /><b>Yeongchi Wu, M.D. </b> Rehabilitation Institute of Chicago, 345 E. Superior Avenue, Chicago, Illinois 60611.<br /> <div style="width: 400px;"></div> Page Number(s) 33 - 44 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg Figure 7 FIGURE 7 (a,b,c) http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg FIGURE 7 (d,e,f) http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-14.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Removable Rigid Dressing for Below-knee Amputees Creator An entity primarily responsible for making the resource Yeongchi Wu, M.D. * Harold Krick, CP. * https://staging.drfop.org/files/original/fd344d1bf2adb584d43dc2883f0c31f1.jpeg 9901599437049b07b6803e1ba24f1ff8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL www.limbsforlife.org Contact Name/Title Randy Titony - Executive Director Address 9604 N May Ave. City Oklahoma City State/Province Oklahoma Countries Served USA Regions: Africa, North America, Central America, Middle East, Asia, South AmericaCountries: Ecuador, Guatemala, Haiti, Mexico, Panama, Philippines, Dominican Republic, AfricaAge Group: Adults, ChildrenFees Charged: No Postal Code 73120 Phone 405-843-5174 Fax 405-843-5123 Email admin@limbsforlife.org Organization Type Including ID and tax status Non-profit Tax ID 73-1422414 Not-for-profit Type 501C-3 Need I Financial Assistance Need II General Background Information Need III Volunteers Additional Info & Comments Mission StatementLimbs for Life is a global nonprofit organization dedicated to providing fully functional prosthetic care for individuals who cannot otherwise afford it and raising awareness of the challenges facing amputees. Historic Information The Limbs for Life Foundation was established in 1995. Prosthetist John A. Sabolich saw a need to assist amputees who did not have insurance coverage for prosthetics. His passion for helping amputees was deep-rooted in his family’s history, as his father Lester opened his first prosthetic clinic in Oklahoma City in 1947. Sabolich grew up watching his father give the gift of movement through prosthetic care. His vision for a global network comprised of clinics and partners to assist amputees in need continues through Limbs for Life Foundation. ​ Since its inception, Limbs for Life has provided thousands of new prosthetic limbs to amputees across the United States. Many more amputees are helped with the distribution of used prosthetic parts and components shared through international partnerships and missions, empowering amputees on five continents. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Limbs for Life Foundation https://staging.drfop.org/files/original/06f6f74cd10bc2ee26ce0685431872f2.jpg a8da2dd297edbf8190bce6c70291735a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL www.altso.org Address 401 Park Avenue South, 10th Floor City New York State/Province New York Countries Served USA Regions: Africa, Middle East, Asia, South AmericaCountries: Afghanistan, Bangladesh, Cambodia, Colombia, India, Indonesia, Nepal, Pakistan, SomalilandSpecific cities, regions, or groups of people: children with limb disabilities in the developing worldAge Group: ChildrenFees Charged: No Postal Code 10016 Phone 212.683.8805 Fax 212.683.8813 Email info@altso.org Organization Type Including ID and tax status Non-profit Tax ID 02-0594709 Not-for-profit Type 501(c)(3) Services Provided Prosthetic Fitting, Orthotic Fitting, Prosthetic Fabrication, Orthotic Fabrication, Medical / Surgical Care, Rehabilitation / Training Need I Financial Assistance Need II Materials, Components, and Equipment Need III Materials, Components, and Equipment: New, Equipment Additional Info & Comments Since 2003, ALTSO has been partnering with local treatment providers in Africa, Asia and Latin America to bring free orthopedic care to children in need. To learn more about ALTSO's mission or about how to get involved, please visit www.altso.org.Specific needs include: financial assistance and prosthetic supplies/equipment and raw materials.All donations and contributions, both monetary and in kind, are acknowledged as tax deductible donations to the full extent permitted by law, upon receipt. Memorials, honorariums, charitable annuities and sponsorships are graciously accepted. Facebook Page <a href="https://www.facebook.com/alegtostandon" target="_blank" rel="noopener">https://www.facebook.com/alegtostandon</a> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Leg To Stand On https://staging.drfop.org/files/original/69e82431a397885067840fb6bbdf7480.jpg 52d97f0792155a612a44e2ce8256fe13 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL www.camo.org Contact Name/Title Kathryn Tschiegg - Director Address 322 Westwood Avenue City Orrville State/Province Ohio Countries Served USA Regions: Central AmericaCountries: HondurasSpecific cities, regions, or groups of people: Western HondurasAge Group: Adults, ChildrenFees Charged: Sometimes Postal Code 44667 Phone 330-683-5956 Fax 330-683-9978 Email camo@camo.org Organization Type Including ID and tax status Non-Profit Tax ID 34-1740695 Not-for-profit Type 501C-3 Services Provided Prosthetic Fitting, Orthotic Fitting, Medical Equipment / Supplies, Education, Funding, Prosthetic Fabrication, Orthotic Fabrication, Medical / Surgical Care, Rehabilitation / TrainingThere is a facility/physical building for patient care at the specified location. Accomodations for volunteers near or at the specified location. Need I Financial Assistance Need II Materials, Components, and Equipment Need III Materials, Components, and Equipment: New, Disassembled, Equipment, Used, Medical Supplies Additional Info & Comments In order to fulfill demand, CAMO is always in need of prosthetic and orthotic components, financial assistance and co-polymer plastic. 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 Central American Medical Outreach, Inc. https://staging.drfop.org/files/original/e55fe02d0cf8042e8e390517f507f005.png 9879f15cbcbb416d004b012e4155375c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL <a href="https://www.designedtolivelatvia.com">www.designedtolivelatvia.com</a> Contact Name/Title Katie Leatherwood - Director City Riga Countries Served Latvia Regions: EuropeCountries: LatviaAge Group: Adults, ChildrenFees Charged: No Postal Code 1010 Phone 371 20621308 Email Katie@designedtolivelatvia.com Organization Type Including ID and tax status Non-profit Not-for-profit Type 501(c)(3), Christian ministry Services Provided Prosthetic Fitting, Orthotic Fitting, Education, Prosthetic Fabrication, Orthotic Fabrication, Rehabilitation / Training Need I Financial Assistance Need II Materials, Components, and Equipment Need III Materials, Components, and Equipment: New, Disassembled, Equipment, Used Additional Info & Comments Designed to Live is a mercy ministry of Bridge Builders International. O&P services are provided to those that would benefit but are unable to get them, due to transportation issues or qualification criteria. Designed to Live works from a mobile care unit to provide O&P services when transportation is a factor. Designed to Live collaborates with local O&P providers to enhance care and education and to avoid encroachment on private and governmental practices.Beyond O&P services, Designed to Live seeks to empower those affected by physical disability through social, emotional, physical, and spiritual involvement. We hope to empower those with disability to live a life of meaning and significance. 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 Designed to Live