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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_128.pdf Text Any textual data included in the document <h2>With a Spring in One's Step</h2> <h5>D.D. Murray, M.D. <a style="text-decoration: none;">*</a> W.J. Hartvikson <a style="text-decoration: none;">*</a> H. Anton <a style="text-decoration: none;">*</a> E. Hommonay, C.P.O.(C) <a style="text-decoration: none;">*</a> N. Russell, C.P.(C) <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> In recent years, there has been a significant number of new developments in prosthetics in both North America and Europe. New concepts for socket molding, knee control, dynamic foot action, and the utilization of space-age materials have expanded prosthetic development and performance. The traditional prosthetic foot had a keel and an articulated ankle. This concept has modern derivatives with multi-axis ankles, but the principle remains the same. The S.A.C.H. foot design is that of the solid ankle and cushioned heel. By virtue of a compressible heel of a selected rubber density, the wearer achieves a simulated ankle motion at heel strike.<a></a> This design has been a mainstay in prosthetic fabrication for several decades. These feet are both essentially passive and accommodating. The Seattle foot, with its cushioned heel and keel spring action, stores energy through the stance phase of gait and releases it at toe-off, thus imparting a dynamic component to gait.<a></a> An added feature of this foot is that of cosmetic molding. The principle of dynamic toe-off to improve the mechanical efficiency of the prosthesis is an attractive one, and it forms the basis for the design of the Seattle foot. The purpose of this study is to evaluate the performance of the Seattle foot and subjectively and objectively determine whether or not it improves prosthetic gait. <h3>Clinical Investigation</h3> A questionnaire was designed to gather general demographic data and review foot function in general living situations. Thirty-three patients were identified in the last two years as having been fit with a Seattle foot, and 31 (94%) responded to the questionnaire. There were 27 males and four females. The age range was from 24 years to 72 years (Fig. 1). <a href="/files/original/8636aa4e4c5c07d52b8abe2b11b37b34.jpg" target="_blank" rel="noopener">Figure 1</a>. The age range was from 24 to 72 years. The weight of the patients ranged from 95 pounds to 195 pounds and their height ranged from 5'1" to 6'4". Amputation dates ranged from 1930 to 1986, with over half of the respondents having been injured since 1975. On average, each patient had 3.75 surgical procedures, with a range from 1 to 24. The length of time from amputation to prosthetic fitting was, for the most part, under one year (Fig. 2). <a href="https://staging.drfop.org/files/original/5b4a9dbd8c695c2a35af0d77111fe2c1.jpg" target="_blank" rel="noopener">Figure 2.</a> The length of time from amputation to prosthetic fitting was, for the most part, under one year. The original foot supplied in most cases was a S.A.C.H. foot. The next most frequent, in order, was a single axis ankle with a keel foot. The remainder are unknown. A significant number of the candidates had been using their original foot an average of 14 years before having it changed to a Seattle foot. For the most part, people were attracted to the Seattle foot because of a better design and newer technology. They wished for added spring, flexibility, and mobility in the foot. Some simply tried it because it was recommended by staff, or because they liked the cosmetic appearance. The length of time for use of the Seattle foot ranges from one month to two years with an average of 8.5 months (Fig. 3). <a href="/files/original/8487fa7a9496454abdd425b5a0d7785f.jpg" target="_blank" rel="noopener">Figure 3.</a> The length of time for use of the Seattle foot ranges from one month to two years, with an average of 8.5 months. The Seattle foot was fit on 29 below-knee amputees and two above-knee amputees. The heel stiffness in the Seattle foot was rated as acceptable in 80% of cases. Twelve percent (12%) felt it was too stiff. Eighty-one percent (81%) of respondents felt that they had good ankle motion with the Seattle foot, and 19% felt they did not. Seventy-four percent (74%) of respondents felt that the ankle motion was greater than with the previous foot, 16% felt it was the same, and 10% felt less ankle motion. When questioned about the shock stress at the hip or knee, 55% felt there was decreased shock stress and 39% felt that there was no change. When questioned about the effect of the Seattle foot on changing gait, 87% felt it was better and 13% felt it was the same. Eighty-seven percent (87%) were aware of toe-off action in the Seattle foot and 13% were unaware of it. The toe-off action was most noticeable when accelerating quickly, climbing up or down, playing ball sports, and running or walking on uneven ground. Forty-eight percent (48%) of the respondents would have preferred greater toe-off action, whereas 52% were satisfied with the toe-off. Half the respondents felt the Seattle foot had made a general difference to their recreational pursuits. When specific activities were rated, at least 50% of respondents felt that walking, going up and down stairs, hiking, dancing, and jogging were consistently easier than with the previous foot. Balance and endurance on the prosthesis was felt to be easier by about 61% of the respondents and smoothness was better in 87%. Uneven terrain was considered easier by 74%, but 3% said it was more difficult. In fact, the Seattle foot does not provide as much forefoot flexibility in the medial-lateral plane as with an articulated ankle joint. Walking and running was easier for 67% of the respondents (48% of the patients jogged). Of the 61% who dance, 74% found it easier. Of those people responding negatively to the Seattle foot, the pattern was either negative responses throughout the questionnaire (by four respondents) or negative responses for certain functions, such as the half who felt there was no difference in the recreational pursuits. Of these negative responses, there was no pattern either in terms of age, weight, or amputation site. The greatest advantages with the Seattle foot were reported to be a more natural and smooth action, resulting in an improved gait (Fig. 4), better ability to handle stairs and uneven ground, and improved abilities in sports. <a href="https://staging.drfop.org/files/original/6d91bb58231e3290cbcf8e2dd6de2830.jpg" target="_blank" rel="noopener">Figure 4.</a> The greatest advantages with the Seattle foot were a more natural and smooth action. The cosmetic design and the anatomical detail were appreciated by 97% of the respondents. Residual limb pain was felt to be decreased in 39% of respondents and unchanged in 45%. Sixteen percent (16%) did not respond to this question. The foot design had not been expected to have any effect on this problem. Skin problems were felt to be decreased in 55% of the respondents. Thirty-five percent (35%) said there was no change. The foot design was not expected to improve this clinical problem either. The Department of Veterans Affairs in Seattle has reported an evaluation of the Seattle foot.<a></a> Although a comparison of amputee groups was not possible, the results of this clinical survey compare favorably with the original study. Fig. 5, <a href="/files/original/07792a7c6f21b09b088faf9389ca2610.jpg" target="_blank" rel="noopener">Fig. 6</a>, and <a href="/files/original/11eb68ee39aa5ebeb200cda4a27eeebc.jpg" target="_blank" rel="noopener">Fig. 7</a> graphically demonstrate the comparison. <a href="https://staging.drfop.org/files/original/1b17acd6b2b5de624697430d6894d59e.jpg" target="_blank" rel="noopener">Figure 5</a>. A comparison of two clinical surveys of the Seattle foot for running and walking. <h3>Laboratory Investigation</h3> Electrogoniometric Evaluation A gait study using a single amputee with many years experience with a S.A.C.H. foot and several years experience with the Seattle foot was undertaken at the G.F. Strong Gait Laboratory. Motion in the lower extremity was analyzed using a computerized electrogoniometric system. This system accurately measures movement in three planes at the hip, knee, and ankle and stores data for subsequent analysis.<a></a> The S.A.C.H. foot, Seattle foot, and non-prosthetic side were compared. Patterns of movement measured at the hip were similar for the S.A.C.H. and Seattle feet and resembled those seen on the non-prosthetic side. At the knee, the Seattle foot produced a more repeatable pattern of internal-external rotation and varus-valgus than did the S.A.C.H. foot (<a href="/files/original/197c2d8a6200d52ac28aef88fcc77fdd.jpg" target="_blank" rel="noopener">Fig. 8 </a>and <a href="/files/original/afdc0eb1a348faf2d0c27285bcbb337e.jpg" target="_blank" rel="noopener">Fig. 9</a>). The greatest differences between the S.A.C.H. and Seattle feet were seen at the ankle. The patterns of forefoot abduction-adduction, plantar flexion-dorsiflexion, and in-version-eversion were all more repeatable for the Seattle foot. Also, the pattern of plantar flexion-dorsiflexion for the Seattle foot more closely resembled that of the non-prosthetic side (<a href="https://staging.drfop.org/files/original/2250f8e6296a64f9cab5e169d1c2b241.jpg" target="_blank" rel="noopener">Fig. 10</a> and <a href="/files/original/6a4612dbdc98238350b49fd1d433b615.jpg" target="_blank" rel="noopener">Fig. 11</a>). In summary, the Seattle foot generally produced a more repeatable pattern of motion at the knee and ankle than the S.A.C.H. foot, and the pattern of plantar flexion-dorsiflexion for the Seattle foot appeared more normal. Force Plate Evaluation Through the facilities of Simon Fraser University Kinesiology Department, a force plate study was done on the same single subject. The vertical compression forces generated by the S.A.C.H. and Seattle feet during stance were measured. Fig. 12 demonstrates typical forces measured during stance in a below-knee amputee on the non-prosthetic side. A maximum peak is seen immediately after heel strike. This is followed by a trough in mid-stance and a second, lesser peak at push-off. <a href="/files/original/013bbfd894737f6f6987e68067760431.jpg" target="_blank" rel="noopener">Figure 12</a>. Typical forces measured during stance in a below-knee amputee on the non-prosthetic side. Fig. 13 illustrates the forces generated in the same individual during stance on his prosthetic side while using a Seattle foot. Fig. 14 shows stance forces generated in the same individual on his prosthetic side using a S.A.C.H. foot. <a href="/files/original/6b60e9da47923de26b69a07869eb13ed.jpg" target="_blank" rel="noopener">Figure 13</a>. The forces generated in the same individual during stance on his prosthetic side while using a Seattle foot. <a href="/files/original/b6a47343d2d4db601a1452d432a910bb.jpg" target="_blank" rel="noopener">Figure 14</a>. Stance forces generated in the same individual on his prosthetic side using a S.A.C.H. foot. The initial peak is greater for the S.A.C.H. than the Seattle foot. This suggests more effective shock absorption at heel strike for the Seattle foot than the S.A.C.H. foot. The second peak is less than that seen on the non-prosthetic side with both feet, but is greater for the Seattle foot than the S.A.C.H. foot. Thus, the Seattle foot more closely approximates normal push-off force than the S.A.C.H. foot. The trough at mid-stance is shorter with the S.A.C.H. foot than on the non-prosthetic side. The mid-stance trough for the Seattle foot more closely approaches that of the non-prosthetic side, suggesting a more normal pattern of foot-ankle motion than with the S.A.C.H. foot. In summary, the Seattle foot generally appears to produce a more normal pattern of vertical forces than the S.A.C.H. foot and produces a greater force at push-off. <h3>Conclusion</h3> The overall patient response to the questionnaire regarding the effectiveness of the Seattle foot was positive. Comparison with the Seattle Study revealed similar results. Gait studies undertaken tended to support the clinical impression with regard to both kinetics and kinematics. Overall, this dynamic foot design offers definite advantages to the prosthetic user. At best, prosthetic users seem to get an increased gait smoothness, with the dynamic toe action positively influencing their abilities on rough ground and inclines. At worst, their gait pattern is not negatively influenced by this spring action. <h3>Acknowledgments</h3> The authors wish to thank the G.F. Strong Gait Lab and Dr. Cecil Herschler, as well as the Simon Fraser Kinesiology Department and Dr. Arthur Chapman for their technical assistance in the preparation of this study. References: <ol> <li>Orthopaedic Appliances Atlas. Vol. 2, Artificial Limbs, Editor J.W. Edwards, Ann Arbor, Michigan, 1960, pp. 149-151.</li> <li>Reswick, J.B., "Evaluation of the Seattle Foot," J. Rehab Research and Development, Vol. 23, No. 3, pp. 77-94.</li> <li>Burgess, E.M. et al., "Development and Preliminary Evaluation of the V. A. Seattle Foot," Journal of Rehabilitation Research and Development, Vol. 22, No. 3, B.P.R. 10-42, pp. 75-84.</li> <li>Chao, Edmund, "Justification of Triaxial Goniometer for the Measurement of Joint Rotation," J. Biomechanics, Vol. 13, 1980, pp. 989-1006.</li> </ol> *N. Russell, C.P.(C) Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. *E. Hommonay, C.P.O.(C) Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. *H. Anton Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. *W.J. Hartvikson Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. *D.D. Murray, M.D. Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. Page Number(s) 128 - 135 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource With a Spring in One's Step Creator An entity primarily responsible for making the resource D.D. Murray, M.D. * W.J. Hartvikson * H. Anton * E. Hommonay, C.P.O.(C) * N. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_008.pdf Text Any textual data included in the document <h2>The Biomechanics of the Foot</h2> <h5>André Bähler <a style="text-decoration: none;">*</a></h5> "The human foot is one of nature's works of art and as such, it has not yet been fully recognized and explained. It will require a deal of scientific investigation before this structure is fully understood." These words of the old master of orthopaedics, Georg Hohmann, from his book "Fuss und Bein" are still applicable today. Thirty years later, the biomechanics of the foot have still not been completely explained, and there are many questions yet unanswered. The many, more or less articulated connections of the foot allow a variety of changes which make it difficult to understand the movement as a homogeneous process. Too many factors can only be qualified, but not quantified. Nor may we forget the reciprocal influence of the position of the foot, knee, and hip joints. Each change in the position of one of these joints automatically involves a change in the position of the other two joints. For example, in the upright position, the neck of the femur forms a posteriorly open angle of approximately 20 degrees. This is determined by the anatomical factors in relation to the frontal plane of the body. The direction of the axis of the hip joint corresponds fairly accurately to the connection inner-malleolus/ outer-malleolus, which have an exterior rotation of approximately 20 to 30 degrees in relation to the frontal plane. Consequently, there is a conformity between the ankle axis and the hip axis. In the upright position, the knee is practically locked due to the automatic rotation, so the position of this axis is of minor importance. When walking, the pelvis rotates approximately 20 degrees forward. As the lower leg also rotates inwardly in relation to the upper leg during flexion, the ankle axis rotates inwardly and the foot takes up a straight position in the swing phase. <h3>Characteristics Of The Foot</h3> The foot has the characteristics of a triple axial joint which allows it to assume any position. The three main axes of movement converge in the talus area (<a href="staging.drfop.org/files/original/557b90124720a7da30c19930ed30060d.jpg">Fig. 1</a>). Particularly during rotational movements to adapt the foot to an uneven surface, all the joints are involved to some extent; nevertheless, the ankle joint, although formed as a hinge joint, forms the main joint for locomotion. According to Kapandji, the foot can be compared architectonically to a vault, which is supported by three arches. Other authors criticize this vault-concept on the basis that it is too static. However, the vault-structure is very meaningful as an aid to analyzing the foot in general (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-02.jpg">Fig. 2</a>). The arrow shows the direction and position of the main weight, which is first taken by the calcaneus (A) and then transferred to the forefoot: inside on metatarsal I (B) and outside on metatarsal V (C). The front transversal vault can also be understood as a supporting construction: on the one side the two corner stones (metatarsal I and metatarsal V) and on the other side, the transverse vault (metatarsal II, III, and IV). This construction enables the forefoot to take a great amount of weight and at the same time allows the foot to adapt to uneven surfaces. Furthermore, it can be seen that when the feet are put together, the position of both cal-canei can be regarded as a vault structure. The position of the calcaneus together with a slight valgus position serves to stabilize the body, particularly during the walking motion of the leg (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-03.jpg">Fig. 3</a>). <h3>The Joints</h3> The joints themselves pose some problems. Let us take for example the development of the inclination of the trochlea of the talus, and the distal tibial epiphyseal cartilage to the longitudinal axis of the lower leg in the frontal plane as described by Lanz Wachsmuth. Left in the infant and right in a two year old (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-04.jpg">Fig. 4</a>), it can be seen that the axes of the ankle joint and the talocalcaneonavicular joint and that of the epiphyseal cartilage are developing. In the 12 year old, left, and in the adult, right, the axis becomes horizontal during normal growth process, stabilizing the support system of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-05.jpg">Fig. 5</a>). The changes in the various process-, movement-, and development-axes of the ankle during the development of the child are probably one reason for the controversial views over the biomechanics of the foot. Biomechanically we are interested in the joints, and in particular, those used when walking. The Ankle Joint The ankle joint (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-06.jpg">Fig. 6</a>) is of particular importance, because in at least one direction it secures a movement without which it would be impossible to walk. This joint could also be described as a hinge joint with a diagonal axis of rotation, which allows a movement of about 20 degrees up and down. This inclination of the ankle joint certainly contributes to stability when carrying weight and can only be fully understood when considered in connection with the talocalcaneonavicular joint. The Talo-Calcaneonavicular Joint The movement of the talocalcaneonavicular joint is decidedly more difficult to understand. Whereas the axis of the ankle joint can easily be defined, the axis of the talocalcaneonavicular joint is drawn obliquely from lateral posterior to medial anterior. It is surprising that both articular surfaces of the talocalcaneonavicular joint are congruent only in the mid-position. An incongruence develops between the two articular surfaces by both eversion and inversion. This incongruence cannot be maintained for long periods when carrying weight. The ankle joint and the talocalcaneonavicular joint must be regarded as a functional unit. The possible movements of these two joints can be compared to a spheroid joint which can be moved freely within its range of motion: flexion, supination, pronation, abduction and adduction which in some respects corresponds to a rotation. Chopart's Joint The talocalcaneonavicular joint, comprising the talus and the navicular, and the joint which is formed from the calcaneus and the cuboid, together all form a sort of working unit. These two joints comprise Chopart's joint which allows a rotational movement of the fore-foot. Lisfranc's Joint The Lisfranc joint is a collective joint where the three cuneiform bones and the cuboid bone on the one side, and the five metatarsal bones on the other side, are united to form an articular connection. The small deflectionary movement can be described as in an obliquely situated hinge exhibiting dorsal and plantarflexion. The Chopart and the Lisfranc joints are connected by taut ligaments so that there is hardly any friction between them. They serve primarily to give elasticity to the foot during pressure and allow it to adapt better to uneven surfaces. The Transversal Anterior Vault of the Foot From metatarsal I to metatarsal V, the metatarsal bones form an oblique arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-07.jpg">Fig. 7</a>). This arch tends to drop due to excessive pressure, which can partly be attributed to walking on level ground. This "even" walking, which always puts pressure on the same points of the foot, leads to over-exertion of the individual metatarsal heads. The Toe Joints The toe joints are limited spheroid joints. That is, they are capable of sideways movement within certain limits, but are primarily intended as hinge joints with movement upwards and downwards. <h3>The Ligaments</h3> It is known that the structure of the foot is held together with muscles and ligaments. These ligaments are so constructed as to be able to withstand the extreme pressures exerted on the foot (long jump and high jump). <h3>The Muscles</h3> Long and short muscles hold and move the foot. If one of the muscles gives way, it is immediately visible from the gait how important the interaction of each muscle group is for locomotion. However, descriptive anatomy is not the theme here and so a further discussion of this aspect must be omitted. <h3>The Mechanics Of Depression Of The Foot</h3> Experience has shown that not every valgus of the calcaneus results in an equivalent drop of the longitudinal vault. The talipes valgoplanus is a collective term for different inadequacies which arise when the foot is under pressure. These can be classified according to different characteristics: (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-08.jpg">Fig. 8</a>) <ol> <li> The pronation position of the calcaneus; </li> <li> Inward rotation of the ankle joint; </li> <li> A forward and inward drop of the talus; </li> <li> Abduction of the fore-foot; and </li> <li> Supination, i.e., a turning upwards of the first metatarsal. </li> </ol> These five basic characteristics of the talipes valgoplanus lead to a variety of outward manifestations, which must be taken into consideration when deciding on a course of action. This wide variety is one reason why the kinematics of the foot eludes an exact biomechanical and mathematical analysis. When pressure is applied in valgoplanus, the calcaneum gives way but the fore-foot remains flat on the ground, regardless of the extent of the flexion. Congenital and ischaemic valgoplanus are exceptions to this but they are not included in the discussion here (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-09.jpg">Fig. 9</a>). Between the calcaneus, rear-, and fore-foot there is a distortion or rotation. If pressure is removed from the foot, the calcaneus falls into a vertical position, but the fore-foot then rotates to the same degree. Consequently the position of the rear-foot relative to the fore-foot remains a constant deformity (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-10.jpg">Fig. 10</a>). What then is the role of the shoe in the standing position and swing-phase? In the standing position, more pressure is exerted medially on the rear part of the shoe (the counter and the heel), depending on the extent of the valgoplanus. However, the front of the shoe remains flat on the ground regardless of the extent of the deformity. In the swing-phase, the distortion between the fore- and rear-foot influences the alignment of the shoe. If the heel is too big or badly fitting, the fore-foot dictates the position of the shoe and as a result there is an unwanted deflection of the heel of the shoe from the heel of the foot. This means that the heel-strike is lateral and as pressure is exerted, it then turns inwards and adapts to the surface whereby it has returned to the original standing position. The distortion between the fore- and rear-foot, combined with an inadequate heel counter, produces a potential risk of injury. A stone on an inclined surface can easily lead to a strained joint (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-11.jpg">Fig. 11</a>). This phenomenon is particularly significant for sportsmen and joggers who train in open country. After suffering such strains, the fear of further injury can hinder training. <h3>Deformity Of The Fore-Foot (Talipes Transversoplanus)</h3> During growth, there is a slight biomechanical change in the lateral metatarsal arch. The first metatarsal rotates pronatorally and this leads to a greater arching in adults. Congenital ligament or tissue weakness can cause this lateral arch to flatten under pressure and so result in a broadening of the fore-foot. Here, the length of the various metatarsal bones compared to the different patterns of pressure exerted on the fore-foot is of significant importance. Depending on the type of foot, the first or second metatarsal will be under greater pressure depending on which is the longer of the two. Instability between the fore- and rear-foot can also result if the inclination between metatarsal one and metatarsal five is too great. This type of foot tends to tilt sideways during the propulsion process of walking. In the case of the high-arched foot, the angle between the metatarsal and the ground increases, resulting in a greater load to the individual metatarsal heads. <h3>The Shoe</h3> From a biomechanical point of view, the shoe plays a significant part in the process of walking and standing. The height of the heel as well as the thickness of the sole greatly influence the conveyance of the weight and consequently influence locomotion itself. This sphere of influence must be duly considered, particularly in cases of static deformity. A build-up of the shoe, i.e., constructing a rocker bottom must be compensated for at the heel, otherwise the relationship between the heel-height and sole-thickness in the front of the shoe will be disturbed, thus having a negative effect on the roll-over process (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-12.jpg">Fig. 12</a>). <h3>Cushion-Heel</h3> The attachment of a cushion-heel also changes the roll-over process in that it acts as a shock absorber at heel strike and at the same time increases the roll-over (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-13.jpg">Fig. 13</a>). <h3>Heel-To-Toe-Roll For The Whole Sole</h3> A heel-to-toe roll sole can be attached to the shoe to protect the ankle joint and Chopart's joint. Measured radially from the knee, this allows a complete roll of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-14.jpg">Fig. 14</a>). <h3>The Use Of Insoles</h3> The insole and the shoe must form a unit with the level ground. Whether the foot is neutral, in pronation or supination, is of no significance. When insoles are made of solid material, their length and shape are important. It is of particular importance with handicapped patients that the insoles are kept somewhat longer in order to reduce the risk of tilting sideways. This pronatory support, especially in the forefoot region, gives the patient a feeling of security. The correction of the talipes valgus should be differentiated from the correction of the talipes varus. With talipes valgus, the rear of the foot should be supinated and the fore-foot pronated in order to achieve a rotation of the foot. With talipes varus, this is not possible. Here, the whole foot must be pronated, i.e., the rear- and fore-foot must be included in an homogenous correction. *André Bähler André Bähler is an Orthotist/Prosthetist from Zurich, Switzerland. References: <ol> <li>G. Hohmann, Fuss und Bein, ihre Erkrankungen und deren Behandlung, Verlag von J.F. Bergmann 1951.</li> <li>J. Lang, W. Wachsmuth, Praktische Anatomie, Bein und Statik, Springer-Verlag AG.</li> <li>I.A. Kapandji, The Physiology of the Joints, Churchill Livingstone.</li> </ol> Page Number(s) 8 - 14 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_015.pdf Text Any textual data included in the document <h2>The Neurophysiological Ankle-Foot Orthosis</h2> <h5>Cyndi Ford, P.T. <a style="text-decoration: none;">*</a> Robert C. Grotz, M.D. <a style="text-decoration: none;">*</a> Joanne Klope Shamp, C.P.O. <a style="text-decoration: none;">*</a></h5> Since the late 1960's when Yates<a></a> and Lehneis<a></a> wrote the first articles pertaining to the use of plastics, orthotic practice has been revolutionized by the design possibilities afforded by total contact devices. However, prescription of lower extremity orthoses for neuro-logically involved patients has traditionally depended solely upon biomechanical principles even as neurophysiological approaches to treatment gained recognition and acceptance. Neur-odevelopmental Techniques (NDT) were developed as a theory of Karl and Berta Bobath and evolved to "a sensorimotor approach to control motor output and in doing so change sensory input."<a></a> Handling techniques which counteract patterns of abnormal tonic reflex activity reduce spasticity and allow facilitation (activation) of normal postural reactions through stimulation of key points of control, which include points on the foot and ankle. Recent advances incorporating neurophysiological principles of inhibition and facilitation into the design of ankle-foot orthoses make possible tone-reducing devices with specific areas of pressure or contact to inhibit abnormal hypertonicity. Eberle, Jeffries, and Zachazewski<a></a> recently reported success with an inhibitive AFO, a concept that was not feasible with metal orthotics. Their report stated that "the technique of fabrication used for the construction of a molded polypropylene AFO allows for all of the tone-inhibiting characteristics of casting ... to be built into the AFO." Although tone-reducing AFO inhibit abnormal hypertonicity in the affected lower extremity, the disadvantages inherent in traditional AFO persist. Limited ankle dorsi-flexion and plantar flexion, create a negative influence upon independent knee and hip function. Floor reaction forces intended to prevent the typical hemiplegic knee recurvatum during stance phase also contribute to increased effort and decreased smoothness in gait. Tonic foot reflexes elicited by contact on the plantar surface of the foot as a means to facilitate normal movement are disregarded. In an effort to address these gait concerns, an orthosis was designed based upon the neurode-velopmental concepts as described by Bobath<a></a> and Utley<a></a>, and the foot reflexes as described by Duncan and Mott<a></a> with the following considerations in mind: <ol> <li> A design configuration intended to utilize both biomechanical principles to limit calcaneal varus and neurophysiological principles (of facilitation and inhibition) to obtain dynamic ankle dorsiflexion and plantar flexion. </li> <li> Selection of a material with adequate flexibility, durability, and shape retention under conditions of continual deformation during ambulation. </li> <li> Ease of donning for the one-handed patient. </li> </ol> <h3>Design Rationale</h3> The Neurophysiological Ankle-Foot Orthosis (NP-AFO) is a custom polypropylene device, vacuum-formed over a plaster model of the patient's affected lower extremity (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-01.jpg">Fig. 1</a>). Within the total contact design are incorporated the following forces: <ol> <li> A three-point pressure system to biomechanically control calcaneal varus (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-02.jpg">Fig. 2</a>). </li> <li> A biomechanical force medial to the achilles tendon to counterbalance and prevent excessive pronation and rotation of the orthosis in the shoe (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-03.jpg">Fig. 3</a>). </li> <li> A neurophysiological force on the medial aspect of the calcaneus, extending to the plantar surface of the longitudinal arch without creating pressure under the navicular itself (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-03.jpg">Fig. 3</a>). This facilitates straight plane dorsiflexion. </li> <li> A neurophysiological force on the lateral aspect of the plantar surface of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-04.jpg">Fig. 4 </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.jpg">Fig. 5</a>) to facilitate the eversion reflex (peroneals) and recruit more proximal controls (vastus lateralis and gluteus medius) for knee and hip stability as discussed by Duncan<a></a>. The amount of dorsiflexion assist may be graded by adjusting the width of the segment joining the heel-cup and the metatarsal arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.jpg">Fig. 5</a>). </li> <li> A neurophysiological force to inhibit the toe grasp reflex (toe flexors and gastroc-nemius-soleus) by unweighting of the metatarsal heads through use of a metatarsal arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-06.jpg">Fig. 6</a>). </li> <li>Biomechanical function through flexibility of the foot and ankle due to the trimlines and configuration of the plastic NP-AFO (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-07.jpg">Fig. 7</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg">Fig. 8</a>).</li> </ol> <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-07.jpg">Figure 7.</a> Medial view, left foot <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg">Figure 8.</a> Lateral view, left foot <h3>Prescription Rationale</h3> The NP-AFO is designed for use in the treatment of the patient with a central nervous system disorder, such as a cerebral vascular accident or closed head injury. Assessment should include analysis of the individual's tone or spasticity, range of motion, and the availability of follow-up by members of the clinic team familiar with a neurophysiological approach to care. Spasticity has been classified as minimal, moderate, or severe in terms of function of the foot and ankle during gait.<a></a> Minimal spasticity allows the patient to land on a stable calcaneus without excessive supination of the forefoot and then shift the body weight over the heads of the metatarsals, although during swing phase the foot assumes a varus or supinated posture. Moderate spasticity causes the calcaneus to assume a position of varus with excessive supination at initial contact; however, during midstance some pronation occurs and the body weight can again be transferred normally across the forefoot. Severe spasticity is characterized by the foot and ankle being held rigidly in a position of equinovarus throughout stance so that the body weight remains on the lateral aspect of the forefoot with little or no weightbearing through the heel or medial metatarsal heads. This varus position persists throughout swing phase also. Patients exhibiting minimal or moderate spasticity are excellent candidates for the NP-AFO. Patients with severe spasticity are candidates only if their tone can be modified through handling techniques and/or inhibitive casting. The use of toe separators (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-09.jpg">Fig. 9</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-10.jpg">Fig. 10</a>, and<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-11.jpg"> Fig. 11</a>) as an adjunct treatment is also effective in patients with a separate toe grasp reflex to inhibit excess tone and reduce pain.<a></a> In order for the NP-AFO to function appropriately, the patient must have at least 15 degrees of passive dorsiflexion with the knee in flexion. <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-09.jpg">Figure 9.</a> Toe separators fabricated from Plastazote® with a Moleskin® cover and toe extension. <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-10.jpg">Figure 10.</a> Toe separators in place under the toes <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-11.jpg">Figure 11.</a> Superior view showing tabs to hold in place under sock. Follow-up by a clinic team familiar with the device is important to monitor the continued fit and function. With most AFO the major concern may be skin breakdown. However, with the NP-AFO the change in fit due to edema, weight loss, or tone variations may require modifications to maintain the critical areas of contact. Contraindications for this device are severe spasticity which cannot be modified through inhibitive casting or handling techniques, and early excessive pronation or calcaneal valgus with the foot pronated at initial contact of stance. <h3>Clinical Experience</h3> The NP-AFO has been prescribed for 35 patients with the following diagnoses: 29 Cerebral Vascular Accidents (CVA), 4 Closed Head Injuries (CHI), 1 Cauda Equina Injury, and 1 undiagnosed Demyelinating Disease. Although three patients were lost to follow-up, the NP-AFO has continued to be worn by the remaining 32 with overwhelming acceptance which seems to be attributed to the comfort and function of the device. Of the four patients converted from traditionally designed orthoses (2 metal, 2 plastic AFO), three have improved gait patterns and prefer the NP-AFO to their previous device. The fourth has rejected orthotic care due to refusal to adapt footwear from inappropriate styles with 2 1/2" heels. Four patients became independent ambulators without the use of any orthotic device. <h3>Fabrication</h3> Polypropylene was chosen as the thermoplastic currently exhibiting the best conformance to the desired qualities, when used in the fabrication process described. <h3>Casting Procedure</h3> The casting technique is similar to that described in Lower Limb Orthotics, A Manual<a></a> and is a procedure commonly used by certified orthotists. The cast must be taken in a position of maximal dorsiflexion, preferably 20 degrees. The calcaneus, midfoot, and forefoot should be in a neutral position. It has been our experience that tone-reducing handling activi-. ties performed by a physical therapist just prior to casting will help assure an optimal position. These activities include forefoot, midfoot, and hindfoot mobilizations as taught by Jan Utley.<a></a> The cast is removed upon hardening and filled with plaster to create a positive model for use in vacuum-forming of the orthosis. The positive model is now ready for modifications to create the necessary biomechanical and neurophysiological forces. <h3>Modification Of The Positive Model</h3> As the key to function of the orthosis is selective inhibitive and facultative forces, accurate cast modification is essential. Plaster removal is performed in the following areas to a depth of 0.5 to 1 cm. depending upon the compressibility of the patient's extremity. These modifications must be sufficient to provide a very firm force to the skin as designated. <ol> <li> Medial and lateral to the achilles tendon using a Scarpa's knife to deeply groove the modification (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-12.jpg">Fig. 12</a>). </li> <li> Medial aspect of the calcaneus extending to the plantar surface of the longitudinal arch without creating pressure under the navicular itself that would stimulate mid and forefoot supination (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-13.jpg">Fig. 13</a>). </li> <li> Along the lateral plantar surface of the mid- and forefoot, excluding the base and head of the fifth metatarsal (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-14.jpg">Fig. 14</a>). </li> <li> Create a metatarsal arch 6mm. proximal of the metatarsal heads for the inhibitive function of unweighting the metatarsal heads and thereby reduce tone (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-06.jpg">Fig. 6</a>). </li> <li> Smooth entire cast. </li> </ol> If an accurate negative cast and positive model were created, no further modifications are necessary. <h3>Vacuum-Forming Process</h3> Leather, nylon, or rope cording is applied to the cast (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-15.jpg">Fig. 15</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-16.jpg">Fig. 16</a>, and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-17.jpg">Fig. 17</a>) to create strengthening corrugations in the orthosis after molding. A separating agent or material is used between the positive model and the hot plastic to create adequate vacuum and to leave a smooth inner surface. For our drape-forming process one layer of perlon with one layer of ladies' nylon knee-high stockings are applied and smoothed with talc. Stress-relieved 3/16" polypropylene is then drape-formed under vacuum to the positive model and allowed to cool for 24 hours. <h3>Trimlines</h3> The orthosis is removed from the positive model using a cast cutter and is sanded to finish according to the following trimlines: <ol> <li> Overall height of the orthosis is equal to the distance from the plantar surface of the calcaneus to the flare of the achilles tendon as it meets the gastrocnemius-soleus group, multiplied by 2. An average overall length for a 175cm. (5'9") adult is 25.5cm. (10"). </li> <li> Length of the plantar extension is terminated 6mm. proximal to the metatarsal heads for comfort. </li> <li> The lateral trimlines (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-18.jpg">Fig. 18</a>) come as far anterior as possible and still allow passage of the leg into the orthosis. The posterior trimline (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-18.jpg">Fig. 18 </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-19.jpg">Fig. 19</a>) approaches the lateral margin of the achilles tendon, but may require modification to prevent a bowstring effect by the heel counter of the shoe against the NP-AFO. Note that flexibility is enhanced by the narrowing anteriorly and posteriorly as the lateral side meets the heelcup. </li> <li> The achilles tendon is left exposed to the point of flare with the gastronemius-soleus (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-19.jpg">Fig. 19</a>). </li> <li> The medial margin is trimmed so as to provide the appropriate forces and yet avoid contact on the medial malleolus and under the navicular. The open area provides for lack of resistance to dorsiflexion and plantar flexion (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-20.jpg">Fig. 20 </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.jpg">Fig. 21</a>). The plantar extension (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.jpg">Fig. 21</a>) may be varied in width depending upon the size of the patient and flexibility desired, but as it serves only to join the metatarsal arch to the heelcup, it should remain as flexible as possible. The distal aspect, including the metatarsal pad, should span the distance between the shaft of the first metatarsal and the extreme lateral margin of the foot to allow maximum facilitation of the eversion reflex.</li> </ol> A full 1/8" Plastazote® liner is glued to the inner surface of the orthosis, with the exception of the areas contained by the patient's shoe to allow ease of donning the same size shoe previously worn by the patient. A Velcro® strap of 2" width is applied to the proximal anterior calf. A lace-tied or Velcro®-closed shoe is recommended to maintain the critical fit of the NP-AFO. <h3>Discussion</h3> The movement allowed by the NP-AFO encourages dynamic control of the entire lower extremity. When sitting, normal weight-bearing attitude can occur with the foot remaining in full contact with the floor throughout a full range of knee flexion. Analysis of the normal movements of the ankle during elevation from a chair has revealed to us that the ankle begins in dorsiflexion and continues to dorsiflex during the initial phase of the elevation before plantar flexing to a relatively neutral position. Devices which eliminate this normal range of dorsiflexion necessarily require a patient to work over an abnormal base and make difficult active weight-bearing during elevation. The ability to assume a normal weight-bearing surface in a position of power as allowed by the NP-AFO encourages weight-bearing on the affected extremity throughout all activities of daily living. Further, dynamic control of the pelvis and knees are encouraged during ambulation by eliminating floor reaction forces inherent in other AFO. Without these abnormal forces, the patient experiences the normal movement of the pelvis and knee over the foot, allowing development of a propulsive toe-off with the NP-AFO. Progressing from use of the NP-AFO to being independent of assistive devices is more feasible, as the patient has the opportunity to gain control of muscles through the normal range of movement. <h3>Summary</h3> The adequacy of traditional AFO to provide a safe, functional gait pattern is irrefutable. However, experience with patients who sustained a CVA five to fifteen years ago and received a traditional metal or plastic AFO reveals they now present problems related to overuse of the sound side: the pathomechanics resulting from a rigid ankle and/or increasing hypertonicity from abnormal weightbearing patterns. As more patients have increased lifespans following a CVA, treatments and orthotic care which assure prolonged quality of life become increasingly important. Neurophysiological treatment attempts to do this through emphasis upon normal movement patterns and integration of the affected and unaffected sides. The NP-AFO is a biomechanically and neurophysiologically effective ankle-foot orthosis that is appropriate for creating a functional gait in the patient with a central nervous system disorder. The design allows for independent motion at the ankle, knee, and hip joints in a lightweight and cosmetic custom-made orthosis. The NP-AFO joins the inhibitive cast and other neurophysiological armamentarium in new approaches to the rehabilitation of the spastic or hypertonic patient. *Joanne Klope Shamp, C.P.O. Joanne Klope Shamp, C.P.O., is with the Shamp Pros-thetic-Orthotic Center in Norton, Ohio. *Robert C. Grotz, M.D. Robert C. Grotz, M.D., is Medical Director for Edwin Shaw Hospital in Akron, Ohio *Cyndi Ford, P.T. Cyndi Ford, P.T., is with the Edwin Shaw Hospital in Akron, Ohio. <h3>Additional Reading</h3> <ol> <li> Bobath, B. "The Application of Physiological Principles to Stroke Rehabilitation—A Special Report," The Practitioner, December, 1979, Vol. 223, 793-4. </li> <li> Ibid, "The Treatment of Neuromuscular Disorders by Improving Patterns of Coordination," Psychotherapy. </li> <li> Bobath, B. and Bobath, K., "The Importance of Memory Traces of Motor Efferent Discharges for Learning Skilled Movement," Developmental Medicine and Child Neurology, 1974, p. 16, pp. 837-8. </li> <li> Cherry, D.B., "Review of Physical Therapy Alternatives for Reducing Muscle Contracture," Physical Therapy, Volume 60, Number 7, p. 877, July, 1980. </li> <li> Effgen, S., "Integration of the Plantar Grasp Reflex as an Indicator of Ambulation Potential in Developmentally Disabled Infants," Physical Therapy, Volume 62, Number 4, pp. 433-35, April, 1982. </li> <li> Freedman and Herman, "Inhibition of EMG Activity in Human Triceps Surae Muscles During Sinusoidal Rotation of the Foot," Journal of Neurology, Neurosurgery and Psychiatry, 1975:38, pp. 336-45. </li> <li> Knutsson, E. et al., "Different Types of Disturbed Motor Control in the Gait of Hemiparetic Patients," Brain, 1979:102, p. 405. </li> <li> Lehmann, J.F., "Biomechanics of Ankle-Foot Orthoses: Prescription and Design," Archives of Physical Medicine and Rehabilitation, Volume 60, May, 1979, p. 200. </li> <li> Ibid, "Plastic Ankle-Foot Orthoses: Evaluation of Function", Archives of Physical Medicine and Rehabilitation, p. 402. </li> <li> Ibid, "A Biomechanical Evaluation of Knee Stability in Below-Knee Braces," Archives of Physical Medicine and Rehabilitation, p. 688, December, 1970. </li> <li> Manfredi, Sacco and Sideri, "The Tonic Ambulatory Foot Response," Brain, 1975: 98, pp. 167-80. </li> <li> Perry, et al., "Determinates of Muscle Action in Hemiparetic Lower Extremity," Clinical Orthopaedics and Related Research: p. 131, March-April, 1978. </li> <li> Walters, R.L., "The Enigma of 'Carry Over'," International Rehabilitation Medicine, 1984:6, pp. 9-12. </li> <li> Watemabe, I. and Obubo, J., "The Role of Plantar Mechanoreceptor in Equilibrium Control," Ann-NY-ACAD-Science, 1981: 374, pp. 855-64. </li> <li> Weiz, S., "Studies in Equilibrium Reaction," Journal of Nervous and Mental Disorders: 88, 1938, p. 150. </li> </ol> References: <ol> <li>Yates, G., "A Method for Provision of Lightweight Aesthetic Orthopaedic Appliances," Orthopaedics: Oxford, 1:2, pp 153-162, 1968.</li> <li>Lehneis, H.R., "New Concepts in Lower Extremity Orthotics," Medical Clinics of North America, 53:3:3, pp. 585-592, 1969.</li> <li>Bobath, K., "The Problem of Spasticity in the Treatment of Patients With Lesions of the Upper Motor Neurone," The Western Cerebral Palsy Centre, London, England.</li> <li>Eberle, E.D.; Jeffries, M.; and Zachazewski, J.E., "Effect of Tone-Inhibiting Casts and Orthoses on Gait: A Case Report," Physical Therapy, 62:4 pp. 453-455, 1982.</li> <li>Bobath, B. and Bobath, K., Motor Development in Different Types of Cerebral Palsy, Heinman, London, 1975.</li> <li>Utley, J., NDT Adult Hemiplegia and Closed Head Injury Certification Course, Columbus, Ohio, July, 1982.</li> <li>Duncan, W. and Mott, D., "Foot Reflexes and the Use of the Inhibitive Cast," Foot and Ankle, p. 145, 1983.</li> <li>Duncan, W., "Tonic Reflexes of the Foot," Journal of Bone and Joint Surgery, July, 1960.</li> <li>Sarno, J.E. and Lehneis, H.R., "Below-Knee Orthoses: A System for Prescription," Archives of Physical Medicine and Rehabilitation, Vol. 54, p. 548, December, 1975.</li> <li>Rehabilitation Engineering Center, Moss Rehabilitation Hospital. Lower Limb Orthotics: A Manual, First Edition, Philadelphia, 1978.</li> </ol> Page Number(s) 15 - 23 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.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/1986_01_015/1986_01_015-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-18.jpg Figure 19 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-19.jpg Figure 20 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-20.jpg Figure 21 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Neurophysiological Ankle-Foot Orthosis Creator An entity primarily responsible for making the resource Cyndi Ford, P.T. * Robert C. Grotz, M.D. * Joanne Klope Shamp, C.P.O. * https://staging.drfop.org/files/original/5fbec4052a52f2f96c332992054740bd.pdf 20e1c68a1e68c26c17ebe0dcbed427db https://staging.drfop.org/files/original/1aa501ac55eba1dc5a0b97d8b3391563.jpg 1c3a60d6625ab486da03f8e2fc2f4e77 https://staging.drfop.org/files/original/16e17501c3eb200567a45563f807c9bd.jpg a2e25a04633c58de9d3fe329ed8a47d6 https://staging.drfop.org/files/original/6dc1d516628f4acd9f6a74eea19e37e0.jpg d80207c27684f55a49e165cd49c6f76a https://staging.drfop.org/files/original/f8ee04e92547ecb0cde7b37fab8d661f.jpg ecad7b10960f167cd183869d747a981e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_024.pdf Text Any textual data included in the document <h2>The Use of the AFO and PTB Orthoses for Severe Pes Planus</h2> <h5>Gustav Rubin, M.D., F.A.C.S. <a style="text-decoration: none;">*</a> Malcolm Dixon, M.A., R.P.T. <a style="text-decoration: none;">*</a></h5> When the severely deformed pes planus foot is rigid, the deformity fixed, and the arch totally dropped, to provide the patient with a conventional molded arch "support" is an exercise in futility. Placement of a shoe insert under the non-existent long arch cannot prevent further dropping on weight-bearing if the talar head is already in contact with the floor and the intertarsal joints are immobile. It is the purpose of this paper to report the use of the Ankle Foot Orthosis and Patellar Tendon Bearing Orthosis for such a situation. Because it would not be feasible to attempt to raise the arch of a rigid foot with an orthosis, the authors decided to employ an orthosis to decrease stresses on the foot and ankle by transferring push-off forces to an AFO.<a></a> This was to be accomplished by fabricating the orthosis with a solid ankle and modifying the shoe to incorporate a long steel spring and a rocker bar. Since it was anticipated that this approach might not provide adequate relief, it was considered that the next procedure would be to introduce partial unweighting with a Patellar Tendon Bearing Orthosis.<a></a> This would also be fabricated with a solid ankle and include a shoe with a long steel spring and a rocker bar. <h3>Case Report</h3> B.L., age 62, was initially referred to the VA Prosthetic Center on June 14, 1982, with a history of painful feet since World War II, which had become worse in recent years. The patient stated that "my feet are going to collapse and I can hardly walk and barely make it when I stand and walk." He had a cerebral vascular accident on January 18, 1982, but had made an almost complete recovery. There was also a history of aortic valve insufficiency and gout. The patient was receiving Coumadin, in-deral, digoxin, and allopurinal for his medical problems. He had not had relief of his foot pain from arch supports in the past. On examination there was noted medial downward dislocation of the talar heads, abduction of the forefeet, absence of the long arches, marked restriction of joint motion, marked splaying of the forefeet and severe hallux valgus, bilaterally (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg">Fig. 1</a>). The dorsalis pedis and posterior tibial arteries were palpable. <a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg">Figure 1.</a> The severe bilateral pes planus noted when patient was first seen at VAPC. X-Rays confirmed the clinical findings of severe pes planus and hallux valgus bilaterally. The patient's private orthopedic surgeon had fit him with short AFOs (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg">Fig. 2</a>). These were a significant improvement over previous arch supports, but were bio-mechanically inefficient. Bilateral solid ankle AFOs and shoes with long steel springs and rocker bars were prescribed (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg">Fig. 3)</a>. <a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg">Figure 2.</a> Orthosis prescribed by patient's private orthopedic surgeon. <a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg">Figure 3.</a> Bilateral AFOs and shoe corrections prescribed at the VAPC. On July 16, 1982 the patient reported that he was much more comfortable. When re-evaluated on October 21, 1982 it was indicated that the left side was subjectively worse than the right. He was experiencing very painful weight-bearing directly on the talar head. The "comfort" that he had reported in the previous note was relative. A PTB orthosis was prescribed for the left side (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg">Fig. 4</a>), in accordance with the originally outlined plan of procedure. <a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg">Figure 4.</a> The final prescription included an AFO on the less symptomatic right side and a PTB orthosis for the left side. On April 19, 1983 the patient stated that the PTB was an improvement over the AFO. On August 7, 1984 he returned for a new orthosis because of loss of fit. The patient had lost weight following cardiac surgery for aortic valve replacement and triple bypass in March, 1984. On October 4, 1984 he reported that the new orthoses were "comfortable, that he feels much better with them, and is able to ambulate." He and his wife both stated that he "would not be able to walk" without these orthoses. <h3>Discussion</h3> Severe pes planus of the type described in this report can only be helped to a limited degree by orthoses. However, if a maximally efficient approach is employed, the limited degree of relief can be significant and allow an almost non-ambulatory patient to achieve a useful degree of ambulation. A solid ankle AFO not only functions to stabilize the ankle and foot, but when combined with shoe corrections (rocker bar and long steel spring), it acts to diminish the stresses on the foot and ankle. The PTB provides, in addition, partial unweighting while retaining the features that permit transfer of forces to the orthosis. We have employed the AFO in other similar instances, but this was the first occasion in which we employed the PTB for severe pes planus. *Malcolm Dixon, M.A., R.P.T. Malcolm Dixon, M.A., R.P.T., is Chief of Clinical Services at the Veterans Administration Prosthetics Center. *Gustav Rubin, M.D., F.A.C.S. Gustav Rubin, M.D. F.A.C.S., is Chief of Special Clinics at the Veterans Administration Prosthetics Center, 252 7th Avenue, New York City, New York 10001. References: <ol> <li>Rubin, Gustav; Dixon, Malcolm; and Danisi, Michael, "VAPC Prescription Procedures for Knee Orthoses," Orthotics and Prosthetics, 31:3: pp. 9-25, September, 1977.</li> <li>Rubin, Gustav, "Patellar-Tendon-Bearing (PTB) Orthosis," The Bulletin of the Hospital for Joint Diseases, XXXIII:2: pp. 155-172, October, 1972.</li> </ol> Page Number(s) 24 - 26 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.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 The Use of the AFO and PTB Orthoses for Severe Pes Planus Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., F.A.C.S. * Malcolm Dixon, M.A., R.P.T. * https://staging.drfop.org/files/original/d7b675b0378cee1912a8d5e84687921d.pdf 9d96407f8c68159964c5da7b9a38bd7f https://staging.drfop.org/files/original/3d9d7c0b41f15695d1d34ad758690f2a.png 69bc94cb8f542767a5c7ce6a7afa1b4a https://staging.drfop.org/files/original/d65d1661f0886e3d968a3606ff3a6a5c.jpg 87ff5e2a3fe1a34b03c0c39672002824 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_033.pdf Text Any textual data included in the document <h2>Immediate Post-Operative Orthotic Impression Technique for Thermoplastic Spinal Orthoses Following Spinal Surgery</h2> <h5>James T. Lehner, M.D. <a style="text-decoration: none;">*</a> Wilbur A. Haines, C.P.O. <a style="text-decoration: none;">*</a> Mark E. Horwitz, CO. <a style="text-decoration: none;">*</a> Cynthia J. King, CO. <a style="text-decoration: none;">*</a></h5> Spinal surgery has been revolutionized in recent years by advances in surgical approaches, surgical techniques, and forms of internal fixation. Post-operative management has progressed from bed rest with log rolling, to mobilization in plaster casts, to modern technology orthoses. Co-polymer plastic composite orthoses have been used by the authors during the last few years. The orthoses have been easy to apply and have been comfortable for our patients. There have been no associated complications which would jeopardize the outcome of the operative procedure. <h3>Patient Selection</h3> The original patient the authors selected for management using a thermo-plastic orthosis was a retarded child with cerebral palsy who had previously been intolerant of casting, developing pressure sores within the cast. Molding for the co-polymer orthosis had to be done while the patient was anesthetized, since this patient was combative and otherwise difficult to work with. While the impression for this patient was being made, it became apparent that this molding technique would be easy to do in the operating room at the conclusion of operative spinal procedures. Initially, this postoperative molding technique was used for "special cases." These included patients with cerebral palsy, myelomeningocele, severe osteoporosis, and patients with severe respiratory problems. Eventually, the older adult idiopathic population which seemed very intolerant of rigid metallic orthoses or casting, was included. Things have gradually evolved to a point where most patients, other than teenage idiopathics, are candidates for this type of orthosis. The authors still prefer using a Kosair metallic axillary crutch style orthosis postoperatively for adolescent idiopathic scoliosis patients, since they seem to tolerate the rigidity of this system well.<a></a> The first 80 patients fitted with the co-polymer postoperative spinal orthotic system are reviewed in this study. Diagnoses include all the aforementioned, plus other types of muscular dystrophy, congenital scoliosis, tumors, post-menopausal deformities, and degenerative spinal deformities. All orthoses were applied after long (minimum of six vertebral levels) spinal fusions. All surgical cases, except those of congenital scoliosis, were routinely done with instrumentation. <h3>Orthosis Impression Technique</h3> The orthotic impression is taken immediately after the spinal surgery while the patient is still asleep. The technique is: <ol> <li> After the skin incision is closed, a light layer of Adaptic® and one layer of sterile four-by-fours are placed over the wound. </li> <li> The skin is bilaterally marked longitudinally along the mid-axilla (mid-coronal line) using a wet indelible pencil. Perpendicular hash marks are randomly made across the mid-axillary line to be used as "key" reference marks later. </li> <li> Sterile Vidrape® is placed across the patient's back to establish an impermeable membrane. </li> <li> The Vidrape® is marked by superimposing onto it the marks made previously on the patient's skin. </li> <li> Plaster splints are draped across the required area of the patient's torso, making sure that the plaster crosses the mid-axillary lines on both sides of the patient. The first layer is applied using two or three thicknesses of plaster. Subsequent reinforcing layers are applied, using about six layers of plaster. Finally, a few strips are applied to help prevent distortion of the mold. These are placed across the mold at two or three locations in the shape of an inverted "V." </li> <li> At this point, the posterior section of the impression is removed from the patient when hard (<a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-1.jpg">Fig. 1</a>). Figure 1. Orthotist removing posterior mold. Note Vidrape® and markings in mid-axillary line.</li> <li> The Vidrape® is then removed in a manner which keeps plaster or water from touching the wound. </li> <li> Sterile dressings are applied by the scrub nurse, who has remained sterile to this point. </li> <li> The patient is placed on the post-operative bed that has been prepared using one extra sheet. </li> <li> Vidrape® is then applied to the patient anteriorly in preparation for the anterior section molding. (Cover breast and groin areas with four-by-fours or diapers.) </li> <li> The indelible pencil marks are again superimposed onto the Vidrape® along the mid-axillary lines, and appropriate relief markings are made on the rib cage and iliac crests. </li> <li> The anterior mold is made using the technique described in step five. When set, the plaster is removed. </li> <li> Finally, the Vidrape® is carefully removed and the patient is ready to go to the post-operative recovery room. </li> </ol> After the impression has hardened sufficiently, a cast cutter may be used to cut along the mid-axillary indelible lines, visible on the inner surfaces of each half of the impression. Using the "key" hash marks established previously, the two impression halves are joined together with plaster strips. The impression is now ready for orthotic fabrication using the method of choice. Since the impression has been made with the patient in the prone and supine positions, the orthotist must take this into account when fabricating the orthosis. The medial-lateral dimension of the patient is distorted normally about one inch due to the flattening effect created by the patient's weight against the operating and post-operative bed. The time required for the impression procedure adds 15 to 20 minutes of extra anesthesia and operating room time. There have been no infections in any of these cases. <h3>Results</h3> The orthosis described has been applied to 80 post-spinal surgery patients between January 1980 and October 1984. There were no cases of rod dislodgement or pseudoarthrosis. Fifty-eight patients had instrumentation done using segmental spinal wiring with either L-Rod or Harrington Rod fixation. One Mongoloid boy broke a wire in his L-Rod fixation, but over a subsequent 24 month follow-up, has shown no further wire or rod breakage. No other incident of internal fixation failure while wearing the orthosis has been encountered to date. Early in the series, one orthosis had to be remade due to pressure problems. No other orthosis has required anything except routine minimal corrections of trim lines. In the beginning, the average time of orthotic application was the eighth post-operative day. Later in the series, this dropped to the fifth post-operative day. Orthotic application varied from the second to the thirteenth day post-op and was determined by the patient's medical condition in all but one case. The patients were placed upright immediately upon application of the orthosis (<a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg">Fig. 2</a>). They were dismissed from the hospital an average of four days after the orthosis was applied. <a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg">Figure 2.</a> Post-op Spina Bifida child two days after brace application and four days post-operatively. Note colostomy site on right lower quadrant. Orthoses were worn about six and one half months post-operatively (the first 25 patients wore theirs for eight months post-op; all subsequent patients have worn theirs for six months post-operatively). Compliance has been monitored by the parents or guardians of the patients. They have reported 100 percent compliance. The parents are instructed that the orthosis may be removed when the patients are supine, for bathing, skin care, and pulmonary toilet as needed. Patients are never allowed up in the sitting position without wearing the orthosis during the six month post-operative period. One-half of the patients were non-ambulatory. <h3>Discussion</h3> This is an easy, quick, and accurate way to measure and apply post-operative thermoplastic orthoses after spinal surgery. It has been possible to eliminate patient discomfort during the molding process and no manipulation of the patient was required during the procedure. While this technique requires a close working relationship between physician, hospital personnel, and orthotist, it has virtually eliminated time delays in orthotic delivery. Historically, orthotic impressions were taken "when the patient was ready post-operative-ly." This left the impression making process in a nebulous time frame. Typically, patients were delayed in the application of their orthosis by a few days. This added additional patient time in the hospital with little benefit. Also, the orthotist had to schedule the impression making process at a time convenient to appropriate hospital personnel. The technique described gives the orthotist and his/her staff adequate time to properly design and fabricate the orthosis. Although none of the patients were felt to be ready to ambulate or sit on the first post-operative day, it would be possible to apply the orthosis, if necessary, within 24 hours. Many of the severe respiratory cases (spinal muscular atrophy) were fitted with their orthoses and sat up while still on a respirator in intensive care. There was only one case where orthotic application delayed patient mobility (orthosis revision was necessary). Usually, comfort was the deciding factor in-getting patients up. Later in this study group, when indications were broadened to include healthier patients, the time frame post-op of ambulation decreased significantly. It is believed that molding for a spinal orthosis while the patient is awake, several days after surgery, is unnecessarily painful. It also places the patient in some jeopardy of dislodging the instrumentation while having the impression made. It is also considered irrational to mold patients for an orthosis at a time when they are actually ready to be up and around. The authors do not trust segmental spinal instrumentation without external bracing, and reports now indicate this conservative approach, including the use of an orthosis, in this group of patients is warranted.<a></a> Retarded children and patients with anesthetic skin easily get into trouble with body casts and non-removable orthoses. The orthotic system described certainly helps to alleviate many of the problems previously encountered with post-operative spinal orthoses. This technique is still not used for the standard adolescent idiopathic patient, who in our judgment currently does well with Harrington Instrumentation fixation and post-operative bracing using a rigid metallic Kosair type orthotic system. <h3>Advantages</h3> The co-polymer post-operative orthotic spinal system has many advantages: <ol> <li> Minimal patient discomfort; </li> <li> Expedient spinal orthosis application; </li> <li> Maximum utility for patient care (skin cleansing, checking anesthetic skin, respiratory therapy, etc.); </li> <li> Taking an accurate impression with minimal post-operative movement of the patient; and </li> <li> Excellent wearing compliance by patients. </li> </ol> <h3>Disadvantages</h3> While there are disadvantages to most anything, the negative points of this technique and system are few. They would include: <ol> <li> Increased anesthesia and operating room time (15-20 min.); </li> <li>Tight post-op scheduling of the orthotist's time (Requires a close working relationship with physician, hospital personnel, and orthotist).</li> </ol> *James T. Lehner, M.D. James T. Lehner, M.D. is from the Wright State University College of Medicine, Division of Orthopedics. *Wilbur A. Haines, C.P.O. Wilbur A. Haines, CO. is President of LaForsch Orthopedic Laboratories, 536 Valley Street, Dayton, Ohio *Mark E. Horwitz, CO. Mark E. Horwitz, CO. is Director of Orthopedic Services for LaForsch Orthopedic Laboratories. *Cynthia J. King, CO. Cynthia L. King, CO. is with the Clinical Orthotic Services at LaForsch Orthopedic Laboratories References: <ol> <li>Benson, S.; McKinley, L.M.; Martin, T., Delto-Pec-toral Axillary Lumbar Thoracic Support. Kosair Orthotic Laboratory, Louisville, Kentucky (Unpublished Data).</li> <li>Broadstone, P.; Johnson, J.R.; Holt, R.T.; Leath-erman, K.D., "Consider Post-operative Immobilization of Double-L Rod S.S.I. Patients," Orthopedic Transactions, 8(1):171-172, 1984.</li> <li>Taddonio, R.F.; Weller, K.; Appel, M., "A Comparison of Patients With Idiopathic Scoliosis Managed With and Without Post-operative Immobilization Following Segmental Spinal Instrumentation With Luque Rods," Orthopedic Transactions, 8(1): 172, 1984.</li> <li>Wallace, S.L.; Fillauer, K., "Thermoplastic Body Jackets for Control of Spine after Fusion in Patients with Scoliosis," Orthotics and Prosthetics, Vol. 33, No. 3, pp. 20-24, September, 1979.</li> </ol> Page Number(s) 33 - 37 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Immediate Post-Operative Orthotic Impression Technique for Thermoplastic Spinal Orthoses Following Spinal Surgery Creator An entity primarily responsible for making the resource James T. Lehner, M.D. * Wilbur A. Haines, C.P.O. * Mark E. Horwitz, CO. * Cynthia J. King, CO. * https://staging.drfop.org/files/original/dd8db7616001226c18971be2d8fcd283.pdf 1ad480aad4abe8298ef123b76f395b42 https://staging.drfop.org/files/original/d5b8d44b32ee77a3f0a1323a80a9afcc.jpg 2d03a3805b271567b07dc8e3a894f760 https://staging.drfop.org/files/original/beabbcc10d39750ad0df0029737fbb9a.jpg 2c4cecf0a116c3038089460eeeb1656d https://staging.drfop.org/files/original/eab5312062924db051a8886268065332.jpg 9a0e042d67cb98394cd3911b39aa9ef8 https://staging.drfop.org/files/original/6a6cd46dbbb7e7a257b0eb28b50d3729.jpg d75170a96119542a41e69cf1cdd9e7c9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_038.pdf Text Any textual data included in the document <h2>Use of a Bivalved Thoracic Suspension Jacket in the Orthotic Seating Management of Severe Arthrogryposis Multiplex Congenita</h2> <h5>Carrie L. Beets, CO. <a style="text-decoration: none;">*</a> Louis Whitfield, R.T. (O) <a style="text-decoration: none;">*</a> Jan Minnich, L.P.T. <a style="text-decoration: none;">*</a> J. Leonard Goldner, M.D. <a style="text-decoration: none;">*</a></h5> <h3> Introduction</h3> The thoracic suspension orthosis<a></a> was developed to aid in the management of patients with neuromuscular disease and has been used primarily in individuals with myelodysplasia. The principle of the device is to use the rib cage as a weight bearing structure and thus provide improved seating posture for the patient while attempting to limit spinal deformity and relieve excess ischial pressure. Additional benefits include improvement of balance and mobility and freeing of the hands and arms for feeding and other activities of daily living. The body image of the patient is improved while seated in a wheelchair, and the patient may interact better with the environment. The thoracic suspension orthosis should be considered for those patients who cannot tolerate surgery or when surgery should be delayed until they reach maturity. The patient presented in this paper does not fit the usual criteria for use of a thoracic suspension orthosis. The needs of this patient went beyond those provided by usual orthotic seating devices and led to the adaptation of established techniques and development of a different design to provide a functional seating arrangement for a severely involved child who had failed with other custom seating devices. This seven year old girl with severe generalized arthrogryposis multiplex congenita had functional limitation in the upper extremities and no voluntary action in the lower extremities. Surgical releases of soft tissue contractures and proximal and distal femoral osteotomies had been performed to adapt the patient to a sitting position. Past attempts to provide molded seating inserts to allow a comfortable sitting position had failed. She was most functional supine in a custom designed and portable bed-like seating insert which permitted feeding. Examination of the child revealed severe muscle atrophy of both upper extremities. There was active elbow extension but no active flexion. She was able to get her left hand to within several inches of her mouth by abducting and forward flexing her shoulder and then allowing gravity to bring her hand to the mouth. The spine revealed right thoraco-lumbar scoliosis, thoracic kyphosis, fixed lumbar lordosis, and a fixed pelvic obliquity in which the left pelvic brim was higher than the right. The left hip had a range of motion from 30 degrees flexion to about 90 degrees for a total of 60 degrees of flexion, with an external rotation deformity. The right hip was fixed in +20 degrees flexion. Both knees had flexion contractures of 70 degrees with 10 degrees motion. In order to flex the right femur for sitting, a subtrochanteric osteotomy had been performed with creation of a silicone capped pseudoarthrosis. While this was relatively successful, pain occurred when the patient was placed in a sitting position with any weight bearing occurring on the right ischium. For this reason, she was evaluated for use of a thoracic suspension orthosis. The patient was initially placed in a plaster cast thoracic suspension jacket for a three week trial. During this time, the periods of suspension were gradually increased. Her skin was not accessible for monitoring; however, since she had normal sensation and was cooperative, we depended on her complaints of pain to assess the support. She tolerated the three week trial period and experienced no skin breakdown or abrasion. At that time, a cast impression was taken for the fabrication and fitting of a thoracic suspension orthosis. <h3>Fabrication And Fitting</h3> Due to the lack of spinal flexibility, the need for easy and accurate application of the orthosis, and the need to make the device as simple as possible for the parents; a bivalved design was chosen rather than the traditional single anterior opening. The bivalved design (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-1.jpg">Fig. 1</a>) necessitated fabrication of two plastazote™ linings complete with conventional additional plastazote™ layers over the inferior costal margins. Special attention was needed to insure that the anterior and posterior halves of the two linings matched up accurately during the vacuum forming process (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-2.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-1.jpg">Figure 1.</a> Lateral view of bivalved thoracic suspension orthosis showing anterior shell trimlines. <a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-2.jpg">Figure 2.</a> View from above, the anterior and posterior linings match up to provide an even pressure just distal to the lateral and anterolateral inferior costal margins. The suspension spools were incorporated into the posterior shell, which was fabricated of low density polyethylene. High density polyethylene was chosen for the anterior shell, as it was felt that the additional rigidity provided by this material would be needed to maintain the integrity of the circumferential containment of the jacket under weight bearing. A large abdominal opening was provided in the anterior shell because the patient had experienced some distress in the plaster jacket, especially following meals, which had been relieved by the addition of an opening in the plaster cast (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-3.jpg">Fig. 3</a>). The two half shells were held in place as a unit with Velcro® closures. <a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-3.jpg">Figure 3.</a> Anterior view of bivalved thoracic orthosis showing abdominal opening. Fitting of the orthosis was followed by an in-hospital program of gradually increasing wearing time both in the nonsuspended and suspended states. Her original supine positioning device was modified to permit her to lie in this with the thoracic suspension jacket on, eliminating the need to take off the jacket between periods of suspension. Since she could not tolerate any weight bearing on her right hip, the suspension brackets on the wheelchair were positioned for full weight bearing suspension. She tolerated the conditioning program well. At the time of discharge, she was wearing the jacket all day long and was tolerating uninterrupted suspension for periods of two and one-half hours. Her electric wheelchair was outfitted with a chin operated joy stick control (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-4.jpg">Fig. 4</a>). While suspended, she could operate the wheelchair well. However, at the end of two and one-half hours in suspension, the patient would begin to complain of discomfort and would be transferred to her supine positioning device. <a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-4.jpg">Figure 4.</a> Patient sitting in suspension in wheelchair. <h3>Conclusion</h3> The application of a thoracic suspension jacket is a way of successfully providing a functional sitting position for a patient with severe arthrogryposis. In conjunction with a modified electric wheelchair, the patient was given an opportunity to interact actively with her environment, including a vertical position for eating. The bivalved design not only affords easy application and removal, but also permits visual monitoring of the skin. The crucial circumferential containment in the area of and just distal to the inferior costal margin was maintained satisfactorily with a bivalved design. *J. Leonard Goldner, M.D. J. Leonard Goldner, M.D., was former Chief of Orthopedics, Division of Orthopedic Surgery, Duke University Medical Center. *Jan Minnich, L.P.T. Jan Minnich, L.P.T., is with Lenox Baker Children's Hospital, Durham, North Carolina. *Louis Whitfield, R.T. (O) Louis Whitfield, R.T.(O), is with the Department of Prosthetics and Orthotics at Duke University Medical Center. *Carrie L. Beets, CO. Carrie L. Beets, CO., is with the University of Virginia. She was formerly with the Duke University Medical Center at the time of submission of this article. References: <ol> <li>Drennan, J.C.; Renshaw, T.S., and Curtis, B.H., "The Thoracic Suspension Orthosis," Clinical Orthopaedics and Related Research, No. 139, March/April, 1979, pp. 33-39.</li> <li>Drennan, J.C., Orthopedic Management of Neuromuscular Disorders, J.B. Lippincott Co., Philadelphia, p.83.</li> <li>Fillauer, C.E.; and Pritham, CH., "The Thoracic Suspension Jacket-Review of Principles and Fabrication, Orthotics and Prosthetics, Vol. 38, No. 1. Spring, 1984, pp. 36-44.</li> </ol> Page Number(s) 38 - 41 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-4.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 Use of a Bivalved Thoracic Suspension Jacket in the Orthotic Seating Management of Severe Arthrogryposis Multiplex Congenita Creator An entity primarily responsible for making the resource Carrie L. Beets, CO. * Louis Whitfield, R.T. (O) * Jan Minnich, L.P.T. * J. Leonard Goldner, M.D. * https://staging.drfop.org/files/original/c9a1d6e7671d63f3fcd52fc82276041f.pdf 7dc5a6a86a368317cbf6867d2a17b66e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_055.pdf Text Any textual data included in the document <h2>Rehabilitation: Goals or Shoals?</h2> <h5>Samuel A. Weiss, Ph.D. <a style="text-decoration: none;">*</a></h5> In the pre-1960 period, the dominant aim of rehabilitation personnel working with amputees was the restoration of the amputee to maximum pre-morbid functioning. Lower-extremity amputees had little choice. A degree of prosthetic restoration consonant with some ambulation was necessary in order to provide some independence and self-sufficiency. Upper-extremity amputees were also presented with the goal of maximum functional restoration. While comfort and cosmesis were given their due, the explicit dogma was restoration to as much premorbid functioning as was mechanically feasible. The writer remembers the dictum of one expert, "a hook for work and a functional, cosmetically acceptable hand for recreation." An upper-extremity amputee might plead that he had learned to "manage" with his intact hand and was, therefore, interested only in an acceptable, passive appendage to fill a sleeve and allow him to mix in society inconspicuously. All in vain. He was regarded virtually as a self-denigrating quitter who was undermining his own livelihood, as well as a heretic in our work ethic society. To an appreciable extent this pejorative judgment was then true because in the pre-60's period there were, as yet, no "Great Society" programs which were to introduce alternative means of financial support. To a worker in the pre-60's period, functional restoration was the life raft which prevented him from sinking unless he was content to gasp through life on the dole and undergo the psychological angina pains of conscience. When the "Great Society" programs were introduced, the work ethic, for better or worse, was to a considerable extent attenuated. Moreover, improvements in technology, reduction in the need for manual labor, and the proliferation of new types of jobs allowed amputees better viability because an entirely intact body was no longer necessary for self-support. Yet the dogma of total, functional restoration hovered in the consciousness of rehabilitation personnel. While society in the 60's became more interested in immediate self-gratification, rehabilitation experts, who had been trained to make men and things "work," retained their pure work ethic consciousness. Physicians desired that body functioning become normal; physical and occupational therapists knew that somatic improvement required vigorous exercise; psychologists believed in maximum self-realization; and engineers and prosthetists yearned for more powerful mechanisms to provide normality. The old-fashioned work ethic had, to a considerable extent, been replaced by a new pay ethic—more pay for less work and poorer service for higher fares. We rehabilitation workers, however, remained aloof on Mt. Sinai, in our pristine innocence, proclaiming the Ten Commandments to stiff-necked and stiff-limbed rehabilitants who preferred to dance around the golden calf of entitlements. While recent political changes are striving to restore the work ethic to its former glory, the average person does not readily relinquish the desire to be presented with a set of options from which to choose. Attempts to enforce one set of standards or goals equally on all rehabilitants are doomed to fail. Perhaps some examples of individual personality types I have encountered among amputees seen at NYU Medical Center and in private practice will illustrate the distinctive rehabilitation goals of different people. <h3>Case Studies</h3> "A" applied as a volunteer experimental prosthesis wearer. He had lost his non-dominant hand in an accident. During the interview, he impressed the writer with his stability. His psychological test profile was exceptional. The writer remembered "A's" well-executed and orderly Bender-Gestalt drawings and recommended him for a position at an agency where he is still employed. I never saw "A" wear anything but a hook when I visited the agency. He never attempted to emphasize his functional restoration goal. His good-natured and efficient performance with his hook spoke for itself. In my conversations with him on various topics, both vocational and personal, he would often become enthusiastic and wave his hook in front of my eyes to emphasize a point. I never "saw" the hook. His efficiency and personality preempted his amputation. All I saw was the person, not the disability. "B" was a double hand amputee volunteer. He was gainfully employed and wished to contribute to amputee rehabilitation. "B" underscored his conviction of absolute normality. He wished to demonstrate this to the staff by maneuvering his two prostheses and a sheet of paper to pick up a dime. He failed a number of times before succeeding, but the note of triumph in his eye compensated for the failures. "B" had convinced himself that he was normal and who were we to question him? He was gainfully employed, easy to deal with, and adjusted to his environment. His "super normality" was irrelevant since this illusion did not interfere with his various roles as a human being. "C" did not require functional restoration for his work. He wore an active, cosmetic hand because of his desire not to attract attention to his disability, and his prosthesis was useful for minor tasks. He refused to wear a hook for more inclusive manual functioning. His goal was mainly cosmetic. The limited function of the type of prosthetic hand then available was satisfactory to him. "D" wore a passive hand with no function. His main goal was to appear normal to the casual observer. To some work ethicists on our staff "D" was regarded as an unactualized individual, but "D's" goals were not the attainment of complete self-actualization, but merely a wish to blend with the crowds on the trains and street. "E" was a prosthesis wearer interviewed for phantom limb experience. Our explanation as to the potential value of the study was misinterpreted by him. He somehow gained the impression that further knowledge about phantom limb sensation and neurological functioning would enable scientists to grow a new, natural limb on his amputation stump (as is the case with some lower animals). He nervously inquired "Will I lose my pension?" This veteran was so satisfied with his prosthesis (and disability pension) that he seemingly rejected the ultimate restoration, a reborn limb! "F" lost his left hand in an accident. He absolutely refused to wear his prosthesis because of discomfort and because he functioned adequately with his intact limb. His empty sleeve was virtually "filled" by his outgoing and warm personality. His interpersonal behavior was the best camouflage for his amputation. He was an amputee who had the best prosthesis of all—his total personality. Unfortunately, he later died, following a disease unrelated to his amputation. The large funeral chapel was packed with people from numerous walks of life. Each of these individuals represents a different personality type with distinctly different goals and levels of achievement, satisfactory to each if not to rehabilitation personnel. My experience as a psychologist has convinced me that different patients are ready for varying levels of growth. Some patients who have made appreciable, but not optimal gains in psychotherapy will leave. A percentage of these will return months or years later, after they have assimilated their original gains, to strive for a higher level of achievement. The choice must be voluntary. *Samuel A. Weiss, Ph.D. Dr. Samuel A. Weiss can be contacted at 7 Park Avenue, Suite 66, New York, New York 10016; tel. 212-686-8324. Page Number(s) 55 - 56 Year 1986 Volume 10 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Rehabilitation: Goals or Shoals? Creator An entity primarily responsible for making the resource Samuel A. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_057.pdf Text Any textual data included in the document <h2>Upper Limb Prosthetic Terminal Devices: Hands Versus Hooks</h2> <h5>John N. Billock, C.P.O. <a style="text-decoration: none;">*</a></h5> No one would argue that the human hand is the most complex and challenging structure of the human anatomy to replace and restore. The hand is an extremely complex structure which moves with a precision and dexterity that has long challenged the minds of researchers in medicine and engineering. Beyond its kinematic capabilities, the hand is also one of the most intricate sensory mechanisms of the human body-with unequaled proprioceptive and sensory feedback capabilities. With this in mind, it is easy to understand why prosthetic terminal devices today (hand and/or hook) offer very little in the way of true functional restoration to individuals with upper limb deficiencies. This is not meant to be critical of past developments, but puts into proper perspective the complexities and challenges of duplicating the human hand. Further emphasis of this is found in a commentary by Murphy<a></a> in which he stated, "Though engineers and prosthetists have made substantial contributions, they need perspective and humility to inspire and guide the very long, sustained efforts required to replace even a few of the roles of the hand." This challenge will doubtlessly keep researchers in prosthetics, and now those involved in robotics, busy with the task of trying to duplicate the kinematic and sensory capabilities of the human hand for years to come. <h3>Prosthetic Terminal Devices Today</h3> There exists today a significant number of prosthetic terminal devices for treating both adult and juvenile complete hand deficiencies. These terminal devices are designed as either mechanical or electromechanical systems and, as such, are either body-powered or electric powered. The body powered terminal devices function by utilizing forces generated by body movement as described by Taylor.<a></a> An electric powered terminal device functions by utilizing the electrical force stored within and generated from a battery. Further, these sources of power can activate or control a terminal device in different ways. The three most commonly used control systems are the Bowden cable control, myoelectric control, and switch control. In order to fully understand the functional potential of a particular terminal device, it is important to understand the control approach or system being used to actuate the device. <h3>Prosthetic Control Systems</h3> Professional opinions vary considerably regarding the most appropriate terminal device and control system to utilize in the design and development of a functional upper limb prosthesis. Bowden cable control systems harness the motions and forces generated by gross body movement to actuate and control, primarily, a mechanical terminal device. They require an adequate degree of force and excursion to actuate and control an upper/limb mechanical terminal device.<a></a> The most common example of this would be the Bowden cable control system of a totally mechanical below-elbow prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg">Fig. 1</a>). This type of control system harnesses the body motion and forces generated by flexion-abduction movements at the glenohumeral joint to actuate and control the terminal device. It is important to note that this form of control does produce a certain degree of sensory feedback related to force and position.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg">Figure 1. Illustration of a typical conventional body powered Bowden cable controlled below-elbow prosthesis with a mechanical hook terminal device actuated by "gross" body movements.</a> Myoelectric control systems utilize the existing neuro-muscular system for actuation and control of an electromechanical terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg">Fig. 2</a>). EMG potentials are monitored with surface electrodes placed over appropriate muscle or muscle groups within the residual limb and are used for either digital or proportional control of the terminal device. This type of control is considered to be quite natural since it utilizes the existing residual neuromuscular system for control.<a></a> This is especially true with synergistic muscle contractions, particularly related to natural hand functions, which can be selected for actuation and control of the terminal device. The use of myoelectric control enhances the feasibility of designing a totally self-contained and self-suspended prosthesis which has proven to be an acceptable and reliable design approach.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg">Figure 2. Illustration of a typical electric powered, myoelectrically controlled below-elbow prothesis with an electromechanical hand terminal device actuated by EMG potentials.</a> Switch control systems are those which utilize the motions and forces generated by "fine" body movements to actuate and control an electromechanical terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg">Fig. 3</a>). They require considerably less force and excursion than a Bowden cable controlled system to actuate and control a terminal device. Switch control systems can incorporate a variety of different types of switches, such as, pull, rocker, push-button or toggle type switch for activation of the terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg">Fig. 4</a>). This type of control is typically indicated in situations when limited body motion and forces are available for Bowden cable control and/or when EMG potentials are inadequate or inappropriate for control of the terminal device. <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg">Figure 3. Illustration of a typical electric powered switch controlled below-elbow prosthesis with electromechanical hand terminal device actuated by "fine" body movements.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg">Figure 4. The actuation characteristics of a typical pull, rocker, push button and toggle switch are illustrated. Switches are generally designed to produce one or more functions such as opening and/or closing of an electromechanical terminal device, (a) Pull (sliding) switch for actuation of two functions; (b) Rocker switch for actuation of two functions; (c) Push Button switch for actuation of one function; (d) Toggle switch for actuation of two functions.</a> <h3>Mechanical Hooks And Hands</h3> Following World War II and especially since the development of the APRL Voluntary Closing Hand and Hook in 1945, considerable controversy has existed regarding the functional aspects of hands versus hooks as terminal devices. Prior to the introduction and clinical use of electric hands in the early 1960's, this controversy only related to mechanical hands and hooks. Mechanical hands, although certainly more aesthetic, were felt by many professionals to be too heavy and awkward for fine prehension activities. Mechanical hooks, by way of contrast, weigh approximately one third the weight of a mechanical hand and provide dexterity comparable to a pair of tweezers. Mechanical hooks were also considered to be more durable because of their simple mechanical design, and the fact that a cover to protect internal mechanisms or provide aesthetics is unnecessary. Because of these mechanical advantages, very little regard was given to the social-psychological advantage and need for a prosthetic hand versus the hook terminal device. In fact, it became common practice within prosthetic clinics and teaching institutions to encourage use of a hook terminal device first before providing the individual with a hand terminal device. The purpose of this practice, which continues today, is to develop the individual's appreciation for the functional advantage of the mechanical hook over the mechanical hand. Further, it was the opinion and experience of many clinics and prosthetists that many individuals, if provided a hand and hook terminal device simultaneously, tended to reject the hook for aesthetic reasons and not develop an appreciation for its functional advantage. Conservative estimates indicate, however, that approximately only fifty percent of those individuals provided with conventional type mechanical prostheses are wearing their prosthesis as reported by LeBlanc.<a></a> This estimate does not distinguish between actual functional use versus simple wearing of the prosthesis. It is the author's opinion and experience that the introduction of a hook terminal device in the early stages of the prosthetic rehabilitation process may in fact be the primary cause of the high incidence of total prosthetic rejection since little, if any, attention is given to the social-psychological aspects of the individual's limb deficiency. The social-psychological aspects of an acquired or congenital upper limb deficiency should be regarded as the first and most significant problem which has to be understood and dealt with appropriately if successful prosthetic rehabilitation and functional use of a prosthesis is to be achieved. Dembo, Leviton, and Wright<a></a> clearly identified the social-psychological problems individuals, as well as those around them, have to deal with in accepting limb loss as part of the total rehabilitation process. If an individual has not accepted a limb loss, or in the case of a congenital limb deficiency, the parents have not accepted the limb loss, it is unlikely that successful prosthetic rehabilitation and functional use of a prosthesis will be achieved. Dr. Howard A. Rusk, recognized by many as the "father of physical medicine and rehabilitation," has identified motivation and timely rehabilitation services as the key elements to achieving successful rehabilitation of an individual's disability.<a></a> An individual can receive the best rehabilitation services available and be provided with the best prosthesis today's technology has to offer. However, if they are not motivated to overcome their disability or adjust to it, acceptable rehabilitation is unlikely. Likewise, the child born with a congenital limb deficiency will not be encouraged to adapt to or functionally utilize a prosthesis if the parents have not accepted their child's disability. <h3>Electric Powered Hooks And Hands</h3> The introduction of electric powered hands into clinical practice in the early 1960's brought about a new era in prosthetics. Acceptance of these "electric hands" by the American prosthetics profession was much slower than in the European countries where they were initially developed. They are, moreover, still considered by many to be not as functional as mechanical hook terminal devices. It is felt that much of this belief can be traced to the attitude that regards mechanical hands as being less functional than mechanical hooks. Electric powered hands, however, have one primary major functional advantage over mechanical hooks and hands. Electric hands can produce finger prehension force which is equal to, and in some cases greater than, that of an adult or juvenile human hand. The average adult male, for instance, can produce an average of 20 to 24 lbs. of finger prehension. The average tolerable amount of prehension that an adult male can generate with a Bowden cable controlled prosthesis and the more commonly used voluntary opening mechanical hook terminal device is approximately 8 to 10 lbs. Voluntary closing mechanical hands and hooks obviously are able to provide greater finger prehension than voluntary opening hooks or hands; however, they have not been widely accepted or used. Another key advantage of an electric powered hand is that it provides forceful "3 jaw chuck" palmar type prehension. This type of prehension has been identified as early as 1919 by Schlesinger,<a></a> to be the most commonly utilized hand-finger prehension pattern for picking up and holding objects in activities of daily living (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg">Fig. 1</a> shows the percentage of use to pick up and hold objects with an electric powered hand. The predominance of "3 jaw chuck" palmar prehension in our activities of daily living accounts for the reason all mechanical and electric powered hands of today are designed with the thumb in opposition to the second and third fingers. The forceful palmar prehension of the electric powered hand, therefore, enhances its overall functional value as a prosthetic terminal device. <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg">Figure 5. Of the six commonly used hand/finger prehension patterns, described by Schlesinger, "3 jaw chuck" palmar type, tip type and lateral type prehension are considered to be the most frequently used during activities of daily living.</a> The only electric powered hook available for clinical use at this time is the Otto Bock "Griefer"<a></a> which was introduced in the U.S. in the late 1970's. As an electric powered terminal device, it has the quality of providing "forceful" prehension. Along with this, it is uniquely designed with multi-axis fingers to keep the grasping surfaces parallel during the entire range of opening and closing (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg">Fig. 6</a>). This design feature allows for even pressure throughout its range of opening and closing which enhances its grasping ability over mechanical hooks. The grasping surfaces of a mechanical hook angle away from one another as the active finger moves in relationship to the stationary finger (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg">Fig. 7</a>). Therefore the larger the object to be held in the mechanical hook terminal device, the less contact with the object and, consequently, the more force required to stabilize the object, dependent upon its shape. The "Griefer," on the other hand, is heavier than the heaviest stainless steel mechanical hook and is not as durable, primarily because its design is more complex than the single axis mechanical hooks. <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-06.jpg">Table 1</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg">Figure 6. This diagram illustrates the angular relationship of the prehension surfaces and the object being held, utilizing a multi-axis prehension design approach, such as in the Otto Bock "Griefer."</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg">Figure 7. This diagram illustrates the angular relationship of the prehension surfaces and the object being held, utilizing a single-axis prehension design approach, such as in the Hosmer/Dor-rance</a><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg"> mechanical hook series.</a> Clinical Experience The terminal device of the prosthesis plays an important key role in developing the motivation which will, hopefully, lead to successful prosthetic rehabilitation. It has been the author's experience, in over 300 cases involving individuals with congenital and acquired limb deficiencies from the wrist to the shoulder, that 95 percent or better of those individuals preferred to have a prosthetic hand rather than a hook terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg">Table 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg">Table 3</a>). In all cases involving juvenile subjects (which represents approximately ten percent of the total case load), the parents and children over the age of five years preferred hand terminal devices to hooks. Forty percent of the total juvenile case load involved children under the age of five years, and in all cases, the parents preferred hand terminal devices. Parents were also found to prefer a passive nonfunctional hand as opposed to the more typically used passive type nonfunctional mitten for children up to 1 1/2 years of age. <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg">Table 2</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-10.jpg">Table 3</a> One might quickly draw the conclusion that this preference was specifically related to the aesthetics of the hand and not necessarily related to function. There is no doubt that the aesthetics of the hand played a key role in the decision. However, this preference also emphasizes the strong social-psychological need for individuals, as well as the parents of children with limb deficiencies, to visually feel as normal as possible within our society. The aesthetics of a hand terminal device obviously satisfies this need more appropriately than a hook terminal device. Beyond this, it is also interesting to note that approximately only one percent of those provided a prosthesis with hand are utilizing a mechanical hand terminal device. Therefore, 99 percent utilize electric powered hands in their prostheses; eighty percent of these are controlled myoelectrically. It is estimated that total rejection of an electric powered hand prosthesis has been approximately 15-20 percent. Actual percentages of rejection have been difficult to verify because of lack of follow-up by the patients, and it is felt that 5-10 percent of the patients are now being followed-up elsewhere. Nevertheless, total prosthetic rejection is considerably less than those provided with conventional upper limb prostheses.<a></a> It is not felt that the acceptance rate of electrically powered hand prostheses is specifically related to aesthetics of the hand. If this were the case, one would expect more individuals to have been utilizing mechanical or passive hands prior to the development of electric powered hands. <h3>Conclusion</h3> Clinical experience has definitely proven, in the author's experience, that an electrically powered prosthetic hand terminal device which is proportionally controlled, utilizing myoelectrical EMG potentials from synergistically related muscles within the residual limb, is the most acceptable and functional upper limb prosthetic design for individuals with complete hand deficiencies. It is further felt that the terminal device is the most important component of the prosthesis; just as the hand is to the normal upper limb. Whenever possible, a prosthetic hand should be preferred to a hook terminal device, in consideration of the individual's social-psychological needs. The individual's social-psychological needs must be of primary concern initially and must be considered before vocational needs can be effectively addressed. This is also true when managing children and is especially important in addressing the social-psychological needs of parents of children born with congenital upper limb complete hand deficiencies. If the vocational or avocational needs clearly indicate the need for a hook terminal device, this must be clinically tested and proven, or the individual must personally desire the hook terminal device. This has been found to be true for all levels of upper limb deficiencies involving the hand, wrist, elbow, and shoulder. This criteria is obviously not the case for everyone with an upper limb deficiency; however, it is felt to be true for the majority and especially those with unilateral upper limb involvement. The prosthetic hand should be thought of as an assistive device to the sound limb, just as the nondominant normal hand is to the dominant normal hand. Many have felt it is important to be able to perform fine motor prehension activities with a prosthetic terminal device and this has been a major argument in favor of hook terminal devices. The fact is, the majority of those individuals with upper limb deficiencies are unilaterally involved and do not use their prosthesis for fine motor prehension activities; just as a non-involved individual does not typically utilize the nondominant hand for such activities. The prosthetic terminal device is most important for gross prehension activities, to hold and stabilize objects while the sound limb performs the fine motor prehension activities. An electrically powered hand terminal device, with adequately controlled functional prehension, best serves this need for the majority of an individual's activities of daily living. It is important to remember that we live in a world made for hands, and most everything we encounter in our activities of daily living is made to be hand held. <h3>Acknowledgments</h3> The author is deeply indebted to those individuals who have sought and benefited from the research which made this paper possible. Special appreciation is given to my wife, Dottie, Jean Ann Pasini, and Gordon L. Grimm for their editorial input and assistance in preparation of this paper, and to the other staff members of the Orthotics and Prosthetics Centre of Warren for their continued understanding and support of the author's professional interests. The illustrations and art work of Jean Ann Pasini are particularly appreciated. *John N. Billock, C.P.O. John N. Billock, C.P.O. is Clinical Director at the Orthotics and Prosthetics Centre of Warren in Warren, Ohio. He is also Chairman of the Research and Evaluation Committee of the American Academy of Orthotists and Prosthetists. References: <ol> <li>Billock, J.N., "The Northwestern University Supracondylar Suspension Technique for Below Elbow Amputations," Orthotics and Prosthetics, Vol. 26, No. 4, pp. 16-23, 1972.</li> <li>Billock, J.N., "Upper Limb Prosthetic Management: Hybrid Design Approaches," Clinical Prosthetics and Orthotics, Vol. 9, No. 1, pp. 23-25, 1985.</li> <li>Childress, D.S. and Billock, J.N., "Self-containment and Self-suspension of Externally Powered Prostheses for the Forearm," Bulletin of Prosthetics Research, Vol. 10, No. 14, pp. 4-21, 1970</li> <li>Childress, D.S., "Powered Limb Prostheses: Their Clinical Significance," IEEE Transactions on Biomedical Engineering, Vol. BME-20, No. 3, pp. 200-207, May, 1973.</li> <li>Childress, D.S.; Holmes, D.W.; and Billock, J.N., "Ideas on Myoelectric Prosthetics Systems for Upper-Extremity Amputees," The Control of Upper-Extremity Prostheses and Orthoses, pp. 86-106, 1974.</li> <li>Dembo, T.; Leviton, G.L.; and Wright, B.A., "Adjustment to Misfortune: A Problem of Social-Psychological Rehabilitation," Selected Articles from Artificial Limbs, pp. 117-175, New York, July, 1970.</li> <li>Gwynne, G., "Mechanical Components," Manual of Upper Extremity Prosthetics, Department of Engineering, University of Southern California at Los Angeles, Second Edition, pp. 33-68, 1958.</li> <li>Le Blanc, M.A., "Patient Population and Other Estimates of Prosthetics and Orthotics in the USA," Orthotics and Prosthetics, Vol. 27, No. 3, p. 38-44, 1973.</li> <li>Murphy, E.F., "Commentary," Selected Articles from Artificial Limbs, New York pp. vii-xii, July, 1970.</li> <li>Rusk, H.A., "Rehabilitation," Journal of the American Medical Association, Vol. 140, pp. 286-292, 1949.</li> <li>Rusk, H.A., "Advances in Rehabilitation," Practitioner, Vol. 183, pp. 505-512, 1959.</li> <li>Schlesinger, G., "Der Mechanische Aufbau der kunstlichen Glieder," Ersatzglieder und Arbeitshilfen, Vol. 3, Berlin, 1919.</li> <li>Taylor, C.L., Schwarz, R.J., "The Anatomy and Mechanics of the Human Hand," Selected Articles from Artificial Limbs, New York, pp. 49-62, 1970.</li> <li>Taylor, C.L., "Biomechanics of Control," Selected Articles from Artificial Limbs, New York, pp. 63-84, July, 1970.</li> <li>Otto Bock "Griefer" is a registered trade mark of the Otto Bock Orthopedic Industry, Inc., Duterstat, West Germany/Minneapolis, Minnesota.</li> <li>Hosmer Dorrance is a registered trade mark of the Hosmer Dorrance Corporation, Campbell, California.</li> </ol> Page Number(s) 57 - 65 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 TABLE I http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-06.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg Figure 9 TABLE II http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg Figure 10 TABLE III http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper Limb Prosthetic Terminal Devices: Hands Versus Hooks Creator An entity primarily responsible for making the resource John N. Billock, C.P.O. * https://staging.drfop.org/files/original/6c2c63ddffe3d550de617cddd2fd3dd0.pdf a968d5b9bd58a10b866f2865888702c4 https://staging.drfop.org/files/original/f79b3b23e95dbeb5afa6c8473cde777c.jpg 8fb5942309fbf39e9a7f9d5b0faa3ad4 https://staging.drfop.org/files/original/c220a5b7800edb8c2f03fbae92a1461e.jpg 87cbf6d646ea79dfe843e1acabdda96f https://staging.drfop.org/files/original/c51a8772e852e3c455899c6ff2c762ce.jpg 33046249d3204db97c4c086dfd5599b3 https://staging.drfop.org/files/original/6900141d8663452725d64428373f8d50.jpg 53e19138614db7dc6c7fb8957ab80aae https://staging.drfop.org/files/original/d95b5a36a5716b9d244ed4df81c74f3e.jpg 4b6a6d211a5d773b43c6faab345690df https://staging.drfop.org/files/original/c9e2d2419431e40d357277310450bc3e.png afc4e7e2abd9dbe853ea3aae3159c753 https://staging.drfop.org/files/original/7097692bfc548e8b707cf8c2c5d4cd0d.png 5eceeff5f79d833e8f2e3a8c26694e06 https://staging.drfop.org/files/original/90edd7a8ef69e6ec44df2371f663927a.png c617fbfef726b1388adcfd1e4d2c584e https://staging.drfop.org/files/original/d1b765c7055d84a8a7222ccbc9c30ff1.png 7cbeda763ee9076246a237debce1071b https://staging.drfop.org/files/original/584c3a08b5ad54660112b465920dd0d6.png d9a078f202590efd229a906944609682 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_066.pdf Text Any textual data included in the document <h2>Upper Limb Powered Components and Controls: Current Concepts</h2> <h5>John W. Michael, M.Ed., C.P.O. <a style="text-decoration: none;">*</a></h5> In order to review the current offerings in powered upper limb components, it is necessary to agree upon certain standardized terms. The following suggestions, based upon a survey of the existing literature, are intended to help insure we are all speaking a common language. Practitioners with strong opinions regarding alternate definitions are encouraged to publish their views as well. It is critical that we agree upon some definition; which particular version is of much less importance. The focus of this paper will be on externally powered prostheses—specifically, those that are electrical in nature. The opposite concept is the familiar body powered prosthesis, which is powered by muscular action and transmitted from remote body locations. Many prosthetists have some experience at the below-elbow level with the components produced by Otto Bock, and assume they have fitted myoelectric devices. Technically, that is not completely correct. The MyoBock system is most accurately termed "Myoswitch" control. This is a much simpler version than true myoelectric control. In the Otto Bock system, the residual myoelectric signal does not directly control the terminal device. Instead, the patient must generate a sufficiently strong signal to cross a threshold, which triggers an electronic switch. A good analogy would be that of sound-activated devices which can be installed in lieu of a standard light switch. Clapping one's hands turns the light on. If the clap is too faint, nothing will happen, but an extremely loud clap has no more effect than one just loud enough to trigger the switch. This is sometimes described as "digital control." This approach does not allow proportional control. That is, the light is either all on, or all off. There is no in-between. Proportional control is provided by a rheostat, which allows one to gradually dim or brighten the lights as the mood dictates. Proportional control is, in this author's opinion, the key distinction in true myoelectric systems. The below-elbow system marketed by Fidelity Electronics is an example of such a design. In this version, a mild myoelectric impulse causes a slow, gentle movement of the hand, while a strong impulse creates a rapid, powerful movement of the hand. Many authorities feel this is the most physiologically natural control, and offers the greatest degree of prehension control as well.<a></a> A good analogy is the accelerator in an automobile, which allows proportional control of the speed of the vehicle. Imagine a switch-controlled car with the throttle either at idle or wide open! Otto Bock has a very clever solution to this dilemma: the automatic transmission. The MyoBock prosthesis has two speeds: a quick, gentle motion when opening and closing, and a slow, powerful motion once the fingers grip an object. This might not be a reasonable solution for the auto industry, but it has proved to be clinically acceptable in prosthetics. The third available control mode is pure Switch Control. This is the least expensive approach and generally requires less bulky electronics. For these reasons, it is often used in juvenile below-elbow designs (for example, Variety Village). It also does not require any myoelectric signals, which can be helpful when control sites are limited or unavailable. Switch controls come in three basic varieties. <ol> <li> Rocker Switches are similar to the on-off control for stereo equipment, and are sometimes used where a mobile acromion is present. </li> <li> Button Switches are also adaptable for acromion control, for use with phoco-melic digits, and any other mobile body parts. They are the electronic analogue of mechanical nudge control. </li> <li> Pull Switches are useful when harness control is desired. Most are multiposi-tional, where initial excursion will cause one motion, and further excursion the opposite motion. These are somewhat analogous to the alternating lock used in the conventional elbows with one motion controlling two or more functions. </li> </ol> These are simply the most common types; literally hundreds of variations can be obtained from electronic supply stores. On rare occasions, they can be arranged in a piano keyboard array, allowing several degrees of freedom to be controlled from one location.<a></a> Another set of related concepts are "site and state."12 Site refers to the number of distinct muscle signals required. Thus, the original Myobock system was a "two site" version, requiring one myosignal for hand opening and a separate signal for hand closing. The University of New Brunswick (UNB) was one of the first groups to develop a commercial system that required only one myosignal. This is particularly advantageous when dealing with young congenital below-elbow patients. Very often they can only generate one mass contraction in the residual limb, and space considerations alone may preclude more than one electrode. UNB termed their system "Single Site/Three State" control. The term "Three State" means that the myopulse both opens and closes the hand; the "third" state is "off." In the last couple of years, Otto Bock has introduced their version of this concept. As in the UNB design, it is a digital "Myoswitch." A quick, hard myopulse causes the hand to open, while a slow, gentle myopulse causes closure. Bock calls this "Double Channel Single Site" control. "Double Channel" accurately identifies the capabilities: one channel opens and the other closes. Unfortunately, the word "channel" has established meanings in other fields that may be a source of confusion. For maximum clarity, the term "Function" is probably preferable.<a></a> This has a clear intuitive meaning. Thus, the system just described would be termed a "One Site-Two Function" system. With suitable changes in the terminal device electronics, Otto Bock can offer what they term "Grip Force" control which is a kind of psuedo-proportional control. In this application, the patient can use the quick, strong pulse to automatically downshift the transmission, thereby increasing the grip strength. A logical extension of this approach is Bock's "Four Channel" design. One electrode controls terminal device opening and closing while the other controls electric wrist pronation and supination—four distinct functions. Clearly, if suitable sites could be found, additional degrees of freedom could be controlled using existing technology. Experience has shown, however, that this is rarely feasible. In the above-elbow realm, the developers at Motion Control argue strongly that proportional control is the ideal. Therefore, they avoid the digital control mentioned thus far. Yet, they have developed a system permitting only two muscle sites to operate elbow raising and lowering, as well as terminal device opening and closing. Thus far, their solution is unique in the field of powered components. The Motion Control design uses a very clever method of electronic switching to separate elbow and terminal device functions. When the arm is first powered on, the two muscle sites proportionally control elbow flexion and extension. (In an ideal candidate, biceps and triceps are the remnant muscles yielding physiologically normal control as well.) Whenever the elbow is in motion, things remain in this mode. However, if the elbow is stopped in a flexed position and held steady for a moment, the arm "senses" that one intends to perform a grasping function. It then locks the elbow and automatically switches itself into a "grasping" mode. The same two sites now control proportional, bidirectional grasp. To return to the "elbow" mode, the patient co-contracts in a specific fashion. The co-contractures cancel each other out so that no motion of the TD occurs, and the electronic switch senses this and changes modes. This strategy can be termed "Sequential Control", and is directly analogous to the familiar mechanical elbow joint where the same shoulder motion moves first the elbow and then the terminal device. The most sophisticated control for a high level amputee would be Simultaneous Proportional Control. Northwestern has done some fascinating work in this area,<a></a> as has the Illinois Institute of Technology and others.<a></a> This would be the most natural-appearing motion, since our biological arms move through multiple degrees of freedom simultaneously with every gesture. However, there are numerous technical and control difficulties with this approach, and all seem to be far from commercial production right now. One major issue is control site availability. Even if one conceives of an arm offering twenty simultaneous degrees of freedom, where on the high-level amputee are twenty independent controlable sites to be found? Much of the current research involves reading data from a few sites and using computer algorithms to simulate multi-degree control.<a></a> Most currently require a mainframe computer to process the data in real time, but perhaps the future will see microchip processors with these capabilities built into upper limb devices. But, for now there are less spectacular components to choose from. What follows is an overview of currently available hardware. Specific details change almost weekly; contact the manufacturer for the latest updates. The final caveat is: the ideal system does not exist. All the components have strengths and weaknesses. When prescribed correctly, one can achieve very satisfying results. When used inappropriately, failure is the inevitable result. As prosthetists gain more collective experience and confidence in the realm of powered upper limb prosthetics, perhaps we can learn to "mix and match," as we do in body powered fittings, to maximize the benefits for our patients. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-01.jpg">Fig. 1. Otto Bock electric hand and electric hook (Greifer). Bilateral powered fittings can be successful in carefully selected cases. (Courtesy of Otto Bock Industries.)</a> <h3>Otto Bock</h3> In the United States, Otto Bock is viewed as the "father" of electrically controlled prostheses. Although all their current designs are digital controls, they offer one of the largest arrays of interchangeable electric components of any manufacturer. At this time, all Otto Bock components are designed for below-elbow use, although they are equally adaptable for higher levels. One ramification of this is that since 1976, they have been using six volts as their standard. (Twelve volt terminal devices can be obtained for use with other manufacturers' systems.) Six volts offers lower battery weights while still providing adequate power for terminal device operation. Otto Bock's battery is a relatively small package, easily interchangeable, but for slow recharge only. Their "Griefer" is the only adult-sized powered hook currently on the market, and it readily interchanges with their adult hands. They also have the only electric wrist rotator currently available. They currently offer four hand sizes, for older children, teens and ladies, standard adult, and large adult males. These have become the de facto standard in the industry; virtually every other company can interface their system with a MyoBock hand. An assortment of wrists are also available. All their electrodes are digital, myoswitch types, as already discussed. They offer optional floating electrode mounts for cases where a change in residual limb volume is anticipated. Since their terminal devices are set up for myoswitch control, it is relatively easy to use regular switch control as well. Otto Bock offers both a rocker switch and a harness pull switch version. With their typical attention to detail, a complete set of Technical Information Bulletins, courses, and specialized tools are available. Otto Bock also offers a variety of well thought out accessories, such as a tweezer (pincer) for the hands, blank Griefer tips for machining custom gripping surfaces, and so on. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-02.jpg">Fig. 2. Variety Village VV2-6 electric hand: the smallest and lightest powered hand commercially available. (Courtesy of Variety Village Electrolimb Production Centre.)</a> <h3>Variety Village</h3> Variety Village components complement Otto Bock's nicely, as they are targeted for smaller children, and include a powered elbow. All their components are switch controlled. They market three switch types: a toggle for phocomelics, a button type, and a pull strap version. In addition, their elbow can have the pull switch built in, or be ordered for use with remote switches. Their elbow is available in either 6 or 12 volts; their hands are 6 volts exclusively. Their smallest hand (for 2-6 year olds) has just been redesigned. Although similar to the Swedish hand, it is three ounces lighter. Their original hands (Models 105 and 106) have been discontinued. Research is currently underway to create the smallest electric hand yet available: thirty percent smaller than their VV2-6. Only prototypes exist at this time, however. They market several battery configurations, including a "Battery Saver Circuit" designed to prevent children from draining the electrical charge by stalling the motor. None are of the quick-charge variety, however. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-03.jpg">Fig. 3. Electric hands imported by Liberty Mutual. The smallest is the System-Teknik from Sweden; balance are Steeper hands from England. (Courtesy of Liberty Mutual Research Center.)</a> <h3>Hugh Steeper Limited</h3> Steeper is the British corporation responsible for upper limb prosthetics in the United Kingdom. They have recently announced the availability of powered hands for small children. These are now being distributed by Liberty Mutual in the United States. The sizes complement the Swedish hand, in that the Steeper hands are a bit larger than either Swedish version. Sometime in 1986, they will probably offer a larger hand for the early teen. These are 6 volt, switch controlled devices for the most part. However, Steeper also offers a "Servo-Control" option. This is a unique kind of proportional switch control: the harder the child pulls on the switch cable, the stronger the grasp. With minor adaptations (which Liberty Mutual will make), they can also be controlled by Otto Bock or UNB myos witches. <h3>System-Teknik</h3> System-Teknik is a Swedish company with two children's hands on the American market. Production rights for these hands have just been aquired by Steeper, so design changes can be expected. Liberty Mutual is the American distributer. At the present time, two Swedish hands are available: one for 2-6 year olds and another for 5-9 year olds. Both are 6 volts, and they use the same size forearm laminating ring for easy interchange. They can be controlled by either the UNB or Otto Bock myoswitches and switch controls. UNB designed its batteries to be mounted within the forearm shell. If space permitted, Otto Bock's could be used as well. To simplify the fitting procedure, Liberty Mutual plans to offer a special wrist unit option, containing all necessary electronics. Planned for use with both the System Teknik and Steeper hands, it will come in one version containing the battery supply, and a shorter version for longer residual limbs with remote battery mounting. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-04.jpg">Fig. 4. Variety of powered components supplied by Liberty Mutual, including the UNB Toy Controller. (Courtesy of Liberty Mutual Research Center.)</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-05.jpg">Fig. 5. Fidelity components, including harness pull switch, electric elbow, and VANU hand. (Courtesy of Fidelity Biomedical Products.)</a> <h3>University Of New Brunswick</h3> All UNB products are available through Liberty Mutual in the United States. When ordering their "Single Site" system, there are three options for battery placement: built-in to the electronics package, mounted inside the forearm section, or mounted externally. As is the case with all manufacturers, you must purchase their particular myotester/trainer to properly adjust their system. In addition, UNB offers a unique single site system with built-in sensory feedback. To aid in myotraining small children, they also market a "Toy Controller," which can be adapted to run with Otto Bock electrodes as well. <h3>Fidelity Electronics</h3> Fidelity Electronics distributes the proportional below-elbow system originally developed at Northwestern University. At one time the United States Manufacturing Company also carried these components, but Fidelity is currently the sole source. This is sometimes referred to as the "VANU" hand. Several things are unique about this product. First, it is a 12 volt system. Secondly, all the electronics are located in a "wrist module," including the battery. Therefore, it is self-contained with minimal risk of wire damage. However, this also prevents fitting very long residual limbs and concentrates all the weight at the distal portion of the prosthesis. Long residual limbs require the use of a switch-controlled version, thus eliminating the wrist module. This hand is sized for adult males only (7 3/4). Fidelity also offers a switch-controlled elbow (again, in adult size only). This is an 8.75 volt system, with its own built-in battery pack. It utilizes an exoskeletal soft foam forearm set-up. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-06.jpg">Fig. 6. The Prehension Actuator provides powered opening for a variety of conventional hooks. Closing force is controlled by the number of rubber bands applied. (Courtesy of Hosmer Dorrance Corporation.)</a> <h3>Hosmer Dorrance</h3> As the "grandfather" of upper limb prosthetics in North America, Hosmer is in a unique position to develop a system of powered components. Their basic philosophy has been to focus on light-weight, straightforward, relatively inexpensive designs. For years, they have offered the "Michigan Hook," which is the familiar child's hook, closed by a rubber band, but opened with a small motor winding a string. Last year, they announced an adult version of this concept, called the "NYU Prehension Actuator." This is a conventional forearm set-up with an electric "winder" included. It can be mated with a variety of voluntary opening hooks, using up to five rubber bands or so. Although it is currently switch-controlled, a single-site "MyoPack" will soon be available, offering the option to convert both the Michigan Hook and the Prehension Actuator to myoswitch control. Hosmer has also released the "NYU Hush" elbow. This is unique in several respects. First, it is designed to permit the familiar mechanical elbow to be substituted for the electric one, even in a finished prosthesis. Secondly, they elected to use standard "grocery store" nickel cadmium batteries to power the system. This dramatically reduces the cost to the consumer. Four AA NiCad cells yield a 5 volt system; if desired, five can be used for 6.25 volts. Either version is rechargable with an inexpensive "dimestore" trickle charger. Hosmer hopes to offer in 1986 a "Free Swing" option for their elbow, which could be retro-fitted to existing units in the field. Once the elbow attains full extension, it would automatically enter the free-swing mode. In addition to enhancing the dynamic cosmesis during ambulation, this may offer some special benefits to bilateral patients. Those who depend on the prosthesis for feeding would then have the option of resting the forearm against the table and using "body English" for elbow flexion. Finally, it can be used with either an endo-skeletal or exoskeletal forearm, as desired. This is a switch-controlled elbow, again keeping the costs lower, which is currently available in a large and medium size, corresponding to the familiar E-400 and E-200 mechanical elbows. Thus, it is suitable for many older children as well as adult men and women. Hosmer's switches have recently been redesigned to increase reliability. In addition to the familiar button and harness switches, they also offer a "Three-Position Harness Switch," permitting one control motion to operate both elbow flexion-extension and the NYU Prehension Actuator. The latest addition to the Hosmer line is an adult male (7 3/4) switch-controlled hand to complement their elbow. This also uses readily available NiCads for 5 or 6.25 volt operation. The "Synergetic Hook" designed by Dr. Dudley Childress at Northwestern University<a></a> should be available sometime in 1986. Beyond that, work is ongoing for a myoelectric elbow and hand, but neither is presently available. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-07.jpg">Fig. 7. Boston elbow, combined with a Hosmer mechanical shoulder joint and Otto Bock electric hand. Combining various international components can enhance prosthetic restoration. (Prosthetic Design by John C. Hodgins, C.P.O.; (Courtesy of Liberty Mutual Research Center.)</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-8.jpg">Fig. 8. Exploded view of the Utah elbow. Highly modular construction facilitates servicing in the field. (Courtesy of Motion Control, Inc.)</a> <h3>Liberty Mutual</h3> Liberty Mutual is the world's largest workmen's compensation insurer. In the United States, one in fifteen workers is insured by this company. Thus, they have a dual motivation in offering sophisticated prosthetic components: both to help the clients they insure, and also to enable the clients to return to work, thus reducing the company's liability. The 12 volt Liberty Mutual "Boston Elbow" can be categorized as a working man's device. And, in fact, it is one of the most durable electric elbows on the market. Although the original version was widely criticized because of the noise it made when operating, the current generation is markedly improved. This is the only elbow offering dual battery chargers. Although Liberty Mutual recommends overnight "trickle" charging for longer battery life, they offer a "quick charge" option, in case the internal battery becomes discharged before the day is over. This is also the only elbow designed to easily convert from proportional myoelectric control to switch control. Simply altering one wire makes the conversion. This can be very useful, for example, in fitting patients early with switch control, then later upgrading to myo-control as their residual limb matures. As mentioned elsewhere, Liberty Mutual also distributes the UNB, System-Technik, and Steeper components. <h3>Motion Control</h3> Motion Control is marketing the powered elbow system originally developed by the University of Utah. In contrast to Hosmer's strategy, this group sought to offer the most technologically advanced components possible. Undoubtedly, they have succeeded in this goal. However, most sophisticated does not necessarily mean best; simpler technology is often more reliable than state-of-the-art. Nevertheless, Motion Control has a unique addition to the prosthetic armamentarium. Their electronic locking mechanism and Sequential Proportional Control have already been discussed. Originally designed for mechanical terminal device operation, this 12 volt elbow can also be ordered with an Otto Bock hand. In this case, however, Motion Control discards the electronics and substitutes their own, thus offering true proportional myoelectric control of the Otto Bock hand. Of all the systems on the market, particularly above-elbow systems, this is the most "pros-thetist friendly." All the inner components are modular and easily exchangeable in the field. The quick-change battery pack is built into the humeral section, but below the elbow axis. This permits fitting longer residual limbs than is possible with other systems, and means there are no external wires to fray and fail. Further, this version offers by far the most adjustments to "fine tune" the elbow for a particular patient. There is a price to pay for this degree of technology, of course. In addition to being the most sophisticated, the Utah Arm is also by far the most expensive powered device available today. It is now possible to add an Otto Bock powered wrist rotator to the Utah Arm, using a variety of control strategies, including UNB or Otto Bock's single-site electrodes, two-site electrodes, and assorted switches. If a mechanical terminal device has been used, the Utah Arm mechanism can be modified to provide dedicated proportional control of the wrist unit. Also, their highly sensitive myotester is finally a commercial reality. Beyond that, Motion Control has just announced the availability, to prosthetists trained in the elbow fitting procedures, of a proportionally controlled below-elbow system, using Motion Control electronics to power an Otto Bock hand with 12 volts in a below-elbow prosthesis. Currently, this requires mounting two Otto Bock batteries, which can present some difficulties, although other battery sources can be utilized in selective cases. Finally, and perhaps most significantly, Motion Control has become the first supplier to offer a rental program for myoelectric components. In marginal cases, if funding has been conditionally approved, the components can be rented on a monthly basis for about ten percent of the total cost. Most of the rental is applied toward purchase of the arm if the fitting proves successful; if not, the parts are returned to Motion Control. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-09.jpg">Table 1</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-10.jpg">Table 2</a> Summary Our powered upper limb armamentarium is now surprisingly complete. Although one must select components from all over the world, it is possible to fit virtually any patient from two years old to adulthood with an externally powered prosthesis. Otto Bock components remain the most widely utilized, and their hands and connectors are becoming the de facto standards in the field. Their own components are designed for below-elbow use, but are routinely adapted to higher levels. Otto Bock has chosen to develop a variety of myoswitch controls, but does not offer true proportional control. Although several voltages are used, a general trend toward 12 volts for above-elbow systems and 6 volts for below-elbow is apparent. And, switch control is used almost exclusively for very small children, progressing to myoswitch control as they mature; proportional control is most commonly reserved for adults. The children's components are all from outside the United States: Sweden, England, and Canada currently offer toddler hands. American designs are often targeted to adults: the Hosmer and VANU hands and Boston Elbow toward males, in particular. Hosmer is aggressively pursuing the inexpensive, low-tech end of the market, emphasizing interchangeability with the familiar mechanical counterparts. Motion Control is equally aggressive in pursuing the high tech, high cost end. Lack of funding is probably the major factor limiting the number of powered fittings currently undertaken. With the ready availability of various switch, myoswitch, and proportional controls, virtually any patient could operate an electric prosthesis. Questions about who is a suitable candidate for powered fittings are still largely unanswered. The evidence suggests that the highest failure rate is with bilateral fittings.<a></a> Perhaps the simplicity and resultant reliability of body powered prostheses makes mechanical solutions more succcessful here. The best system cannot be found, and few practitioners are brave enough or experienced enough to freely mix these international components. The issues of proportional vs. digital control, high tech vs. low tech design, hybrid vs. purely mechanical vs. purely powered fittings are all open to debate. And some very provocative data is emerging suggesting that the issue of when to fit is at least as significant as the issue of what to fit.<a></a> It is beyond the scope of this paper to resolve these complex issues. Rather, the intent is simply to bring into focus the basic concepts, components, and controversies in the field of powered upper limb fittings. It is hoped that clarifying these issues will encourage prosthetic practitioners to deepen their involvement and understanding in this rapidly evolving area. As we struggle collectively with these problems, our patients and our profession will ultimately reap the benefits. <h3>Appendix</h3> V.A.N.U. Products Fidelity Biomedical Products 6000 N.W. 153 Street Miami Lakes, Florida 33014 (800) 327-7939 Hush Elbow; Prehension Actuator Hosmer-Dorrance Corporation 561 Division Street P.O. Box 37 Campbell, California 95008 (800) 538-7748 Boston, UNB, Steeper, Systek Products Liberty Mutual Research Center 71 Frankland Road Hopkinton, Massachusetts 01748 (617) 435-9061 Utah Elbow, BE System Motion Control, Inc. 1005 South 300 West Salt Lake City, Utah 84101 (800) 621-3347 MyoBock Products Otto Bock Industry 4130 Highway 55 Minneapolis, Minnesota 55422 (800) 328-4058 Variety Village Products Variety Village Electrolimb Production Centre 3701 Danforth Avenue Scarborough, Toronto CANADA MIN 2G2 (416) 698-1415 *John W. Michael, M.Ed., C.P.O. John W. Michael is Director of Prosthetics and Orthotics, Duke University Medical Center, Box 3885, Durham, North Carolina 27710. References: <ol> <li><a href="poi/1981_02_092.asp">Agnew, J.P., "Functional Effectiveness of a Myo-Electric Prosthesis Compared with a Functional Split-Hook Prosthesis: A Single Subject Experiment," Prosthetics and Orthotics International, 5(2), pp. 92-96, 1981.</a></li> <li><a href="cpo/1985_01_023.asp">Billock, John N., "Upper Limb Prosthetic Management-Hybrid Design Approaches," Clinical Prosthetics and Orthotics, 9(1), pp. 23-25, 1985.</a></li> <li>Childress, D.S., "An Approach To Powered Grasp," Proceedings of the Fourth International Symposium on External Control of Human Extremities, Dubrovnik, Yugoslavia; pp. 159-167, 1973.</li> <li>Doubler and Childress (1984), "Design and Evaluation of a Prosthesis Control System Based on the Concept of Extended Physiological Proprioception," Journal of Rehabilitation Research and Development, 10(39), pp. 19-31.</li> <li><a href="http://www.acpoc.org/library/1983_04_001.asp">Ferguson, Shirley, "Electric Power In Upper Limb Prosthetics: The Michigan Experience," Inter-Clinic Information Bulletin, 18(4), pp. 1-8, 1983.</a></li> <li>Graupe, et al., "A Multifunctional Prosthesis Control System Based on Time Series Identification of EMG Signals Using Microprocessors," Bulletin of Prosthetics Research, 10(27), pp. 4-16, 1977.</li> <li>Jacobsen, et al., "Development of the Utah Artificial Arm," IEEE Transactions on Biomedical Engineering, BME-29, (4), pp. 249-269, 1982.</li> <li>Malone, et al., "Immediate, Early, and Late Post-surgical Management of Upper-Limb Amputation," Journal of Rehabilitation Research and Development, 21(1), pp. 33-42, 1984.</li> <li>Millstein, Heger, and Hunter, "A Review of Failures in Use of the Below-Elbow Myoelectric Prosthesis," Orthotics and Prosthetics, 36(2), pp. 29-34, 1982.</li> <li>Murphy and Horn, "Myoelectric Control Systems- A Selected Bibliography," Orthotics and Prosthetics, 35(1), pp. 34-47, 1981.</li> <li>Northmore-Ball, et. al., "The Below-Elbow Myo-Electric Prosthesis: A Comparison of the Otto Bock Myo-Electric Prosthesis with the Hook and Functional Hand," Journal of Bone and Joint Surgery, 42-B(3), pp. 363-367, 1980.</li> <li>Scott, Robert NL, "My?-Electric Control of Prostheses," Archives Of Physical Medicine and Rehabilitation, 47(3), pp. 174-181, 1966.</li> <li>Scott, R.N., An Introduction to Myoelectric Prostheses. Bio-Engineering Institute, University of New Brunswick, Fredricton, N.B., pp. 37, 1984.</li> <li>Spaeth and Klotz, Handbook of Externally Powered Prostheses for the Upper Extremity Amputee, C. Thomas, Springfield, IL, p. 107, 1981.</li> <li>Wirta, Taylor, and Finley, "Pattern-Recognition Arm Prosthesis: A Historical Perspective-A Final Report," Bulletin of Prosthetics Research, 10(30), pp. 8-35, 1978.</li> </ol> Page Number(s) 66 - 77 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-05.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/1986_02_066/1986_02_066-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-8.jpg Figure 9 TABLE I http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-09.jpg Figure 10 TABLE II http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper Limb Powered Components and Controls: Current Concepts Creator An entity primarily responsible for making the resource John W. Michael, M.Ed., C.P.O. * https://staging.drfop.org/files/original/e0d0a9bb3f547362ad9876b219fa7714.pdf 9335229897eae76821807d7a78f7836d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_078.pdf Text Any textual data included in the document <h2>In Support of the Hook</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration: none;">*</a></h5> If this were a perfect world, each person would have two perfect, versatile, beautiful hands. Unfortunately, there are individuals who lack one or both of these exquisite devices, whether cogenitally or adventitiously. Thus far, any substitute can only represent a very limited compromise and partial selection of varying fractions among the many desirable functions and cosmetic features needed for a true replacement. There seems no reasonable hope of providing the numerous muscles, nerves, reflexes and voluntary controls needed to position and stabilize mechanical imitations of the multiple joints in the natural hand. Because uncontrolled flexibility, like a loose chain, is merely unstable, the designer is forced to limit the joints severely, providing fixed curves which offer rigidity, yet maximize function. Fortunately, the customary wrist disconnect mechanisms allow reasonable interchanges to suit specific needs. These changes may not be quite as simple for the amputee as for the normal person who dons warm gloves for cold weather, picks up tongs, tweezers, or pliers to "handle" hot, tiny, or rough objects, or scrubs and manicures in preparation for a party. Nevertheless, the possibility of interchange does allow considerable versatility rather than a forced, even heartbreaking, choice of a single limited terminal device. Each amputee may use an artificial hand with substantial but limited function, and lifelike cosmetic glove when appearance is important, but, then change to a considerably more functional terminal device when appropriate, much like changing evening or business clothes to sports clothes or overalls.<a></a> In this context of voluntary choice, then, let us consider the appropriate roles for split mechanical hooks. Note that we can assume that we are far beyond the single hook with sharpened point made notorious by Captain Hook, useful as that was in its time. For the near future, though, we seem limited in practice to a single active control that provides adequate force at any point in a reasonable range of motion and is capable of rapid change, delicate adjustment, and prolonged holding, and preferably offers substantial sensory feedback. The typical Bowden cable (secured to shoulder harness, activated by body motion, and providing some sensory feedback from kinesthetic awareness of human joint position and tactual perception of pressures) provides a substantial degree of function. A source of external power under a single voluntary control, whether valve, switch, or myoelectric signal, may have greater or lesser speed of response, precision of adjustment, and maximum force, but so far it probably supplies less sensory feedback. Occasional adjustments, locking, or presetting of parts can be made by a unilateral amputee with the other hand or by a bilateral amputee through gross motion of the prosthesis to press the terminal device against an object, or squeeze it between the knees, etc. Thus far, both practical clinical experience and research studies have indicated that additional substantial sources of power, control, and feedback are so limited that they are better used for other functions like elbow flexion, elbow locking, or perhaps wrist rotation instead of for additional motions within a hand or hook. If additional practical sources do become available, of course, they can be used to improve both hand and hook by reshaping either for still greater versatility, or to actuate and release a lock, thereby improving both devices. The hook, though, is intrinsically more versatile than a mechanical hand of equivalent control and sophistication. It may be useful to recall that the Klingert artificial arm and hand at the end of the Eighteenth Century attempted to control some, ten independent motions by cords ending in knobs which the unilateral amputee could move with his good hand along a vest-like garment.<a></a> Presumably the user soon decided to use the good hand directly for most tasks! Like many current robots, remotely operated manipulators for nuclear "hot cells" have typically been designed with seven degrees of freedom, including grasp by simultaneous and equal motion of opposing surfaces of the terminal device. Usually a single able-bodied operator has controlled two manual master-slave manipulators, one with each arm, plus assorted leg and body motions to assist in positioning. Even so, we were told some years ago,<a></a> performance of relatively simple tasks typically took eight to ten times the time needed to do them directly with the bare hands, and early unilateral electrical manipulators took over ten times as long as mechanical master-slaves! At a series of conferences called Project ROSE with participants in the prosthetics research program and others,<a></a> experts from the nuclear and space programs seemed awed to learn that no bilateral arm amputee (even though substantially limited in independent body motions) needed anywhere near that additional time to perform complex tasks of industry or of daily living. The current interest in applications of robotics to aid quadriplegics may help to revive these interdisciplinary exchanges. It may be suggested that the performance advantages of the amputee lie not only in motivation, past therapy, and full-time usage, but in basic design philosophy. The classic UCLA studies summarized by Taylor<a></a> and Taylor and Schwarz<a></a> pointed out the great complexity of the human hand and upper extremity, analyzed the motions and forces used for a variety of activities, suggested reasonable priorities and limitations, and preset or limited position selections in contrast to the equal priority and great range assigned to all motions in many manipulators. The designs of prosthetic hooks typically provide a fixed point of reference for arm placement in the fixed finger. This allows relatively easy and accurate positioning against one side of an object, followed by closing of the hook to surround and grip the object as securely as desired. (The slowly moving thumb or "finger" of the Northwestern University<a></a> synergetic hand or hook substantially follows this concept, with the rapidly moving member(s) encircling and the high-force thumb then clamping.) In contrast, if both hook fingers (or the thumb opposing the index and middle fingers of a hand) move simultaneously, the user must initially position the arm in relation to an imaginary centerline while mentally allowing for subsequent (perhaps even unequal) motion of the opposing surfaces. This harder task can be learned by long practice and tolerance of frequent error (as we know from sports involving catching objects), but it seems relatively risky for approaching tall unstable objects like laboratory glassware. It also requires good vision, emphasizing the importance of the large safety window in a hot cell and the limitations of periscopes, mirrors, and television systems. The vast resources of the human hand allow very rapid shaping, grasping, and squeezing to hold objects of assorted sizes, with a reflex adaptation that grips more tightly if slippage starts yet also minimizes the risk of crushing fragile objects. A natural hand spontaneously exerts only modestly more gripping force than needed, whereas the amputee tends to overgrip. With a single control, an artificial terminal device must have a single general shape, though the opposing fingers of the hook may be markedly different. They should encircle and pull in objects within a wide range of sizes rather than extruding them from a V-shaped clamp. At least three contact points are needed for stability; two flat tongs are inadequate or at least require substantial forces to grip rounded objects. The two-position thumb of the APRL hand, preset to normal or wider positions by pressure against some object, is helpful but does not allow the flattening needed to enter pockets. Attempts have been made to provide unusually large thumb motion. This is to allow the choice of palmar prehension of the finger tips against the thumb or more complete flexion of the fingers into the palm, e.g., the Tomovic Beograd (Belgrade) hand.<a></a> That kind of versatility requires at least sensor pads and relatively complex logic such as that used by Tomovic or preferably a second hand control. The addition of independent lateral prehension of the thumb, in which the thumb is rotated to press against the partially flexed fingers, is a commonly used human motion, but is limited to small objects and is not considered useful as the primary grip. It might even require dedication of a third control to the terminal device. In contrast to the severe limitations of an artificial hand with present control sources, a split mechanical hook or other gripping tool may be designed to grasp objects of a wide range of sizes, yet remain sufficiently slim near its closed position to enter pockets to retrieve coins or other objects. Instead of imitating natural form and motion, the hook can be designed solely for function, attaining a sleek though mechanical appearance. In addition, it can be used to push, pull, pry, hammer, touch and hold hot or cold objects, and in general perform many tasks for which even the wonderful human hand requires tools. By ingenious shaping of fingers and choice of axis, the same hook may be used as tweezers for pins, to securely grip many medium-sized objects of daily life, and to surround and lift large objects. Mass-produced hook fingers (in contrast to earlier hand-forged and slightly variable models) may be economically provided with vulcanized rubber lining for higher friction while retaining a slippery metallic outer surface. (In early field tests with this feature, everyone liked the ability to slip easily into pockets or sleeves. However, one subject, who was long accustomed to starting a sewing machine by pushing the flywheel, complained of the absence of the chemical laboratory tubing used over older hooks. Nothing is perfect!) There may well be a major role for softer external surfaces, especially for children's terminal devices so to prevent injuries. Obviously, the materials should be nontoxic, non-allergenic, noncarcinogenic, and durable. The APRL and Northrop-Sierra hooks were designed with symmetrical lyre-shaped aluminum fingers held to the case by jam nuts, allowing replacement. Among the many unfinished items on the old research agendas discussed at the frequent conferences and workshops, was the deployment of stainless steel fingers and alternative shapes, including axes canted in relation to a thin sheet gripped by the hook fingers. Occasionally, there was speculation about color in place of the customary polished metal, or of a cosmetic glove designed to fit over a hook. Greater use of the three-jaw chuck concept, characterized by the index and middle fingers of the APRL hand moving in somewhat inclined planes toward the thumb, is sometimes suggested. However, greater stability must be balanced against greater bulk when closed. The literature, particularly in patents, discloses a great variety of concepts and shapes of terminal devices. Many were invented by amputees to meet their individual needs, especially in farming or industry. Some designers, notably Steeper in England, emphasized development of many special-purpose tools for daily living as well as for agriculture, industry, and avocations, together with disconnect devices for easy interchange. The demonstrator typically had a fitted case carrying a wide assortment. English colleagues have mentioned that a specific amputee typically received a dress hand, a split mechanical hook, perhaps a single tool appropriate to his particular trade, and (particularly in the case of a bilateral) a long straight split device helpful for grasping toilet paper. Since 1945, American research programs have emphasized the development of devices to permit any amputee to independently conduct the activities of daily living. Bimanual activities are so varied, due to the size of objects and the gripping force and dexterity required, that vocational guidance for a motivated amputee should include the selection of appropriate vocations which can be carried out with the same device(s) used in daily living. Indeed, most personal tasks are performed on or close to the body, perhaps suggesting wrist flexion devices, whereas vocational tasks normally are conducted on a table or workbench that do not require wrist flexion. A wide network of clinic teams is available to assist amputees select a prosthesis, return to former occupation, or choose a new vocation. In addition to a reasonably functional hand with cosmetic glove, the unilateral normally receives a versatile hook. The bilateral amputee rarely can function adequately with two artificial hands; sometimes he can use one hand and one hook, if appearance is more crucial than dynamic and independent function. Commonly, the bilateral amputee selects two hooks for routine use. Fortunately the number of bilateral amputees is very small, yet their needs are particularly great. Paradoxically, to meet their special needs, it has been necessary to first develop devices and techniques which are sufficiently versatile and which are accepted by a majority of the much larger unilateral market (and the professionals who serve amputees). Though present terminal devices are useful and cosmetically acceptable, further research on the specific problems of bilateral amputees is needed. *Eugene F. Murphy, Ph.D. Dr. Murphy resides in New York City and has long been associated with the American Prosthetic/Orthotic R&D Program. For many years he was in charge of the VA's office of Technology Trades and Editor of the Bulletin of Prosthetic Research. References: <ol> <li><a href="al/1955_02_047.asp">Dembo, Tamara, and Ester Tane-Baskin, "The Noticeability of the Cosmetic Glove," Artificial Limbs, 2(2), pp. 47-56, May, 1955.</a></li> <li>Borchardt, M., et al., Ersatzglieder und Arbeitshilfen, Berlin, Springer, pp. 404-405, 1919.</li> <li>Goertz, Ray, Advancements in Teleoperator Systems, A colloquium held at the University of Denver February 26-27, 1969, Washington, Office of Technology Utilization, National Aeronautics and Space Administration, NASA SP-5081,pp. 176-186, 1970.</li> <li>Murphy, Eugene F., "Manipulators and Upper-Extremity Prosthetics, Bulletin of Prosthetic Research, 10(2), pp. 107-117, 1964.</li> <li>Taylor, Craig, "The Biomechanics of the Normal and of the Amputated Upper Extremity," in Paul E. Klopsteg, Philip D. Wilson, et al., Human Limbs and their Substitutes, pp. 169-221, New York, McGraw-Hill, 1954; reprint edition New York, Hafner, 1968.</li> <li><a href="al/1955_03_004.asp">Taylor, Craig, "The Biomechanics of Control in Upper-Extremity Prostheses," Artificial Limbs, 2(3), pp. 4-25, 1955</a>; reprinted in Selected Articles from Artificial Limbs, Huntington, N. Y., Krieger, pp. 63-84.</li> <li><a href="al/1955_02_022.asp">Taylor, Craig, and Robert J. Schwarz, "The Anatomy and Mechanics of the Human Hand," Artificial Limbs, 2(2), pp. 22-35, 1955</a>; reprinted in Selected Articles from Artificial Limbs, Huntington, N. Y., Krieger, pp. 49-62.</li> <li>Childress, Dudley S., John N. Billock, and Robert G. Thompson, "A Search for Better Limbs: Prosthetics Research at Northwestern University, "Bulletin of Prosthetic Research, 10(22), pp. 200-212, 1974.</li> <li>Veterans Administration Prosthetics Center Research, Bulletin of Prosthetic Research, 10(9), pp. 142-144.</li> </ol> Page Number(s) 78 - 81 Year 1986 Volume 10 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource In Support of the Hook Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/d73a255fee4b364de1484751b0070bc2.pdf f4268f1f8160ca988e58b8d68c70e4d7 https://staging.drfop.org/files/original/9cd3809f346695203e049ecda06076b9.jpg 4a70f8736bfa8404d75ca3f32d5a0525 https://staging.drfop.org/files/original/fe34c6884c1d4f9cd65bd37a903a8070.jpg b70af2800e997203f2319c46296de5b7 https://staging.drfop.org/files/original/30a3a403da09b29c8a7c41ae21ae5364.jpg 8449acd023022b2f713fc97fc94bb381 https://staging.drfop.org/files/original/a6edecd2ad6203347d70e896ca018d83.jpg 9ce2a9f49884881e3a6ed64718708be7 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_082.pdf Text Any textual data included in the document <h2>Voluntary Closing Control: A Successful New Design Approach to an Old Concept</h2> <h5>Bob Radocy, M.S.T.R. <a style="text-decoration: none;">*</a></h5> The arrival in early 1980 of the "Prehensile Hand,"<a></a> a new design and concept for terminal devices, sparked a revitalized interest in body power and voluntary closing control. Voluntary closing control and terminal devices are not new to prosthetics, but little interest in this system and technology has existed since the 1950's. Retrospectively, voluntary closing control never achieved dramatic success nor did it have any permanent, positive influence on the direction of upper-extremity prosthetic development until recently, meaning 1980-1985. The acceptance and success of the "GRIP,"<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-1.jpg">Fig. 1</a>) and more recently the children's "ADEPT"<a></a> terminal devices, are strong indicators that voluntary closing control is an extremely viable concept. Furthermore, it confirms previous opinions that poor performance characteristics, reliability factors, and the inappropriate design criteria of early volunteer closing control systems and terminal devices<a></a> were responsible for the demise of voluntary closing systems and correspondingly for the dominance of voluntary "opening" control systems and terminal devices in the profession today. <a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-1.jpg">Figure 1. (Top to bottom) GRIP I, GRIP II, ADEPT B, ADEPT C, and ADEPT I.</a> This is not to say that voluntary closing devices and systems were not put to excellent use by certain amputees, but that they failed to appeal to the majority of the upper-extremity limb deficient population, i.e. the traumatic or congenitally limb deficient below-elbow unilateral amputee. The standard voluntary opening split hook has continued to be the primary body-powered prescription, while experience now strongly illustrates that correctly designed voluntary closing terminal devices offer superior performance to the limb deficient. Training is no more difficult with voluntary closing; gripping force range is expanded and directly proportional to output, reflex grasping actions are improved, muscles of the affected limb and shoulder are utilized continuously and more effectively, and "feedback" sensations (<a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-2.jpg">Fig. 2</a>) are produced inherently<a style="text-decoration: none;">*</a> and are more easily assimilated, thereby enhancing control, than in voluntary opening systems. The mere fact that children three to six years of age have accepted the concept and have either learned with or converted to voluntary closing control and achieved good to excellent performance should open the minds of even the most conservative in our profession as to the value of the voluntary closing control prescription. Recently, we have seen and heard a great deal about the success of myoelectric devices for children and how a child's performance is improved with myoelectric systems as compared to "body-powered" systems.<a></a> Unfortunately, body power in these comparisons refers only to the voluntary opening split hook systems, and not to voluntary closing systems. It is my firm belief that, if given proper training, limb deficient children will perform as well or better with voluntary closing body powered systems than with myoelectric systems. Furthermore, considering the cost and reliability of externally powered limbs, voluntary closing body powered terminal devices should be prescribed as the primary complements to external powered units, rather than voluntary opening split hook systems. The logic for this assertion is simple. First, muscles of the torso and limb are used more actively with the voluntary closing system, and healthy, strong muscles can only enhance externally powered control and utilization. Second, the new designs in voluntary closing terminal devices offer an opposed thumb and finger gripping configuration, similar to powered hands, enabling the user to incorporate already "learned" patterns of gripping behavior, rather than having to constantly switch patterns of grasp to accommodate "split hook" prehension. Third, children with voluntary closing systems can achieve gripping prehension which equals or exceeds their anatomical capabilities, while voluntary opening systems remain inferior in this area. Comparable prehension bilaterally can only encourage bilateral function and increase prosthetic usage, two primary goals in prosthetic rehabilitation. The success of voluntary closing systems can be related to the design rationale and criteria of the 80's systems. Rationale and criteria are as follows: <ol> <li> Utilize an accepted natural prehension configuration. Previous studies indicate that cylindrical, palmar, and lateral are the most often used gripping patterns.<a></a> Opposed thumb and forefinger prehension satisfies these patterns. </li> <li> Design gripping shapes and surfaces to allow for a wide variety of holding tasks. Complementary curved gripping surfaces enhance cylindrical control and are especially important due to the vast numbers of curved object surfaces we handle daily (<a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-3.jpg">Fig. 3</a>). Additionally, a "clevis" tip configuration imitates the three point chuck of the thumb, index and long finger, important for utensil and implement control (<a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-4.jpg">Fig. 4</a>). </li> <li> Emphasize a simple, anesthetic, easily maintained, reliable design that can be understood and accepted by the user- a design with positive psychological connotations, reflecting the capability of the user. </li> <li> Incorporate passive support and suspension capacity (internal hook or bump) for carrying objects with handles or for supporting body weight while climbing or hanging. </li> <li> Require continuous control for grasping and holding to discourage muscle atrophy, enhance muscle development and allow for rapid reflexive grasping. Continuous control also creates an uninterrupted flow of pressure feedback information required for performance handling of objects. </li> <li> Select materials suitable for individualized age groups, rather than a single material for all models. Consider both the needs and the characteristics required for each population and design the model accordingly for each targeted group. </li> <li> Consider weight as a factor, but balance the need for light weight against the strength requirements for the terminal device. Also consider the tolerance the need for light weight against cause variation in age and corresponding tolerances vary. </li> <li> Redesign models as necessary to better answer the needs of the population they serve. </li> </ol> Exclusive of these criteria, a variety of factors exist which have aided the reintroduction of voluntary closing systems and which will increase the use of these systems in the future. Compatibility, harnessing, prosthesis design, proper rehabilitation and weight conditioning are all important if good to excellent prosthetic use is to be achieved. Voluntary closing terminal devices are compatible with all standard prosthetic components. Minor cable modifications or adjustments are usually required to optimize the user's energy output. Unlike previous voluntary closing designs, the user is harnessed under "controlled tension" rather than into a "no tension" system. Accordingly the thumb of the terminal device is not fully open, but pulled partially closed when the arms are relaxed at the user's sides. This tension harnessing allows for improved control of objects, during initial training, and while objects are manipulated close to the medial line of the body. Harnessing should be as simple as possible. A modified Northwestern #9 when possible is excellent, utilizing a ring and "rapid adjust" type buckle.<a></a> This harness system will enhance range of motion control at the shoulder, improve object manipulation overhead, and enable quick excursion adjustments. Prosthesis design should lean towards self suspending (supracondylar) sockets to minimize harnessing. Modified Muenster, Otto Bock, and similar designs can be employed depending on the limb's morphology. New designs such as ISNY or similar flexible sockets may also prove valuable. New patients should be educated in range of motion and pre-prosthetic exercise techniques.<a></a> This is especially important for traumatic limb loss and in instances where complete rehabilitation was lacking and the shoulder girdle and upper limb-musculature is weak and atrophied. Similar atrophication can occur due to disuse of the prosthesis or lack of vigorous bilateral use. Initially, muscle soreness at the shoulder may be experienced by the converting amputee, or the new amputee undergoing rehabilitation. This early soreness is a positive sign of muscle rejuvenation and should be regarded as improved health. However, long term muscle aggravation and soreness may be an indicator that the prosthetic system is not operating optimally. Prior to prosthetic fitting and after initial rehabilitation with the new voluntary closing prosthesis, weight training can be encouraged. Pre-prosthetic training can be accomplished by a knowledgeable therapist and should include a range of motion exercises, dynamic tension, and active bilateral resistance exercises using cuff weights, specialized training equipment, or a simple weight harness in conjunction with dumbbells. Post-prosthetically, the voluntary closing terminal device is capable of handling adjustable resistive weight equipment or free weights, although the former are easier to use, safer, and enable rapid, satisfactory results. An emphasis on strength and endurance conditioning rather than muscle building is suggested due to the needs for adequate range of motion in prosthetic control. This dictates lower resistance loads with more repetitions of exercises. Special applications for voluntary closing systems have also arisen in recent years. Brown<a></a> has achieved excellent success in patients with partial hand amputations. The success, I believe, is due to the common sense simplicity of the prosthesis and harness design, and the utility of the terminal device, which allows prehension in excess of 100 lbs. This amount of gripping force enables the partial hand amputee to be functionally bilateral in a manual working environment. Other terminal devices applied to the case of partial hand amputation cannot offer all the advantages of the new voluntary closing systems. Obviously, the partial hand prosthetic user will not wear the prosthesis all the time, but it is an effective functional tool for many occupations. The increased potential may enable the partial hand amputee to maintain an existing vocation rather than consider retraining for an entirely new occupation. In summary, the new voluntary closing systems offer a great deal of potential for the upper-extremity limb deficient of all ages. They can offer superior performance compared to any other systems, body powered or externally powered, and complement the externally powered prescription, when cosmesis is the primary consideration and function considered only of secondary importance. Voluntary closing systems are not a cure-all for the upper limb deficient individual, and the system is not applicable to everyone, even though all types and levels of amputees including bilaterals have used the technology successfully (excluding shoulder disarticulates). Success also has a lot to do with the attitude of the amputee and the capability of the rehabilitation team, including the prosthetist. Voluntary closing systems will continue to increase in popularity because the technology is reliable, improves performance, and more closely imitates the natural system. The voluntary closing systems will also continue to improve as more innovative research and development in better "total" body powered and hybrid body powered/external powered prosthetic technology evolves. References: <ol> <li>Trade name of product manufactured by T.R.S., Inc. of Boulder, Colorado.</li> <li>Trade name of product manufactured by T.R.S., Inc. of Boulder, Colorado.</li> <li>Trade name of product manufactured by T.R.S., Inc. of Boulder, Colorado.</li> <li>Klopsteg, Paul E. and Philip Wilson, Human Limbs and Their Substitutes. Hafner Publishing Company; New York. 1964. Reprint of 1954 Edition by McGraw Hill Company.</li> <li>Weaver, S.A. and L.R. Lange, "Myoelectric Prostheses versus Body Powered Prostheses with Unilateral, Congenital, Adolescent, Below-Elbow Amputees," American Orthotic and Prosthetic Association National Assembly Scientific Presentation on October 16, 1985.</li> <li>Mann, R.W., "Evaluation of Energy and Power Requirements for Externally Powered Upper-Extremity Prosthetic and Orthotic Devices," American Society of Mechanical Engineers. Publication No. 62-WA-121, 1962.</li> <li>Radocy, Bob, "The Rapid Adjust Prosthetic Harness," Technical Note, Orthotics and Prosthetics, Volume 37, No. 1, pp. 55-56, 1983.</li> <li>Bates, Marion D. and J.C. Honet, "Isometric Exercises for the Upper-Extremity Stump," Physical Therapy, Volume 44, No. 12, pp. 1093-94, December 1964.</li> <li>Deaver, G.G. and E.H. Daniel, "The Rehabilitation of the Amputee," Archives of Physical Medicine, Volume 30, No. 10, p. 638, October 1949.</li> <li>Gullickson, G. Jr., "Exercises for Amputees," Therapeutic Exercise, 2nd Edition. Sidney Licht, Editor, pp. 581-640.</li> <li>Klopsteg, D.E. and P.D. Wilson, Human Limbs and Their Substitutes, Hafner Publishing Co., pp. 739-756, 1968.</li> <li>Reilly, G.V., "Preprosthetic Exercises for Upper Extremity Amputees," The Physical Therapy Review, Volume 31, No. 5, pp. 183-188, May 1951.</li> <li>Olivett, Bonnie L., "Management and Prosthetic Training of the Adult Amputee," Rehabilitation of the Hand, 2nd Edition, C.V. Mosby, 1984.</li> <li>Brown, Russell D., "An Alternative Approach to Fitting Partial Hand Amputees," Orthotics and Prosthetics, Volume 38, No. 1, pp. 64- 67, Spring 1984.</li> <li>Radocy, Bob and Ronald E. Dick, "A Terminal Question," Orthotics and Prosthetics, Volume 35, No. 1, pp. 1-6, March 1981.</li> </ol> *Bob Radocy, M.S.T.R. Bob Radocy, M.S.T.R. is President of Therapeutic Recreation Systems (TRS), Inc. 1280 28th Street. Suite 3, Boulder, Colorado 80303-1797. Footnote A major objective of externally powered systems is to develop a reliable 'feedback' system for improved prehension control. Voluntary closing, body-powered systems offer the feedback system inherent in the design. Page Number(s) 82 - 86 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-4.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 Voluntary Closing Control: A Successful New Design Approach to an Old Concept Creator An entity primarily responsible for making the resource Bob Radocy, M.S.T.R. * https://staging.drfop.org/files/original/527606029dde597c9241e01480a56072.pdf 4c755f2a1ca5cf1398a468e307fd2dea Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_087.pdf Text Any textual data included in the document <h2>Upper Extremity Cosmetic Gloves</h2> <h5>Sandra Bilotto, M.A., C.P.O. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> Upper extremity rehabilitation includes the restoration of function and cosmesis to simulate the human hand.<a></a> Producing a replica of the hand which is functionally and psychologically beneficial to the amputee and quite importantly, acceptable to those with whom the amputee socially interacts,<a></a> is both challenging and of high priority. The technology for producing either custom made or mass produced cosmetic gloves has changed little in more than 20 years.<a></a> However, within the last several years, with the advent of new materials, there have been new developments. More specifically, there have been developments in a family of silicone elastomers the application of which offers solutions to problems associated with existing cosmetic glove technology. Briefly, cosmetic gloves have been made with latex, urethanes, and RTV silicones, but these materials were not successful because they had serious drawbacks. Latex skins were impermanent, coloration was unacceptable, tear strength was very low, absorption of clothing dyes was common,<a></a> and they did not last very long before deteriorating. Urethanes held promise, but the components to produce a plastic film are very difficult to control in small laboratories. They are too sensitive to moisture and extraneous contaminants, and require precise measuring. After limited use, they are weakened by ultraviolet light and thus their useful life as terminal device coverings is limited.<a></a> RTV or room temperature curing silicones, when first utilized in prosthetic restorations and glove-making, proved ineffective because the material required complicated molding procedures, was often manufactured pre-colored, had extremely low tear strength, and had very low elasticity and flexibility. In addition, one small tear would easily propagate, rendering the glove useless. <h3>PVC Gloves</h3> PVC, or polyvinyl chloride, has dominated glove making and still does to the present. Historically PVC is inexpensive and readily available. Gloves can be fabricated en masse in metal molds or custom made in flexible slush molds. In either technique, the plastisol cures against the wall of the mold, producing a thin skin of vinyl which can either be intrinsically and/or extrinsically colored.<a></a> Stabilizers and plasticizers are introduced to make the cosmetic glove flexible and resistant to degradation by ultraviolet light. Replication of the human hand has been adequate using PVC and thus these gloves have been widely available for most amputees. However, there are disadvantages associated with PVC as a material for use in prosthetic gloves. First and foremost is the inability of PVC to resist attack by most chemicals, soiling and staining agents, and newsprint. These substances are absorbed by the plasticizing agents and are impossible to remove. At temperatures close to freezing, the PVC stiffens and its flexibility is greatly reduced. This can inhibit the proper functioning of an electric or mechanical hand as the inability to open a finger or thumb can render a terminal device useless.<a></a> In warm temperatures, the plasticizers and stabilizers tend to bleed to the surface of the glove, causing peeling of the extrinsic coloring, as well as darkening and stiffening. PVC "feels" like plastic and not like human tissue, and for the most part, unless a PVC glove is custom made and tinted, the surface is rather opaque and cadaverous looking. Custom made PVC gloves present all of the above problems, but do match skin tone, hand shape, and surface characterization of the intact hand better. The time required to fabricate a custom glove is much longer because the technique is more elaborate, and as a result more expensive. Of course, the success of the glove is directly proportional to the ability of the prosthetist to make the cosmetic glove appear natural and reasonably well matched to the other hand. No matter what technique is utilized, the consensus is that PVC gloves are rather short lived: two weeks to eight months on average. Efforts to strengthen the glove with nylon fabric reinforcement or to retard discoloration by spraying clear solutions on the surface of the glove produce disappointing results.<a></a> Finally, there is a problem donning and doffing a PVC glove due to the inflexibility of the material proximal to the wrist. This gave rise to the practice of sewing zippers into gloves. Besides being bulky and unsightly, zipper installation is time consuming and the zipper may be easily jammed or broken. Thus, a better material which might resolve some of the above problems is needed. <h3>Silicone Gloves</h3> Silicone rubber offers excellent solutions to some of the aforementioned problems, and they now have properties which make them more readily processed in glove making.<a></a> In general, the new generation of silicones are tougher, more resilient, more durable, and more permanent than previously utilized materials. While not ideal, the silicone gloves presently being developed resist chemicals, dyes, soiling, and staining almost completely. The skins may be washed with mild detergents and water for cleaning. Unlike PVC, lower or higher temperatures have little effect on the strength, flexibility, or elasticity of the glove.<a></a> The result is better functioning of electro/mechanical hands, and in some cases, the elastic resistance of gloves can actually enhance functioning of the terminal device. Unlike PVC, silicone rubber may be modified to increase its elasticity where necessary without loss of tear strength. Cosmetic gloves of silicone elastomers may be intrinsically or extrinsically colored as with PVC. However, there is much greater adhesion of external pigments to silicone gloves and the resultant glove rarely sheds its external tinting. It is more color stable and is less affected by ultraviolet light than its PVC counterpart; Silicone neither darkens nor stiffens with the passage of time. Once fabricated, the glove is non-toxic as compared with PVC. This is an obvious advantage when fabricating gloves for babies and toddlers, as harmful agents do not leach out to the surface of the glove to enter the baby's mouth. Silicone can be formulated to reflect and absorb light in much the same way human skin does, producing a more natural and life like appearance. Likewise, silicone also simulates the "feel" of skin more closely as it relates to softness and texture.<a></a> Its higher coefficient of friction helps prevent glasses and other objects from falling out of the hand's grasp. <h3>Discussion</h3> There are some disadvantages in the production of silicone gloves which need to be addressed. The cost of manufacturing, the increase in fabrication time, and the slightly higher cost of silicone rubber<a></a> is retarding the availability of such gloves. However, if the technology to produce silicone gloves improves, and if they become more widely available, their cost and fabrication time should decrease. They have greater durability and esthetic appeal than PVC, and there can be no doubt that silicone offers possibilities heretofore unavailable with PVC. Silicone cosmetic coverings for the lower extremity are a future possibility. Swim and sport legs could be greatly inhanced by these tough, resilient and cosmetic coverings. Silicone compounds are presently used in maxillofacial prosthetics, breast prostheses, partial hands, partial feet, leg and arm buildups, and other body restorations.<a></a> There is no doubt that a more natural, functional, esthetically and psychologically appealing cosmetic glove is needed by upper extremity amputees and that silicone gloves, despite some imperfections, will prove to be more promising and acceptable than PVC gloves. References: <ol> <li>Arkles, B., "Look what you can make out of Silicones," Chemteck, Vol. 13, No. 9, pp. 542-555, September 1983.</li> <li><a href="al/1955_02_057.asp">Carnelli, W.A.; Defries, M.G.; and Leonard, F., "Color Realism in the Cosmetic Glove," Artificial Limbs, Vol. 2, pp. 57-65, May 1955.</a></li> <li>Davies, E.W.; Douglas, W.B.; and Small, A.D., "A Cosmetic Functional Hand Incorporating a Silicone Glove," Journal of International Society of Prosthetics and Orthotics, Vol. 1, No. 2, pp. 89-93, September 1977.</li> <li><a href="al/1955_02_047.asp">Dembo, T. and Tane-Baskin, E., "The Noticeability of the Cosmetic Glove," Artificial Limbs, Vol. 2 pp. 47-56, May 1955.</a></li> <li>Fillauer, C and Quigley, M., "Clinical Evaluation of an Acrylic Latex Material used as a Prosthetic Skin on Limb Prostheses," Orthotics and Prosthetics, Vol. 33, No. 4, pp. 30-38, December 1979.</li> <li><a href="al/1955_02_078.asp">Fletcher, M. and Leonard, F., "Principles of Artificial Hand Design," Artificial Limbs, Vol. 2, pp. 78-94. May 1955.</a></li> <li>Lee, D. and Harlan, W., "Medical Sculpture: A Valuable Aid to Patient Rehabilitation," American Family Physician, Vol. 15, pp. 110-114, February 1977.</li> <li>Journal American Dental Assoc., "Maxillofacial Prosthetic Materials," Council on Dental Materials and Devices, Vol. 90, pp. 834-848, April 1975.</li> <li>Klasson, Bo, Personal communication, Een-Holmgren, Stockholm, Sweden.</li> </ol> *Sandra Bilotto, M.A., C.P.O. Sandra Bilotto, M.A., C.P.O., currently resides in Yonkers, N.Y. She received her education in prosthetics and orthotics at N.Y.U. Prior to that she received training in sculpture. Cosmetic restoration is a particular interest of hers. <div style="width: 400px;"></div> Page Number(s) 87 - 89 Year 1986 Volume 10 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper Extremity Cosmetic Gloves Creator An entity primarily responsible for making the resource Sandra Bilotto, M.A., C.P.O. * https://staging.drfop.org/files/original/7726a0b6d065fcfc2a69ee0f0fbdd82a.pdf aaecbd42a917de5b36eeb049f73ef608 https://staging.drfop.org/files/original/907b3b60ab891d2c062f4ceb5bb2af8d.jpg 31530cab1a56fffba73f07af39b2d077 https://staging.drfop.org/files/original/3a4e9c51a778e57578a9fabe571b7158.jpg c30f2899c6c3b59f9ad0d33d8b10c9bf Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_090.pdf Text Any textual data included in the document <h2>Technical Note: The Soft Socket</h2> <h5>Arthur Forman, B.S., M.A. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> Oftentimes we are presented with an above-knee amputee who poses difficult problems for a successful prosthetic fitting. Some of these problems include advanced age, atrophy, trigger points, bony prominences, surgical implants, cardiopulmonary problems, short residual limbs, and other complications. Any one of these conditions might make for a difficult fitting, but any combination of these could contribute to an unsuccessful fitting, or a situation which precludes ambulation. It is my contention that given the current generally accepted practices and when presented with an involved patient as indicated above, we are doomed to failure, in terms of comfort and ambulation. Further, it is my contention that very often, although these patients may be confined to a wheelchair even after prosthetic fitting, it is of paramount importance that they be fitted as comfortably as possible. Although they have lost a limb, they may be just as motivated as any other patient and can suffer psychological stigma. Therefore, it is our duty as prosthetists to provide a prosthesis that will allow these patients to ambulate as much as possible, resulting in both psychological and physical benefits. <h3>Soft Socket Rationale</h3> As we all know, the quadrilateral above-knee socket was originally designed and fitted for World War II traumatic amputees. They were fairly young, usually with no other complications, good musculature, and in many cases of long length. Today we are faced with a high geriatric amputee population with conditions quite different than the World War II veteran. The quadrilateral above-knee socket design impinges directly on the neurovascular bundle in the area of the Scarpa's triangle. The posterior seat area bears directly on an anatomical area which is usually atrophied to the point of being uncomfortable. These features alone call into question the viability of the quadrilateral design when considering an involved patient as described previously. The soft socket design as described, owes its inception to the CATCAM design. The soft socket is almost an exact anatomical negative duplication of the residual limb without extreme scarpas impingement and without concentrated ischial weight bearing. It is lined with 1/2" thick Plastizote, or similar forgiving material that enhances soft tissue bearing, hence "soft socket." It is compatible with all existing above-knee components, far more cosmetic, aligned using current practices, and is fabricated only in a slightly different fashion. Also, it will allow the amputee to ambulate in a comfortable non-restrictive manner. <h3>Case Study</h3> A seventy-six year old man was presented for prosthetic fitting. He was a traumatic amputee who had lost his leg during the Korean War and was left with a four inch length femur. He had been wearing an exoskeletal system with an hydraulically controlled knee, conventional quadrilateral socket, hip joint, and pelvic belt. The prosthesis weighed approximately 13 pounds. The lateral wall of the socket was modified at mid-femoral length to impinge on the femoral shaft. The patient had recently undergone surgery to repair a fractured femoral head on the amputated side due to a fall. He had also recently developed emphysema and had lost a significant amount of weight. During weight bearing on the sound leg, he exhibited extreme fatigue and loss of breath. Despite these contraindications to prosthetic fitting, he expressed great motivation. I proceeded with the standard impression technique using the Berkeley brim. The patient experienced discomfort while suspended in the Berkeley brim. He indicated specific areas of discomfort including the ischial/gluteal area and the lateral femoral area. This continued despite angular adjustments to the brim. An impression was taken. Upon examination of the impression and after discussion with colleagues, it was decided that a conventional fitting would not work. After mulling over the situation, it was decided to hand wrap a new impression, while the patient laid on his sound side. This was done in a very particular way, encompassing the gluteals, and hand forming the medial and posterior wall. A very anatomic impression was obtained. Modification was minimal and consisted mainly of smoothing up and adding a layer of 1/2" Plastizote (<a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-1.jpg">Fig. 1</a>) after lamination. The prosthesis weighed 7 1/2 pounds. This included a modular safety knee, extension assist, hip joint, pelvic belt, foam cover, foot, and shoe (<a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.jpg">Fig. 2</a>). The patient has been wearing this prosthesis and is quite satisfied. <a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-1.jpg">Figure 1.</a> The Berkeley brim above the AK prosthesis with hip joint and pelvic band. Note presence of Plastazote pad in the ischial seat area. <a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.jpg">Figure 2.</a> The completed prosthesis. <h3> Conclusion</h3> It is my belief that we, as prosthetists, should approach our patients as individuals and if necessary, modify or completely discard commonly accepted techniques in order to successfully fit the uncommon patient. We should continue to examine our techniques in order to upgrade our profession and better serve the community. <h3>Acknowledgments</h3> Kevin S. Garrison, CP., Mahnke's Prosthetics-Orthotics, Inc., Fort Lauderale, Florida; Joseph Leal, C.P., Custom Prosthetics of Tucson, Arizona; John Sabolich, C.P.O., Sabolich, Inc., Oklahoma City; Thomas Guth, C.P., R.G.P. Orthopedic Appliance Co., Inc., San Diego, California; Ivan Long, C.P., Polycadence, Inc., Arvada, Colorado; Timothy B. Staats, C.P., Director of Prosthetics, education training programs, UCLA. *Arthur Forman, B.S., M.A. Arthur Forman, B.S., M.A., is a prosthetist formerly with Mahnkes Prosthetics and Orthotics, Inc., 1915 N.E. 45th Street, Fort Lauderdale, Florida 33308. Page Number(s) 90 - 92 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.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 Technical Note: The Soft Socket Creator An entity primarily responsible for making the resource Arthur Forman, B.S., M.A. * https://staging.drfop.org/files/original/0bbc53a6aa62aebf038a53dd53472ffc.pdf 54b8c595e4ec188d6a8b8159ebc5c71f https://staging.drfop.org/files/original/b31f453e857faf7e7c85a9dc242a2129.jpg 9df96fc4ee9a837d85bbaece371c46fc https://staging.drfop.org/files/original/0ee976b743595cde154bc870afa7a224.jpg a3b8fbd6a6cea81286d669f3a25bd448 https://staging.drfop.org/files/original/63c4901b6d5f332233ffdb0f2c00b116.jpg 1c1cb3009b38e53630bde0cda90c9c89 https://staging.drfop.org/files/original/37f7edd8f4b869d37f92eb967037f82a.jpg 117dc9625d7e146431f643fdb0d17f6d https://staging.drfop.org/files/original/79cc93918eb2d23f152ee4043b75be4e.jpg cc9511daf3e04fdecb2f5c18ed011951 https://staging.drfop.org/files/original/a3b0d6d764f90dc9b9f455667be76a39.jpg 27c4183a32ace08a6dfa6980ba988b0c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_101.pdf Text Any textual data included in the document <h2>Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets</h2> <h5>C. Michael Schlich, C.P.O. <a style="text-decoration: none;">*</a> Tony Lucy </h5> Transparent test sockets have been available in various materials for more than ten years,<a></a> but their use has not been as widespread or as routine as one would expect. Only recently has the emergence of new materials and new evaluation techniques, as well as third-party awareness and reimbursement, made the use of test or check sockets more appealing. The objective of this article is to present a refined technique for using test sockets and aliginate to guarantee that total contact exists between socket and stump. This technique has been developed as a standard procedure for each and every below-knee amputee fitted with a prosthesis at the University of Virginia. We consider it to be the single most important and recent technique for enhancing the fit of prostheses for our below-knee amputees. Robert Hayes, CP., described his alginate technique first in 1975 in Orthotics and Prosthetics<a></a> and more recently in an updated version in Clinical Prosthetics and Orthotics.<a></a> In 1984, Timothy Staats, CP.,<a></a> described a technique for introducing alginate into the negative cast mold, which is used as a test socket after molding. No doubt there are other prosthetists using similar or variations of these techniques. However, the important point is not who or how many are using the technique, but how many still do not use this technique for refining below-knee socket fit. Equally important is the fact that any system of diagnostic socket evaluation should be more than just algination. The routine use of multiple, transparent, skin-fit sockets, evaluated both statically and dynamically as a progressive system, will provide assurance of optimum socket fit. It seems rather obvious that if amputees can ambulate successfully with a skin-fit, hard socket, then use of a definitive socket with a minimal number of prosthetic socks, with or without a soft liner, will be that much more comfortable and successful. A 12" x 12" sheet of 3/8" thick Durr-Plex<a></a> or Thermocheck<a></a> is used for the average below-knee socket. This material is transparent, strong and rigid, is easily vacuum formed (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg">Fig. 1</a>) using the frame and platen technique, and can be modified later by spot heating. Of course, any other transparent material that can be vacuum formed is equally suitable. <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg">Figure 1.</a> A transparent socket is vacuum-formed over a plaster cast that has been modified in the usual manner. Lubrication of the stump with petroleum jelly, or equivalent lubricant, is necessary for donning the check socket when it is used without a prosthetic sock. The patient then stands bearing weight in the test socket, which rests on a platform or stand that can be adjusted in height so that weight-bearing is the same on each side and the pelvis is level (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg">Fig. 2</a>). While the patient continues to stand, the stump in the transparent socket is evaluated by identifying changes in skin color. Blanching, or even whiteness, indicates that the pressure levels are acceptable. Excessive shiny blanching indicates increased pressure, which is perhaps excessive. Redness indicates voids or lack of total contact. If a patient complains of too much pressure when an area is surrounded by red, then algina-tion should provide relief by establishing total contact. If the patient complains of too much pressure when an area is surrounded by white and blanching, relief is provided by spot heating and stretching the socket in the area of complaint. A thin flat probe, like a corset stay, is often useful for specifically locating pressure areas for purging small pockets of trapped air, or gauging skin tensions within the socket (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg">Figure 2</a>. The patient bears one half of his weight in the transparent socket for evaluation of fit by the prosthetist observing the color of the skin <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg">Figure 3.</a> Evaluation of fit by observation can be augmented by use of a flat slender probe. A reliable technique for the evaluation and modification of the fit of below-knee diagnostic test sockets is available using the dental material, alginate. The viscosity and other properties of alginate makes it suitable for: (1) filling any voids between the socket and stump to insure total contact, or total surface bearing; (2) providing proper compression of soft tissues for better distribution of weight-bearing pressures. A mixture of 20 grams of powdered alginate<a style="text-decoration: none;">*</a> and 6 ounces of water provides the proper ratio and amount for most below-knee patients. The water should be lukewarm and dyed with food coloring to provide a definite contrast in color to the skin and socket. The socket is sanded lightly on the inside to promote adherence of the alginate, and escape holes are drilled medially and laterally approximately one inch proximal to the distal end. Small pin holes are also drilled over void areas to allow air to escape as the alginate fills. The water and powder are mixed with an electric drill and paint stirrer, and then poured into the test socket and slushed around the walls to completely coat the inside of the socket. The patient then enters the socket and stands with equal weight-bearing bilaterally. The alginate fills void areas, establishing total contact. The excess is evacuated, and gelling occurs in one to three minutes (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg">Fig. 4</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg">Fig. 5</a>). The patient is then seated and the socket is carefully removed, after breaking the suction seal. The alginate will adhere to the inside of the socket. <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg">Figure 4.</a> Alginate fills void areas while patient bears one half of his weight into the socket. Excess alginate flows through small relief holes drilled for this purpose. <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg">Figure 5.</a> Alginate solution cures between one and three minutes. When the socket is filled with plaster, a positive model that has been redefined by the alginate under weight-bearing conditions is obtained. When the plaster has set, the test socket is removed by cutting it off. The alginate will adhere to the cured plaster model (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg">Figure 6.</a> Alginate is removed from new positive model before smoothing and vacuum-forming definitive socket or a new check socket. The new positive model is now evaluated. Information such as location and thickness of the alginate fill is useful feedback concerning the original casting and model modification. At this point the alginate is removed and the new positive model is smoothed using sand screen. The model is now ready either for use as a follow-up transparent test socket or for fabricating a definitive socket. If one chooses to proceed with the definitive socket, prosthetic socks are added over the model before the liner or socket is fabricated to allow for the thickness of socks desired in the final fit. <h3>Results</h3> Records were kept and studied for a series of 40 below-knee amputees fitted using the alginate test socket system. The data recorded were: (1) location of areas filled by alginate (i.e. voids in the prealginated socket); (2) thickness of fill with respect to location; and (3) results of dynamic and final fittings (i.e. adjustments required to improve socket fit at post-algination fitting sessions). Areas filled with alginate were very consistent and included the posterior distal soft tissue area, the tibial tubercle, the lateral tibial flare, and the anterior distal tibia. As the series progressed, the model modification technique changed based on this previous experience. As a result, the thickness of the alginate fillers gradually decreased, as did the plaster build-up over bony prominences on the original model. None of the 40 subjects required socket adjustments to improve comfort or fit at the time of dynamic alignment, delivery alignment, or delivery of the prosthesis. We have been involved, either directly or indirectly, with fitting more than 150 patients in this manner. The use of alginate with multiple transparent test sockets is a valuable tool in patient management and helps provide better below-knee sockets through improved weight-bearing pressure distribution. References: <ol> <li>Durr-Fillauer Medical, Inc. 2710 Amnicola Highway, Chattanooga, Tennessee 37406.</li> <li>Friddle's Orthopedic Appliance, P.O. Box AR, Honea Path, South Carolina 29654.</li> <li><a href="cpo/1985_03_013.asp">Hayes, Robert F., "A Below-Knee Weight-Bearing Pressure Formed Socket Technique," Clinical Prosthetics and Orthotics, 9:3, Summer, 1985, pp. 13-16.</a></li> <li>Hayes, Robert, F., "A Below-Knee Weight-Bearing Pressure Formed Socket Technique, Orthotics and Prosthetics, 26:1, March, 1972, pp. 1-13.</li> <li>Mooney, V. and R. Snelson, "Fabrication and Application Of Transparent Polycarbonate Sockets, Orthotics and Prosthetics, 26:1, March, 1972, pp. 1-13.</li> <li>Staats, Timothy, "Advanced Prosthetic Techniques For Below-Knee Amputation," Orthopedics, 8:2, February, 1985, pp. 249-258.</li> <li><a href="cpo/1985_03_011.asp">Quigley, Michael, Jr., "The Role of Test Socket Procedures In Today's Prosthetic Practices," Clinical Prosthetics and Orthotics, 9:3, pp. 11-12.</a></li> </ol> Footnote Type II, Normal Set Alginate, Coe Laboratories, Inc. Chicago, Illinois 60658 *C. Michael Schlich, C.P.O. C. Michael Schuch, C.P.O., and Tony Lucy are with the Department of Orthopedics and Rehabilitation at the University of Virginia. Page Number(s) 101 - 104 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.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/1986_03_101/1986_03_101-6.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 Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets Creator An entity primarily responsible for making the resource C. Michael Schlich, C.P.O. * Tony Lucy https://staging.drfop.org/files/original/37c3fec692e2b57f47245df169887b35.pdf 4946ee134a3401f408e0f322622aa167 https://staging.drfop.org/files/original/cda236ac9cde9b85325e3b96250a8f34.jpg 26aeac3a42f4a49224918f719d96a7bf https://staging.drfop.org/files/original/61e5df6689a2f5df64d735ec336e8dd7.jpg 25e56e96ed63a1d92e654c1dfd5447c9 https://staging.drfop.org/files/original/fd0fd82498d9cf6124c858bd221e6da0.jpg ceb9e4d935e7a64a1a6b54d44300cd2f https://staging.drfop.org/files/original/d3c8b0e372904833805dd1044f5bb20f.jpg b836b034c8fba7dd52dcbf61c62f7557 https://staging.drfop.org/files/original/c807aa7a3fefd3330cb672958e4f9744.jpg cef35b057b604843a8fda814493e07bd https://staging.drfop.org/files/original/ef44f82ae71f82036a91bd66e369ab5f.jpg 0a8cf7b7df88f1f5875f99e02d60f2a1 https://staging.drfop.org/files/original/aae5019d6873ca6c365835a4c4706720.jpg ebaef7afe5ead98ddf0119032fb488da https://staging.drfop.org/files/original/00f96c383c511633e3f05f8c9f266f5b.jpg 17c8c67c8c1a64cd510eedfe1639eb79 https://staging.drfop.org/files/original/0b29948807ab4359f31ff27cd2112168.jpg 1cafb32b82c0b235dc700d48c8dcba50 https://staging.drfop.org/files/original/9500eb71d186ca76e567a337583202af.jpg e86c2a546d0bea141aba88885bd080ed https://staging.drfop.org/files/original/5644f8d878cf4491ab0b287029eb3741.jpg 0d76a9bdf9ccd33b508307f1bd262151 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_105.pdf Text Any textual data included in the document <h2>The Use of Surlyn and Polypropylene in Flexible Brim Socket Designs for Below-knee Prostheses</h2> <h5>C. Michael Schlich, C.P.O. <a style="text-decoration: none;">*</a> A. Bennett Wilson, Jr. <a style="text-decoration: none;">*</a></h5> The need for improved prosthetic socket designs to increase amputee comfort and function has long been recognized by prosthetists and other health care professionals involved in amputee rehabilitation. Reduction of the hardness and stiffness of wood and plastic laminate sockets has been addressed with various soft liners or inserts in an attempt to improve comfort and function. The subject is well covered in literature from Radcliffe's and Foort's initial description of leather and Kemblo® liners in 1961,<a></a> through Leon Bennett's work with gel liners in 1974,<a></a> to Tim Staats' description of multi-durometer liners in 1984.<a></a> Liners have no doubt been useful in below-knee prosthetics, but the proponents of soft liners seem to have overlooked the potentials offered by flexible brims. At least two engineers active in prosthetics research have for some time raised questions concerning socket brim stiffness as a negative factor with respect to socket comfort. Dr. Eugene Murphy first considered this theme as early as 1957<a></a> when he proposed, "minimize the stiffness gradient between the rigid socket wall and the flexible skin, i.e., taper flexibility of the socket brim." As Dr. Murphy<a></a> later relates: <blockquote> "This theme was eventually published as the introduction to an extensive series of theoretical and experimental papers by Bennett. The series ended with limited clinical trials of sockets with flexible brims made of plastic laminates. These sockets appeared to be helpful for patients previously troubled by chronic or recurrent cysts, but the mechanical durability of the laminate was so poor that the sockets often lasted only six months."<a></a> </blockquote> In the course of developing the ultralight weight below-knee prosthesis at Moss Rehabilitation Hospital,<a></a> A. Bennett Wilson, Jr. recognized the possibilities afforded by the use of thermoplastics to achieve flexible brims that would be sufficiently durable. During the past year, we have been funded by the Veterans Administration Rehabilitation Research and Development Service to carry this idea further. After reviewing the theories set forth previously and considering the properties of new materials and techniques now available, a set of criteria for socket design was established: <ol> <li> Flexible brim </li> <li> Tapering flexibility of the socket in the brim area </li> <li> Flexibility options in other areas of the socket </li> <li> Light weight, but durable </li> <li> Thermoplastic and modular (i.e. no lamination, no epoxy, no glue, etc.) </li> <li> Compatibility with existing modular component systems </li> </ol> The resulting socket design (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg">Fig. 1</a>) consists of the following components: (1) a Surlyn® inner socket or liner; (2) a polypropylene frame for socket support and attachment; (3) silastic foam soft end pad for establishing total contact; (4) United States Manufacturing Company<a></a> adaptor hardware<a style="text-decoration: none;">*</a> for attachment to Otto Bock<a></a> modular systems; and (5) neoprene sleeve suspension. <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg">Figure 1. Complete prosthesis, except for cos-mesis and suspension, incorporating a socket with flexible brims.</a> Fabrication of this socket system is as follows: <ol> <li> The cast is modified for a PTB-supracon-dylar socket design, and the distal end of the model is extended approximately one inch to allow for a silastic foam end pad and the modular adaptor (U.S. Mgf. Co.) for connection of the pylon to the socket (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg">Fig. 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg">Figure 2. The modi-fled plaster model of the stump is extended to allow for location and alignment of the U.S.M.C. adaptor connector plate for the pylon.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg">Figure 3. The modified plaster model complete with adaptor, ready for vacuum-forming of the Surlyn® inner socket.</a></li> <li> An inner liner of Surlyn® is vacuum formed using either 12" x 12" x 3/16" Surlyn® for light to regular duty sockets, or 12" x 12" x 1/4" Surlyn® for heavy duty sockets (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg">Figure 4. Vacuum-forming the Surlyn® inner socket.</a></li> <li> One layer of thick stockinette and a nylon stocking are applied over the vacuum-formed Surlyn® liner to facilitate separation of socket frame and liner (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg">Figure 5. Application of stockinette and nylon sock over Surlyn® inner socket to provide for separation of the polypropylene outer socket to be vacuum-formed over it.</a></li> <li> The socket frame is vacuum formed of polypropylene directly over the inner socket. A piece 12" x 12" x 3/8" is suitable for light duty while a piece 1/2" thick is usually adequate for heavy duty (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg">Figure 6. The outer socket frame is vacuum-formed over the inner socket</a> </li> <li> After the final vacuum forming stage, the socket liner and socket frame are separated from each other and from the cast model (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg">Figure 7. The inner socket and socket frame before trimming</a></li> <li> The Surlyn® liner is trimmed for a PTB-SC design and the polypropylene frame is trimmed for a PTB socket design and is fenestrated over the tibial crest anteriorly and the gastrocnemius area posteriorly (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg">Figure 8. The socket frame and inner socket after trimming</a></li> <li> The Surlyn® liner is now inserted into the polypropylene frame (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.jpg">Fig. 9</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.jpg">Figure 9. The socket frame and inner socket assembled.</a></li> <li> The U.S. Manufacturing Co.<a></a> adaptor hardware is used to attach the socket to the Otto Bock<a></a> titanium modular endo-skeletal components and an appropriate foot. </li> <li> During initial fitting, the distal end pad is foamed in place while the patient stands to provide total contact. </li> </ol> The Otto Bock modular system has sufficient range of adjustment to suffice for alignment of prostheses for most geriatric patients. However, the use of the Berkeley BK alignment device might be desirable for some of the more active patients (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg">Fig. 10</a>). A special adaptor plate is made of 1/8" aluminum sheet so the Otto Bock 4R22 adaptor component can be used between the socket and the alignment device. <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg">Figure 10. View showing adaptor needed when the UCB adjustable below-knee "leg" is used for alignment trials.</a> Cosmetic finishing may make use of any of several foam cover systems available, such as the round styrofoam cover available from the U.S. Manufacturing Company (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg">Fig. 11</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg">Figure 11. The completed prosthesis with cosmetic stocking pulled down to show the carved styrofoam cover.</a> Below-knee patients fitted at the University of Virginia during the past two years, who voluntarily agree, are being refitted by their original prosthetist with the flexible brim thermoplastic system described here. Our initial conclusions are very positive. To date, eight flexible brim thermoplastic sockets have been fit on seven patients, with one patient having worn his for over one year. There have been six fittings since February, 1986. Only one socket failure has been noted, that of the Surlyn® inner flexible socket which split along the tibial crest on a patient weighing over 350 pounds. That particular socket lasted approximately four months. Though not indicated for use on someone of this weight, we were interested in determining its durability limits. Subjective evaluation includes patient questionnaires and comments, comparing their existing prosthesis with the new flexible brim thermoplastic socket system. Patient reaction, thus far, indicates enhancement of patient comfort and awareness of reduced prosthesis weight, especially with our geriatric subjects. Although not originally designed for geriatrics, this patient population has specific needs that can be met by this socket design, such as socket flexibility, less confining brim, reduced proximal shear forces, and extreme light weight. When used with Otto Bock titanium modular components and a "Lite" SACH foot, this system weighs between one and a half and two pounds. Current objective evaluation includes collecting heart rate and step count data in the patient's home environment, using a newly developed ambulatory physiological monitoring system. This includes physiological data with the patient's existing prosthesis in addition to that collected with the flexible brim thermoplastic socket system. This system of patient monitoring, or surveillance, electronically records heart beats (EKG), standing versus sitting posture, and step count, plotted against time up to 24 hours. The goal is to document any changes in activity level and energy expenditure that occur with use of new prostheses, such as the flexible brim thermoplastic socket system presented in this paper. In conclusion, a new socket design rationale and system utilizing existing thermoplastic materials has been presented. Patients fit with this system are currently being evaluated both subjectively and physiologically. Fittings and evaluations will continue until a significant number are completed and related data gathered. A follow up report will follow with final conclusions and statistical data presented. References: <ol> <li>Bennett, Leon, "Gel liner effects," Bulletin of Prosthetic Research, BPR 10:21; Spring, 1974, pp. 23-53.</li> <li>Otto Bock Orthopedic Industries, Inc., 4130 Highway 55, Minneapolis, MN 55422.</li> <li><a href="cpo/1984_03_004.asp">Murphy, Eugene F., "Sockets, Linings, and Interfaces," Clinical Prosthetics and Orthotics, 8:3, Summer, 1984, pp. 4-10.</a></li> <li>Murphy, Eugene F., "Transferring Load to Flesh," Bulletin of Prosthetic Research, BPR 10:16; Fall, 1971, pp. 38-44.</li> <li>Radcliffe, C. W., and J. Foort, "The Patellar-Tendon-Bearing Below-knee Prosthesis," Biomechanics Laboratory, Dept. of Engineering, Univ. of Calif., Berkeley, and School of Medicine, Univ. of Calif., San Francisco, 1961.</li> <li>Staats, Timothy B., "Multiple Durometer Socket Liners for P.T.B. Prostheses," Orthotics and Prosthetics, 38:4, Winter, 1984, pp. 63-68.</li> <li>United States Manufacturing Co., 180 North San Gabriel Boulevard, Pasadena, Calif., 91107.</li> <li>Wilson, A. Bennett, Jr., "Ultralight Prostheses for Below-knee Amputees," Orthotics and Prosthetics, 30:1, March, 1976, pp. 43-48.</li> </ol> <div style="width: 400px;">Footnote USMC Part Nos. 41014, 42012, 43026, and 29316 </div> *A. Bennett Wilson, Jr. The Department of Orthopedics and Rehabilitation at the University of Virginia. *C. Michael Schlich, C.P.O. The Department of Orthopedics and Rehabilitation at the University of Virginia. <div style="width: 400px;"> </div> <div style="width: 400px;"></div> Page Number(s) 105 - 110 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Use of Surlyn and Polypropylene in Flexible Brim Socket Designs for Below-knee Prostheses Creator An entity primarily responsible for making the resource C. Michael Schlich, C.P.O. * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/a75bb5af32b91c1f69b33d56c8e8c13c.pdf 7038d74466afb3f6db7db53e207d99f1 https://staging.drfop.org/files/original/83201447bfbcd1b4e9c4e43420cb46c0.jpg bbea9d1c00254560b22e2b807b1c8d08 https://staging.drfop.org/files/original/7ea7735793548661de0e6720877337e8.jpg b400e6e9832514b4295b6404a02ba862 https://staging.drfop.org/files/original/0dd26f7dd4ed5f35fb0c91028a1a8e1d.jpg 366678f0b5ceb5eadc4f020eee144577 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_111.pdf Text Any textual data included in the document <h2>Restoration of Walking in Patients with Incomplete Spinal Cord Injuries by Use of Surface Electrical Stimulation: Preliminary Results</h2> <h5>T. Bajd <a style="text-decoration: none;">*</a> B.J. Andrews <a style="text-decoration: none;">*</a> A. Kralj <a style="text-decoration: none;">*</a> J. Katakis <a style="text-decoration: none;">*</a></h5> This article was reprinted with permission from Prosthetics and Orthotics International, 9, 1985, pp. 109-111. Further information about Prosthetics and Orthotics International can be obtained from Joan E. Edelstein, Secretary-Treasurer, US Member Society ISPO, 317 East 34th Street, New York, N.Y. 10016. <h3>Introduction</h3> A group of patients who are good candidates for the application of Functional Electrical Stimulation (FES) to restore reciprocal walking is described. They have incomplete lesions of the spinal cord. Because of the degree of preserved voluntary control, proprioception and sensation, some of these patients can achieve crutch assisted walking by means of multichannel electrical stimulation. In a number of cases the patient has sufficient strength and voluntary control in the upper limbs and at least one leg to provide safe standing for short periods in forearm crutches. For these patients a two channel stimulator controlled by a hand-switch was applied to achive safe and practical crutch assisted walking in a relatively short period of time. <h3>Background</h3> A new group of patient which can benefit from the orthotic use of functional electrical stimulation (FES) has been identified. These are incomplete spinal cord injured patients. This group of patients is increasing in numbers mainly due to improvements in primary care. The clinically incomplete lesion of their spinal cord results in preservation of some voluntary movements of the lower extremities. Some of these patients are able to walk with the help of various short-leg or long-leg orthoses which fix the knee and ankle joints. Support of the foot is often provided by the addition of a toe spring. Locomotion of most other incomplete spinal cord injured (SCI) patients is performed with the help of a wheelchair. They can walk only for very short distances, usually in their homes. Some tetraplegic patients are totally confined to a wheelchair. The reason is often very strong spasticity or developed contractures. The upper extremities are also partially paralyzed. Nevertheless, the arms and hands are strong enough to provide support on crutches. Wrist and finger movements are often limited and the grip is rather weak. However, the patients are in most cases able to hold the handle of the crutch. It was found that a minimum of four channels of FES was required for synthesis of a simple reciprocal gait pattern in the complete thoracic patient (Bajd et al., 1983; Kralj et al., 1983). During the stance phase, knee extensor muscles are stimulated, while the swing phase is accomplished by eliciting a synergistic flexor response in hip, knee and ankle joints through electrical stimulation of an afferent nerve. It was observed in the present study that in most of the incomplete tetraplegic patients one leg was almost completely paralyzed while the other leg was under voluntary control and sufficiently strong to provide safe standing for short periods using only crutches. Unilateral stimulation of knee extensors and an afferent nerve was helpful in these patients. Less frequently it was found that the patients could stand but were unable to take a step with one or both legs. Unilateral or bilateral stimulation of afferent nerves proved helpful for them. There are also patients whose extension and flexion capabilities in both lower extremities are so poor that they need three or even four channels of stimulation. <h3>The Fes Orthosis</h3> From the point of view of control of the patient, the gait cycle was divided into stance and swing phase. The transition from one phase to another was achieved by pressing a hand switch mounted on the handle of the crutch. When the switch was not pressed, knee extensors were stimulated. When the switch was pressed, the afferent nerve was excited, resulting in the swing phase of walking. The duration of the swing phase was regulated by the time of pressing the switch. In the present investigation the peroneal nerve was stimulated near fossa poplitea. The stimulation of this mixed, sensory and motor, nerve provided direct dorsi-flexion and eversion of the foot and simultaneously also the reflex knee and hip flexion. The gait of most of the incomplete SCI patients can be restored by the two-channel stimulator only. Any stimulator can be used for the described application where the stimulation parameters can be adjusted close to the following values: 0.3 ms pulse duration, 20 Hz pulse repetition frequency, and an amplitude up to 120 volts (measured with a 1k Ω load. Surface electrical stimulation of the knee extensors was delivered to the muscles through large (6 x 4 cm) sheet metal electrodes covered with water soaked layers of gauze. When stimulating the common peroneal nerve, two small round electrodes (diameter 2.5 cm) made of sheet metal and covered by gauze saturated with water were used. The interconnection of the hand switch with the outputs of the stimulator to the electrodes can be readily accomplished. The hand switch was attached to the handle of the crutch by adhesive tape for trial purposes. <h3>Patient Tests</h3> Five patients with incomplete spinal cord lesions have so far been included in the program of FES assisted walking. Only a short strengthening program was required for disuse atrophy of their thigh muscles. The learning program of walking was extremely fast and simple. After the first few days the patients were able to go from mobile parallel bars to crutches (<a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg">Fig. 1</a>). The difference between walking with and without FES was evident. The patients were not able to take a single step with their severely paralyzed extremity when the stimulator was switched off. After a few days of training they were able to rise from the sitting to the standing position independently with the help of the crutch support and knee extensor stimulation only. Soon they were able to walk on uneven ground (<a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg">Fig. 3</a>) and go up and down steps (<a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg">Fig. 2</a>). The subject shown in <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg">Fig. 3</a> has an incomplete lesion at the level T6/7 (age 36 yrs., height 168 cm., mass 61 kg., 7 yrs. post injury). The subject shown in <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg">Fig. 1</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg">Fig. 2</a> has an incomplete lesion at the level C6 (age 21 yrs., height 188 cm., mass 70 kg., 3 yrs. post injury). In both cases one leg was paralysed while the other had sufficient voluntary control to maintain safe standing with crutches without stimulation. <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg">Figure 1.</a> Paraplegic subject with incomplete lesions at T6/7 walking on a level surface. <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg">Figure 2</a>. Tetraplegic subject with incomplete lesion at C6 negotiating uneven steps. <a href="http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg">Figure 3</a>. Patient walking on uneven ground; end of swing phase for the paralyzed leg. <h3>Discussion</h3> Such activities can only be achieved in a few completely paraplegic patients after many months in the training program. These differences between incomplete and complete spinal cord injured patients are due not only to the remaining voluntary movements of their lower extremities, but also to the preserved sensation and proprioception. The present FES orthotic systems provide active movements at the joints of the limbs, but no feedback is available in practical clinical systems. The patients feel safe and secure when unattended because in the event of a failure of the orthosis, they are able to support themselves. For these reasons the incomplete SCI patients appear to be the most appropriate candidates for FES. The FES assisted walking may require less energy from the SCI patients with incomplete lesions than walking with passive mechanical knee and ankle orthoses, because no hip hiking is necessary with active FES systems. Finally, FES assisted walking is much more aesthetic to the observer than orthoses assisted and is preferred by the patients. There may be a number of therapeutic benefits to be gained from the use of FES orthoses such as the prevention of pressure sores, contractures, muscle atrophy and bone demineralisation. <h3>Acknowledgments</h3> The authors wish to acknowledge the financial support of the Multiple Sclerosis Society and the A. Onasis, Public Benefit Foundation. The work was conducted at the Bioengineering Unit, University of Strathclyde, Head, Prof. J.P. Paul and in collaboration with Mr. P.A. Freeman F.R.C.S. and staff of the West of Scotland Spinal Injuries Unit at the Philipshill Hospital, Glasgow. References: <ol> <li> Bajd, T., Kralj, A., Turk, R., Benko, H., Sega, J., "The use of a four channel electrical stimulator as an ambulatory aid for paraplegic patients," Phys. Ther., 63, pp. 1116-1120, 1983. </li> <li> Kralj, A., Bajd, T., Turk, R., Krajnik, J., Benko, H., "Gait restoration in paraplegic patients. A feasibility demonstration using multichannel surface electrodes FES," J. Rehabil. Res. Dev., 20, pp. 3-20, 1983. </li> </ol> *J. Katakis Member of the Bioengineering Unit at the University of Strathclyde in Glasgow. *A. Kralj Member of the faculty of Electrical Engineering at Edvarda Kardelja University in Ljublana. *B.J. Andrews Member of the Bioengineering Unit at the University of Strathclyde in Glasgow. *T. Bajd Member of the faculty of Electrical Engineering at Edvarda Kardelja University in Ljublana. Page Number(s) 111 - 114 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_111/1986_03_111-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Restoration of Walking in Patients with Incomplete Spinal Cord Injuries by Use of Surface Electrical Stimulation: Preliminary Results Creator An entity primarily responsible for making the resource T. Bajd * B.J. Andrews * A. Kralj * J. Katakis * https://staging.drfop.org/files/original/b95e5342fe7eaaa21c950572d787fbda.pdf 22900e4b73ce0e89c1e8e6b35ce978e9 https://staging.drfop.org/files/original/69a206a2aa84ed680056a9fdc2139438.jpg d2cf4a108bb4637b1831508eed43a6bb https://staging.drfop.org/files/original/bbdcebf3e88af2b9c4154c6ab8600941.jpg 1742853ff042c4f63024eb1c3f70a128 https://staging.drfop.org/files/original/f6b252668fde0f741327f4ce578605b4.jpg d7e17f3201c463458fb90ab1fc6ed3c9 https://staging.drfop.org/files/original/072c8063021ab7603ec812365ca28462.jpg 844e15bf47ec63eb59e4d48548c2ffda https://staging.drfop.org/files/original/3f19c0d013a453a5a3aac4a18fd62be7.jpg 059db7ef417cd22394cde20c77c23ff8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_115.pdf Text Any textual data included in the document <h2>An Alternative Technique for Fabricating Flexor Hinge Hand Orthoses Using Total Contact Molded Plastic Finger Pieces</h2> <h5>Greg Moore, R.T.O. <a style="text-decoration: none;">*</a></h5> The flexor hinge hand orthosis is one of the most demanding orthoses for the orthotist to fit properly. The slightest error can result in failure of the orthosis and loss of patient confidence in the orthotist. Presented here is a technique for fabricating the orthosis with increased fitting accuracy and reduction of patient-practitioner contact time. The procedures presented here have been accumulated from the measurement and fabrication techniques of various practitioners (see acknowledgments) and assimilated into this single technique. <h3>History</h3> The flexor hinge hand splint was originally based on the principle of the flexor hinge hand as described by Nickel, Perry, and Garrett in 1955.<a></a> In the years that followed, it was developed by them and their co-workers, using the principle of the modified three-jaw chuck, in which the index and middle fingers move together towards the thumb. This is accomplished by immobilizing the thumb in a position of opposition and placing the index and middle fingers in a position of semiflexion at the inter-phalangeal joints. To prevent slippage of the object grasped, the thumb pad must oppose the pads of the two fingers. The flexor hinge is that part of the orthosis which hinges at the MP joint and holds the index and middle fingers in a functional position. The range of motion is from a position of full extension of the MP joints to a point where the finger pads contact the thumb. The orthosis is operated in one direction by internal or external power under voluntary control, and returned to the starting position passively, usually by a spring or gravity. The orthosis was originally developed to restore upper extremity function of patients with poliomyelitis. As the incidence of poliomyelitis decreased, the orthosis was used with other patients with severe upper-extremity paralysis such as cervical spine injury, hemiplegia, and brachial plexus injury. The results of treatment in these patients indicated that it is the degree of functional loss rather than the diagnosis that is significant. To a large degree, management of upper-extremity paralysis is the same regardless of the cause.<a></a> <h3>Fabrication Technique</h3> After the patient has been assessed by the rehabilitation team and the orthotic design has been determined, the patient is seen by the orthotist. Appropriate measurements are taken and recorded for fabrication of the forearm and/or palmar pieces. Following this initial visit, the orthotist shapes and assembles the pieces according to the measurements, with special attention to accurate placement of the MP mounting plate for the flexor hinge finger piece. Temporary straps are also attached to the orthosis to eliminate migration of the orthosis during trial fitting. Other fabrication steps that can be completed at this time are the placement of temporary padding (if used) and the attachment of the adjustable actuating lever kit (Rancho style wrist-driven). The thumb post can be shaped, but should not be attached to the palmar piece until it has been properly fitted to the patient on the second visit. With the patient's second visit, the forearm and/or the palmar pieces should be fit to the patient and necessary adjustments made to provide for optimal fit and function. The thumb post is fit and attached to the palmar piece in the normal manner at this time. With this accomplished, the orthosis is placed on the patient's hand and secured with the temporary straps. The index and middle fingers are taped together at the distal phalanges using 1/4" masking tape, so as to keep the middle finger slightly longer than the index finger. A position of 35-40° of flexion at the MP joint, 30° of flexion at the proximal interphalangeal joint, and 5-10° of flexion of the distal interphalangeal joint is needed to position the fingers in opposition with the thumb.<a></a> When the positioning of the fingers has been accomplished to the satisfaction of the orthotist, the fingers and thumb are coated with a thin layer of petroleum jelly in preparation for casting. Four layers of 4" plaster bandage material are measured and cut so that the ends of the bandage extend over the ends of the fingers by 3/4" and at the other end over the proximal edge of the MP mounting plate by 3/4" (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg">Fig. 1</a>). The plaster bandage is then dipped in water and with the fingers held in a position of opposition to the thumb, the plaster bandage is placed over the dorsal aspect of the fingers. The edge of the bandage extends distally so that the tip of the thumb is included in the impression. Proxi-mally, the bandage extends over the MP mounting plate so that an impression of this is included. The bandage should not cover the volar (palmar) side of the fingers. The bandage is rubbed into the fingers, tip of the thumb, and the MP mounting plate to obtain a clear impression, and the edges of the bandage should be folded back approximately 1/4" to reinforce the borders (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-2.jpg">Fig. 2</a>). After the bandage has hardened, it can be removed without the use of a cast saw by gently disengaging it from the MP mounting plate area and tilting it up over the fingers. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg">Figure 1.</a> Preparation for casting fingers. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-2.jpg">Figure 2</a>. Cast impression incorporating MP joint plate and fingers. The proper length of the temporary straps should be marked and the fitted forearm and palmar pieces removed. The patient's hand can now be cleaned, and he/she can be scheduled for a final return visit. The impression is prepared for filling by enclosing it in plaster bandage and coating the inside with a thin layer of liquid soap. A small mandrel should be contoured to fit the inside of the impression, extending as far distally as the tips of the fingers to prevent fracturing of the positive model (a length of 1/2" O.D. aluminum tubing works well for this). The impression is filled with plaster of Paris and stripped, using great care not to fracture the positive model. The model will have good detail, showing the contours of the finger nails, skin lines, and MP mounting plate. The positive model is prepared for vacuum forming, using a length of nylon stocking as the interface for the 1/8" polyethylene. If Surlyn® is used, the Surlyn® is vacuum formed directly over the lightly smoothed impression without an interface. The clarity of Surlyn® facilitates visual assessment of pressure distribution when used with a sensation impaired hand. The plastic should be vacuum formed and not drape formed to insure an exact fit. Once the vacuum forming has been completed, the plastic piece can be removed by using a cast saw and carefully avoiding excessive damage to the impression. The finger piece is now ready to be trimmed using the following general guidelines. The distal border should be 1/8" distal to the proximal edge of the fingernails of the index and middle fingers. The proximal border should be trimmed to the proximal aspect of the proximal phalanges. In the coronal plane, the plastic piece is trimmed along the midline of the fingers. The plastic finger piece is then placed back on the positive impression and a stainless steel superstructure is fabricated using the MP mounting plate impression as the reference for the MP operating lever (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-3.jpg">Fig. 3</a>). This saves an enormous amount of time since the reference between the palmar piece and finger piece is part of the positive impression. A regular Jaeco style proximal finger piece is used for the proximal bar of the superstructure, and a 3/32" rod connects it to a distal stainless bar located at the middle of the middle phalange. Both of the bars are silver soldered to the 3/32" rod and simply bent to the contours of the plastic finger piece. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-3.jpg">Figure 3</a>. Shows ease of aligning MP joint and finger pieces with MP joint included in the cast. The proximal finger piece is connected to the MP operating lever in the usual manner. A Velcro® closure can be attached to the distal superstructure bar on a stainless steel closure and can be fabricated using the bar as the dorsal half of the closure. With the finger piece completed and the remainder of the orthosis finished, the patient can be fitted and the orthosis delivered (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-4.jpg">Fig. 4</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.jpg">Fig. 5</a>). Patient training and minor adjustments are done following regular rehabilitation procedures. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-4.jpg">Figure 4.</a> Complete orthosis wih polyethylene finger piece. <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.jpg">Figure 5.</a> Orthosis showing use of Surlyn® finger-piece for observation of the skin. <h3>Summary</h3> Fabrication of the intimate fitting flexor hinge component of the flexor hinge wrist hand orthosis can be tedious. The procedure detailed here can facilitate fabrication of a more accurately fitting flexor hinge. The use of a vacuum formed finger section assures a total contact fit resulting in fewer pressure problems on the fingers. The optional use of Surlyn® for fabrication of the plastic finger piece permits direct skin observation when deemed beneficial. <h3>Acknowledgments</h3> I would like to express my special thanks and admiration to Jack E. Greenfield, CO. at Rancho Los Amigos Hospital and David Bird, CO. at University of Michigan Hospitals for their willingness to share their experience and knowledge. References: <ol> <li>Nickel, V.L., Perry, J., and Garrett, A.L., "Development of Useful Function in the Severely Paralyzed Hand," Journal of Bone and Joint Surgery, 45:933, 1963.</li> <li>Rae, J.W., Jr.: Personal communication. Conference on Upper Extremity Devices, Rancho Los Amigos Hospital, Downey, California, May 15-16, 1957.</li> <li>Malick, M.H., and Meyer, C.M.H., "Manual on Management of the Quadriplegic Upper Extremity," Har-marville Rehabilitation Center, 1978, p. 39.</li> <li>Engel, W.H., Kmiotek, M.A., Hohf, J.P., French, J., Barnerias, M.J., and Sievens, A.A., "A Functional Splint for Grasp Driven by Wrist Extension." Archives of Physical Medicine & Rehabilitation, January, 1967, pp. 43-52.</li> <li>Bisgrove, J.G., "A New Functional Dynamic Wrist Extension-Finger Flexion Hand Splint-A preliminary report, Journal of Ass. Phys. Ment. Rehab., 8, September-October 1954, pp. 162-163.</li> <li>Redford, J.B., ed. Orthotics Etcetera. Baltimore, Md. Williams and Wilkins, 1980, pp. 238-248.</li> </ol> Greg Moore, R.T.O. At the time of writing, Greg Moore, R.T.O., was a student in the Long Term Orthotic Practitioner Program at 916 Vo-Tech. He may be reached at: c/o Bill Moore, 7366 S. Bannock Drive, Littleton, CO 80110. <div style="width: 400px;"> </div> Page Number(s) 115 - 118 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Alternative Technique for Fabricating Flexor Hinge Hand Orthoses Using Total Contact Molded Plastic Finger Pieces Creator An entity primarily responsible for making the resource Greg Moore, R.T.O. * https://staging.drfop.org/files/original/275fab2ea3b3d6677f16b2fc3c4f84d4.pdf c2bbef75d554db7e69924d9f9f9c3be5 https://staging.drfop.org/files/original/945444737a803091f2f7bb1f33166de1.jpg a44bea2f00eb9d7426d0babc659224e9 https://staging.drfop.org/files/original/805377d1e0c88a555e639acf4505f9d9.jpg a43839ca800ea32a700efaf4bfa8c04c https://staging.drfop.org/files/original/765458c0a65fb32f59bc3f28a9e0a770.jpg aa8eff94b32c7b7db5b52dffb56eec36 https://staging.drfop.org/files/original/d780ea0687580fe5cebc29a049984303.jpg 5a3a3e48efd9f9539ee371ddb261a7a2 https://staging.drfop.org/files/original/d7de2d0bc53c05faa2e263ccba47e3c2.jpg 0245c6a4e08793989816f7455b5379d8 https://staging.drfop.org/files/original/c83d9d8de2014f43049249a501eaf7ac.jpg 8e116daad4f180da07481663e4931c0f Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_119.pdf Text Any textual data included in the document <h2>Technical Note: RMB Reinforcement</h2> <h5>Robert O. Gooch, CP. <a style="text-decoration: none;">*</a></h5> Because of the humid climate, the Department of Prosthetics and Orthotics at Duke University Medical Center receives many prescriptions for hard socket below-knee prostheses. The great majority are supracondylar wedge suspension, utilizing the Removable Medial Brim (RMB) concept. For the past several years, we have designed and fitted approximately 150 such prostheses annually. Based on this experience, we have developed a method to reinforce the RMB structure and prevent gradual loss of alignment under the constant pressure of the femoral condyles. We now use this technique routinely, and find it greatly enhances the stability of the removable brim. <h3>Method</h3> Fabricate the socket in the conventional manner, following the instructions supplied by the hardware manufacturer.<a></a> Rather than packing the mechanism with clay, we prefer to substitute Johnson's Stik-Wax,<a></a> which is easier to work with and lubricates the assembly, allowing easier removal. Once the lamination is fully cured, break out the positive model. At this point, the medial brim is cut away from the socket. Although a variety of tools can be used for this operation, we prefer a simple modification of an ordinary hacksaw blade. Grind the fine-tooth hacksaw blade into the contour shown in (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-1.jpg">Fig. 1</a>). This is preferable to a commercial sabre saw blade, because its wide, thin shape creates a smoother, less irregular cut. <a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-1.jpg">Figure 1.</a> Fine-toothed hacksaw blade, modified to fit sabre saw. Using the sabre saw, cut the anterior and posterior portion of the brim free, being careful not to nick the metal upright. Cut the area adjacent to and over the metal upright with a cast saw or sharp knife. Carefully pry the medial brim free with a thin-bladed screwdriver. Grind the distal end of the upright an amount equal to the saw kerf, to insure the wedge will seat fully (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-2.jpg">Fig. 2</a>). Place the brim back onto the socket to be certain it fits properly, with minimal gapping along the cut edge. <a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-2.jpg">Figure 2.</a> Grind distal upright to insure the wedge fits without gapping. <h3>Reinforcement</h3> Remove the brim and apply PVC tape<a></a> to the lateral surface and distal trimline. This serves as a parting agent, and prevents the resin used in subsequent steps from bonding the wedge back onto the socket. Roughen the socket immediately beneath the cut-line, to insure good adhesion for the reinforcement lip (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-3.jpg">Fig. 3</a>). Lubricate the cut edge with petroleum jelly and reapply the wedge carefully to avoid gapping. <a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-3.jpg">Figure 3.</a> Tape wedge and roughen socket prior to lamination of lip. Cut three 1 1/2" wide strips of Xynole-polyester<a></a> fabric long enough to cover the saw cut. This material saturates readily when used with polyester resin and forms a thin, strong, and rigid reinforcement. Promote a small amount of pigmented polyester 4110 (rigid) resin. Paint the roughened area of the socket with resin, and apply one layer of Xynole reinforcement extending at least 1/2" onto the wedge (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-4.jpg">Fig. 4</a>). Brush additional resin onto the Xynole until it is fully saturated, and apply the second layer. Fully saturate this layer and apply the final layer. Saturate this in a similar manner. <a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-4.jpg">Figure 4.</a> Saturate Xynole layers individually with the polyester resin. When the resin has gelled, but not fully set, remove the wedge. This insures that the wedge will insert smoothly, without binding, in the finished prosthesis. Once fully cured, trim the reinforcement to form a 3/16" lip (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-5.jpg">Fig. 5</a>). Using a felt arbor, bevel the inside edge of the lip and the outside edge of the wedge (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-6.jpg">Fig. 6</a>). This unobtrusive lip will significantly reinforce the wedge, particularly against malrotation. <a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-5.jpg">Figure 5.</a> Trim lip to 3/16" above socket edge. <a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-6.jpg">Figure 6.</a> Posterior view of lip with wedge in place. Note bevel on inner edge of lip and outer edge of wedge. <h3>Finishing</h3> Once dynamic alignment and transferring are completed, the prosthesis is ready for the finish lamination. We typically set the wedge aside and relaminate the prosthesis without the proximal brim in place. An old RMB upright can be inserted into the channel and clamped in a vise. This prevents resin from filling the channel and provides a mandrel to secure the prosthesis during the lamination procedure. Lubricate the upright with Stik-Wax<a></a> to fully seal the channel. <h3>Summary</h3> Fabrication of a Xynole reinforcing lip significantly improves the stability of the supracondylar wedge when using the Removable Medial Brim procedure. Based on the Duke experience with hundreds of RMB prostheses, we recommend this be done routinely. References: <ol> <li>Durr-Fillauer Medical, Inc.  P.O. Box 5189  Chattanooga, TN 37406  RMB Hardware Kit  Catalog #127019 (Heavy Duty)  Catalog #127001 (Standard Duty)</li> <li>S.C. Johnson & Sons, Inc.  Racine, WI 53403  #140 Stik-Wax-15 oz. container</li> <li>Otto Bock Industries  4130 Highway 55  Minneapolis, MN 55422  Coroplast PVC tape  Catalog #616F8</li> <li>Durr-Fillauer Medical, Inc.  P.O. Box 5189  Chattanooga, TN 37406  Xynole-Polyester cloth  Catalog #211094</li> </ol> *Robert O. Gooch, CP. Robert O. Gooch, CP., is with the Department of Prosthetics and Orthotics at the Duke University Medical Center. <div style="width: 400px;"> </div> Page Number(s) 119 - 121 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-5.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/1986_03_119/1986_03_119-6.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 Technical Note: RMB Reinforcement Creator An entity primarily responsible for making the resource Robert O. Gooch, CP. * https://staging.drfop.org/files/original/1d0b1902a4d7fb7cc437f75ca2c997b1.pdf f5ec7dfc784092ec4c05b42b0a9ca722 https://staging.drfop.org/files/original/07c03e80401b5c87d8d82c363e054d8c.jpg 53dd0b9a9b94ba4619665e0dc21d6fd3 https://staging.drfop.org/files/original/ace09578c7da7ee48bdd67c240b778fe.jpg f52289221839e24d1976512808b88d40 https://staging.drfop.org/files/original/ad5dc9979c8c97cb0bd8047ec31bc02f.jpg 5bf470bdcf3132b882ae78d66b4fd38d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_122.pdf Text Any textual data included in the document <h2>Research and Development Considerations and Engineering Perspective</h2> <h5>Douglas A. Hobson, P. Eng. <a style="text-decoration: none;">* </a></h5> <h3>Background And Introduction</h3> Contrary to the impression given by a segment of current literature, the rapidly emerging field of specialized seating remains largely an art rather than a science. Established clinical principles, supported by a documented knowledge base are sparse, and clinical decision making remains largely subjective. That is, seating practice is not promulgated by an organized educational process. Specialized seating is still in the 1950's era. At that time, significant advances in prosthetics and orthotics were being made. Prosthetics advancements included below knee and above knee socket fitting, fabrication, and alignment principles. In the 1970's, orthotics introduced vacuum formable plastics to the field. Only in the last five years has specialized seating offered more than one or two commercial options for individuals requiring custom contoured body support. Specialized seating is still a comparatively young, but now a rapidly developing sub-specialty of rehabilitation technology. It is probably of value to attempt to define what is meant by the field of specialized seating. First, it is a clinical process which attempts to maximize function through the provision of appropriate "body support" for a nonambulatory person, usually in the seated posture, and usually in combination with a wheeled device, such as a wheelchair. The nature of the body support is dependent largely on the needs arising from the individual's disability. It can be thought of as providing seated body support in a manner that is usually less intimate and technically demanding than is required by conventional spinal orthotics (i.e., a body jacket). Specialized seating has been an exciting area for involvement and research and development, especially during the last ten years or so. Engineers first became clinically involved in specialized seating in the late 1960's in Canada. During the intervening years, other professionals such as prosthetists, orthotists, therapists, and technicians throughout North America and Europe have been actively involved in specialized seating developments. This article attempts to focus on the research and development process that has led to the emerging principles and products that are now becoming common place throughout the delivery system, especially for individuals with cerebral palsy. Perhaps of importance are the experiences that have shaped the views (and biases) of the author regarding the research and development process in the rehabilitation field. Firstly, early design experience in lower extremity modular prosthetics (Winnipeg, 1963-69), strongly reinforced the opinion that research and development should ideally take place in close proximity to an ongoing clinical commitment. Secondly, design and development must take place with a sense of reality towards the strengths and limitations of the manufacturing, marketing, and delivery system associated with the particular technology. This later view is the result of many frustrations, failures, and sometimes successes, in attempting to guide approximately a dozen "ideas" from conceptualization through clinical application over the past 15 years. The R&D process for the field of rehabilitation engineering technology may be viewed as consisting of three interrelated phases of activity, a) research, b) design and development, and c) clinical utilization. The approach taken in this article will be to examine each of these activities as they relate to the development of principles and devices currently employed in the field of specialized seating. Emphasis will be given to applied clinical research versus basic research. The final section will address the current status of the field and suggest future needs for its continued growth. Along the way, developments familiar to the author will be used to illustrate key points. The flowchart (<a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg">Fig. 1</a>) illustrates the process and suggests the primary outcomes from each step of the process. <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg">Figure 1. The three steps in the seating product development process, suggesting the major outcome for each step.</a> <h3>Research Contributions</h3> The engineer, especially when entering new clinical areas, can be overwhelmed by the apparent opportunities to employ engineering principles towards what appear to be readily resolvable problems. With the passing of time, the realization emerges that most problems are much more complex than they first appeared and the best solutions involve creativity, simplicity of design, patience and a good deal of perserverance. Applied research, as it applies to technology and rehabilitation, could be defined as "a logical process which attempts to reduce chaos in favor of logical problems solving, during which time a few significant principles and related devices can be developed." This definition may appear rather non-scientific; however, most developments of significance to date have resulted from attempts to solve a morass of seating problems. From these attempts we see repeated positive results become positioning principles and related successful devices become commercial products. At this point the question could be asked, What, of significance, has been learned about meeting the needs of individuals requiring specialized seating over the past 15 years? First, every person has a unique set of needs, therefore one generalized solution does not work for all. Second, it has been possible to group needs, or residual abilities, which can greatly assist in clinical decision making regarding the choice and provision of technical options. Third, there are three disability related (intrinsic) factors that dictate both research and clinical activities in specialized seating. These are a) lack of postural control (i.e., resulting from spasticity); b) existing or potential deformity; and c) the degree of loss of tissue sensation. The schematic diagram (<a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg">Fig. 2</a>) combines these intrinsic factors in a three dimensional array. As can be seen, postural control can be graded as good, fair, or poor; deformity as mild, moderate, and severe; and sensation as normal, impaired, or asensitive. The groupings that result (Groups 1, 2, 3) give an indication of the degree of body support that the seating system must provide to compensate for the patient's intrinsic deficiencies. For example, a child with cerebral palsy, with a mild deformity, good postural control, and essentially normal sensation falls into Group 1. Individuals with Group 1 needs usually do not require custom contoured body support and often only need a simple seat insert (standardized modular insert) that can provide midline orientation and improve the fit of the wheelchair. Whereas a teenager with Duchenne Muscular Dystrophy, who has poor postural control, severe deformity, but normal sensation, would be in Group 3. This individual would require extensive custom contoured support, including pressure relief throughout the seating surface to accommodate for the discomfort associated with prolonged stationary sitting. A person with a low level spinal cord lesion (paraplegic) with only moderate deformity and fair postural control would fall into Group 2. In this case, some contoured support may be necessary to compensate for deformity and loss of postural control. Also, a primary concern may be the loss of tissue sensation, so pressure redistribution over the seat surface would be necessary. <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg">Figure 2. A three-dimensional representation of the key intrinsic factors (control, deformity, and sensation) that guide decision-making in specialized seating.</a> Let us now go a step further and briefly look at a few disabilities in more depth. For example, individuals with cerebral palsy typically demonstrate a wide range of symptomatic intrinsic factors. It's usually obvious what group (i.e., Group 1, 2, or 3) they fall into for their general seating needs. However, what will be the short and long term postural needs for the child, how these needs can best be met through the seating system, and how the whole seating system must relate to the child's primary environments are all extrinsic factors that are best addressed by our therapy colleagues. That is, not only does one type of seating device not work for all, the manner in which it is configured for an individual, as well as how well it compliments the broader needs of the individual and the families are equally important. Experience has shown that specialized seating is best accomplished through a multidisci-plinary approach in which the technical and therapy contributions are orchestrated within a medical environment, with a physician assuming primary medical responsibility. In recent years, clinical research has begun to scientifically investigate the therapeutic principles related to positioning children with cerebral palsy. For example, Nwaobi<a></a> has shown that under certain conditions approximately 90° of hip flexion tends to minimize spasticity and optimize upper extremity function. More recent work by the same group<a></a> has also shown the importance of posturing in order to improve respiratory function in children with cerebral palsy. Present studies are looking at the potential contributions of posturing and seating support to reduce asymmetrical spinal muscle activity, which is thought to be a caustive factor in spinal deformity in the child with cerebral palsy. Earlier work in Rehabilitation Engineering at Rancho Los Amigos Hospital with the spinal cord injured<a></a> established safe pressure level thresholds for the tissue over the bony prominences, such as the ischial, coccyx, and the greater trochanters. These thresholds provide guidelines for clinicians when fitting cushions for individuals who require pressure relief in order to prevent development of pressure sores. This early work has paved the way to more recent work that is now modifying and refining these principles.<a></a> Clinical programs employing these techniques have significantly reduced the onset and development of pressure sores. For example, Ferguson-Pell<a></a> has developed a computer program which assists therapists and others in decision-making regarding the selection and fitting of wheelchair cushions. This system combines and integrates much of the existing knowledge in terms of pressure sore prevention and guides the clinician towards a logical solution in which the chances for error are minimized. Research in recent years has also developed other useful clinical tools. Again, for the spinal cord injured, there are now at least three commercially available devices (Scimedics TIPE, Oxford Pressure Monitor) that will measure and record the pressure that exists between the seated person and his support surface.<a></a> Other seating approaches use what is termed a "simulator approach" to assist in evaluation and fabrication of seating devices. For example, the MPI system<a></a> for cerebral palsy in children uses a multiadjustable frame and quickly detachable seat and back modules to allow the therapist to rapidly simulate the definitive seating arrangement. Tools of this type help in terms of therapy decision making and the subsequent communication with the technical staff responsible for the fabrication and fit of the device. Another research effort<a></a> is concerned with the collection of anthropometric data derived from taking measurements of a patient positioned in a subjectively good posture. This information will eventually be useful in the design of standardized componentry that will better match the dimensions and shapes of the individual. Another outcome of research activities has been the classification of seating devices into five generic groups based on their methods of fabrication. Space does not permit detailed discussion of this classification scheme, especially since it has been published elsewhere.<a></a> The following table is a synopsis of the classification scheme as it applies primarily to individuals with cerebral palsy. The table also incorporates the needs groupings discussed previously. This overall scheme has proven useful in helping inexperienced clinicians to better understand the key issues involved to match a client's needs with available commercial options. In addition, the above classification scheme provides a framework through which a student in the field of specialized seating can begin to appreciate the differences that exist between the various technical options; and more importantly, what general needs each system is designed to meet. Further study involves learning the fabrication steps involved in the various systems, the positive and negative features associated each approach, and how features from various types can be combined to produce hybrid devices for meeting very specialized user needs. Probably the most significant advancement is that both research and clinical experiences are now being brought together in the form of educational manuals<a></a> and instructional courses. This development is a major step towards establishing the body of knowledge that is so crucial if specialized seating is to progress from an "art" to a recognized field of professional endeavor. <h3>Design And Development</h3> One of the obvious benefits of a research team working in close proximity to clinical activities is the potential for identification of "real" needs requiring technological intervention. Once these needs are identified, they then form the basis of design specifications which become the goals for the initial phase of the design and development process. Of all the endeavors involving rehabilitation engineering technology over the past twenty years, this step of defining what needs to be done has probably been the most poorly managed. There is probably no greater waste of technological resources than to solve problems for which there is either already an existing solution, or for which a solution cannot be sufficiently generalized to meet the needs of a commercially viable segment of the population. Assuming a "green light" is still on after the "real" needs are identified, the next step is to develop a prototype solution, which in this context could be a technique, a clinical tool, or a seating device. The development is usually very "fragile" at this time, and the sooner it can be subjected to clinical trials and critique in a positive environment the better. Invariably, modifications and design refinements are required until a solution is developed that is acceptable to both the clinicians and their test subjects. Ideally, the development should then be exposed to wider critique within environments different from those in which the development took place. Also, manufacturing, marketing, and costing analysis should take place in preparation for the preproduction phase. Assuming all these steps yield positive outcomes, an initial preproduction run is made so controlled evaluations can be done in selected external environments. The results of the external evaluations should be carefully monitored, documented and made available to the production design team. Over the past six years, four such developments from the University of Tennessee Rehabilitation Engineering Program have gone through this process, some more rigorously than others. These developments, the Modular Plastic Insert, the Spherical Thoracic Support, the Foam-In-Place, and the Bead Seat System, are now all commercial products being marketed by three different commercial firms. The final stages of the design and development process can vary depending on development and the resources of the commercial firm involved. In general, the market volume for seating devices is still relatively low. Therefore, it is important that the "front end" cost to the commercial firm be minimized. This can be accomplished in several ways by the development team. First, it is crucial that the design be "elegantly simple" so that it can be reproduced in relatively low volumes inexpensively. Secondly, design refinements and problems solving support should be provided well into the commercialization phase. Royalty arrangements and other "front end" type payments to the developer should be minimized and based on product sales. And finally, support in terms of providing educational materials, publications, and instructional seminars all assist in creating a receptive market place. <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-3.jpg">Table</a> <h3>Clinical Utilization</h3> This final phase of the R&D process is most often neglected, since it is usually not very exciting to the development team. From the R&D perspective, this design activity addresses those features of the development that will make it an attractive alternative to existing methods or devices being used. Again, development of instructional materials, provision of evaluation prototypes to "trend setters" and conducting instructional courses have already been mentioned. However, these supporting activities in themselves are usually not the key influencing factor. The development team must address the question, Why would a service provider working within a particular service delivery system choose the new development over another technical option? The answer usually is that the service provider can provide a higher quality service at equal or lower cost. Therefore, the new development must provide improved function to the user, and possibly increased status for the clinic/provider, at costs that can be paid for by the payment structure in which the service is provided. Failure by the design and development team to recognize the realities of the delivery system in which the development must be marketed is probably a primary reason why so many developments fail to make the transition from laboratory to widespread clinical application. <h3>Current Trends In Specialized Seating</h3> A 1985 survey of 26 facilities in 17 states<a></a> provides considerable insight into the state of maturity of the field of specialized seating. Of the 26 respondents, 12 were hospital based, six were state funded programs or institutions, and 8 were from private industry. The majority reported the use of plywood and foam technology (61 percent) or custom produced molded plastic parts (17 percent). The payment was received primarily from Medicaid, State Crippled Chil-drens Services, or private insurance carriers. The average number of clients fitted with new devices per year/facility was 185, with a total number fitted of 3,293. The importance of this survey, in the context of design and development, is that the majority of the facilities reported the use of basic "bench" fabricated technology (78 percent). This is not surprising since the majority of the new developments have only been available commercially for less than three years, and related educational programs are just beginning to have a significant clinical impact. Continuing education programs supported by the American Academy of Orthotists and Prosthetists, the Rehabilitation Engineering Society of North America, and institutions like the University of Tennessee Rehabilitation Engineering Program, Newington Children's Hospital, and Elizabethtown Children's Hospital, and private firms, such as Pin Dot Products, and Mobility Plus have been the primary sources for training in the new concepts and seating systems. As these efforts are expanded to involve larger numbers of clinicians, the newer technology in seating will permeate into the service delivery system. Of importance to the prosthetic and orthotic professions is that many of the professional skills and shop resources required to deliver improved specialized seating services are already in place. Also, specialized seating is now becoming recognized by many of the major third party payment sources as a recognized clinical service. The new commercial systems have been designed to be less labor intensive and to permit the provision of a quality product at a reduced cost. The overall result is that it is now feasible to invest in the education and inventory required to enter the field and expect to realize a return on that investment over a 2 to 3 year period. That is, specialized seating now presents a viable growth area for the prosthetic and orthotic field. Projecting into the future, one may speculate as to what developments are likely to take place in the field. As far as design and development, it is likely that refinements to the newer commercial products will preoccupy the efforts and available development resources over the next two to three years. New and ongoing basic research will continue to develop or validate positioning principles for the cerebral palsy population. We should see refinement and expansion in the use of computerized expert systems, primarily by institutional settings that are doing larger volumes of evaluation and prescription of seating devices. Educational courses should become more available on a regional basis through several of the participating professional associations. Hopefully, the American Academy of Orthotists and Prosthetists will continue its continuing education efforts in this area. Probably the most urgent and difficult issue to be resolved is the further education of third party payment sources, so that seating services can be provided and reimbursed throughout the country. In this regard, initial efforts by the Rehabilitation Engineering Society of North America appear promising. Similar, and probably coordinated, efforts by other organizations such as the American Occupational Therapy Association, the American Orthotic and Prosthetic Association, and the American Academy of Orthotists and Prosthetists would be most timely. In summary, research and development has made significant contributions to the field of specialized seating. This statement is based in the fact that there are not less than six new seating developments that have become available to the practitioner over the past five years. Basic studies, published articles, and manuals are establishing the foundation for educational activities that are becoming more widely disseminated. Third party payment sources have been slow to respond, but diverse efforts throughout the country have been successful at receiving reimbursement for seating services. In conclusion, more remains to be accomplished, and research and development can be expected to continue its contribution. Specialized seating is being transformed from an "art" to a recognized field of professional endeavor. References: <ol> <li>Nwaobi, O.M., Hobson, D.A., Trefler, E., "Hip Angle and Upper Extremity Movement Time in Children with Cerebral Palsy," Proceedings of the Eight Annual Conference of the Rehabilitation Engineering Society of North America, Memphis, Tennessee, June, 1985, pp. 39.</li> <li>Nwaobi, O.M., Smith, P.D., "Effect of Adaptive Seating on Pulmonary Function of Children with Cerebral Palsy," Develop. Med. Child Neurol., 28, 1986, pp. 351-354.</li> <li>Rodgers, J.E., Rewsick, J., "Program for Prevention of Tissue Breakdown," Annual Report, Rancho Los Amigos Hospital-REC, 1974/75, pp. 24-31.</li> <li>Paterson, R., "Is Pressure the Most Important Parameter," Proceedings, National Symposium on Care Treatment and Prevention of Decubitus Ulcers, Paralyzed Veterans of America, Washington, D.C., November, 1984, pp. 73-74.</li> <li>Ferguson-Pell, M., "Research Relating to Pressure Sore Prevention," Proceedings, National Symposium on Care Treatment and Prevention of Decubitus Ulcers, Paralyzed Veterans of America, Washington, D.C., November, 1984, pp. 53-54.</li> <li>—Scimedics, 170 Vander St., Units A & B, Corona, California 91720.  —TIPE-Tee Kay Applied Technology, 11915 Meadow Trail Lane, Stafford, Texas 77477.  —Oxford Pressure Monitor-International Medical Equipment Corporation, 11000 E. Rush Street, Suite 4, South El Monte, California 91733; (213) 350-1410.</li> <li>Modular Plastic Insert System marketed by Pin Dot Products, Inc., 2215 Belmont Street, Chicago, Illinois 60618.</li> <li>Reger, S., Hobson, D.A., "Seat Design Factors for Wheelchairs," Annual Report, University of Virginia- REC, 1985, pp. 25028. Charlottesville, Virginia.</li> <li>Hobson, D.A., Trefler, E., "Towards Matching Needs with Technical Approaches in Specialized Seating," Proceedings of the Seventh Annual Conference of the Rehabilitation Engineering Society of North America, June, 1984, Ottawa, Canada, pp. 486-488.</li> <li>Bergen, A., Colangelo, C, Positioning the Client with CNS Deficits: The Wheelchair and Other Adapted Equipment, Valhalla Rehabilitation Publications, Ltd., New York, 1982.</li> <li>Trefler, E. (Ed.), Seating for Children with Cerebral Palsy: A Resource Manual, University of Tennessee Center for the Health Sciences-Rehabilitation Engineering Program, Memphis, Tennessee, 1984.</li> <li>Ward, D., "Positioning the Handicapped Child for Function," Pin Dot Products, Chicago, Illinois, 1983.</li> <li>Holte, R., Shapcott, N., "A Survey of Wheelchair Seating Service Delivery Programs in the USA," Proceedings of the Eighth Annual Conference of Rehabilitation Engineering Society of North America, Memphis, Tennessee, June, 1985, pp. 157-159.</li> </ol> *Douglas A. Hobson, P. Eng. Douglas A. Hobson, P. Eng., is Technical Director at the Rehabilitation Engineering Center, for the University of Tennessee Health Science Center, 682 Court Avenue, Memphis, Tennessee 38163. <div style="width: 400px;"></div> Page Number(s) 122 - 129 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg Figure 3 TABLE http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research and Development Considerations and Engineering Perspective Creator An entity primarily responsible for making the resource Douglas A. Hobson, P. Eng. * https://staging.drfop.org/files/original/83648b0b711c382f195cc6bdaa6ab376.pdf 0d93f48bc78669170b984704c62a93b6 https://staging.drfop.org/files/original/51ee9f592b7e05126ec1e1eeec2c8f87.jpg e2e5e9a0ff445f9d032735045a3720b6 https://staging.drfop.org/files/original/cd87e6b8e63780897953794d33b1a88f.jpg 611cb47da091fa4220b0a84a5621f946 https://staging.drfop.org/files/original/ee0b549a0ac2ac1213258d9a7cf6bde6.jpg 13dc19f7b6d5ad835d26c445b688647b https://staging.drfop.org/files/original/9268367df64346914dfcd44ac7f8e280.jpg dccae3622fdb0d507ef88c33387b8ecf https://staging.drfop.org/files/original/748805f5859f6d87f7e3d2763cbd306e.jpg 4dd495359ed8ab36487f3abc0abf6221 https://staging.drfop.org/files/original/46b2b805c5456f6a9b6763b29e69dd6e.jpg c6ddf3929559d51cb9a4c5ac217b757d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_130.pdf Text Any textual data included in the document <h2>Adaptive Seating in Pediatrics</h2> <h5>Robert S. Lin, C.P.O. <a style="text-decoration: none;">*</a> Susan S. Lin, O.T.R. <a style="text-decoration: none;">*</a></h5> Adaptive seating represents one of the most complex areas of orthotic management. No other area of clinical practice requires the degree of knowledge and application of biomechanics, design engineering, tissue physiology, wheelchair design and the clinical manifestation of the many neuromuscular disorders involved. No other area of management effects as many aspects of the patient's life and treatment programs initiated by other professionals. Therefore, it is imperative to solicit input from all members of the multidisciplinary team (<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-1.jpg">Fig. 1</a>). The orthotist, physician, physical therapist, occupational therapist, educator, speech pathologist, social worker, psychologist, and wheelchair vendor must all take part in the prescription formulation (<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-2.jpg">Fig. 2</a>). Unfortunately, formal training for the aforementioned professionals provides very little, if any, information for the evaluation, assessment, and design of adaptive seating systems. <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-1.jpg">Figure 1.</a> Input from all members of the rehabilitation team is solicited. <h3>Development</h3> To compound the difficulty of equipment provision, pediatrics offers additional complications that aren't as prevalent in management of the adult population. Because the child is still undergoing physical development and maturation, the clinical picture he/she presents is expected to change. Some of the changes are due to growth (longitudinal and/or circumferential), yet some are due to disease progression, developmental abnormalities, and psycho-social problems that result from an increasing awareness of the physically handicapping condition. The adaptive seating system must be able to accommodate growth, environmental, and clinical changes in the child. This is particularly important in view of the funding restrictions on equipment replacement set by state or private payment sources. <h3>Education</h3> Another very important consideration in positioning a child is the child's educational goals and limitations. Aside from the physical barriers that a school may present, safe transportation to and from the school in a bus or van must be achieved. Few wheelchair bases are compatible with the lock down mechanism used by local transportation systems. This basic mechanical problem can hamper the educational process even before it begins. Once the child is in the school environment, many subtle factors can influence the success and acceptance of the adaptive seating system. These factors include whether or not the child is mainstreamed or in a special education program; the physical design of the school such as elevators for multilevel institutions and overall wheelchair accessibility; whether the communication needs of the child are met in a group setting; desk height, which can profoundly effect actual integration; whether medical/nursing facilities are available; and the kinds of recreational provisions offered for physical education. <h3>Information Collection</h3> Because the breadth of information concerning the patient can be extensive, there must be a mechanism to facilitate the collection of this critical data. It is imperative that the primary treating professionals provide this input because of familiarity with the patient and pre-established goals. The following In-take form was developed by author Susan Lin, O.T.R. in an effort to provide a concise patient data collection sheet. While the completion of this form can be time consuming, we have found that access to this information is essential (<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-3.jpg">Fig. 3</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-4.jpg">Fig. 4</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-5.jpg">Fig. 5</a>, and<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-6.jpg"> Fig. 6</a>). <h3>One Approach To Adaptive Equipment Provision</h3> In 1981, Newington Children's Hospital initiated its first formal Adaptive Equipment Clinic. The clinic is covered by seven members of the core team with three others forming the ancillary team. The core consists of a physician, orthotist, seating specialist, physical therapist, occupational therapist (who serves a dual function as the Adaptive Equipment Coordinator), speech pathologist, and social worker. The ancillary team is comprised of an educator, psychologist, and durable medical equipment vendor. The clinic is held one morning per week, divided into four one-hour appointments. Every third week of each month is reserved for a re-check clinic and follow-up care is provided every six months. The follow-up appointments are one half hour long, with eight patients checked in a morning. Prior to the first patient evaluation, the In-take forms for all new patients scheduled that day are reviewed and discussed. This enables us to establish a preliminary game plan as well as discuss certain confidential factors that may influence management. Formulation of the actual prescription occurs during the hour appointment, with various tasks assigned to appropriate team members to ensure follow-up of our recommendations. Over the past five years, the NCH Adaptive Equipment Clinic has provided an ideal forum for patient and equipment evaluation and prescription. The aforementioned protocol evolved slowly and has worked very well considering our resources, patient population, time and cost constraints. Those factors that have universal application are the need for a multidisciplinary approach, the need for follow-up appointments, and a sound understanding of seating principles. The recent emphasis on adaptive seating has finally enabled the orthotist to assist in management of the entire spectrum of patients, not just those who are candidates for ambulation. The appropriate seating system can be a therapeutic tool which enhances the quality of life and serves as an adjunct to other rehabilitation efforts. *Susan S. Lin, O.T.R. Susan Lin, O.T.R., is the Director of Occupational Therapy at Forestville Nursing Center and an Adaptive Equipment Consultant at Hudson Home Health Care. She was the primary developer of the Adaptive Equipment Clinic at Newington Children's Hospital and was the Hospital's first Adaptive Equipment Clinic Coordinator from 1981 to 1985. *Robert S. Lin, C.P.O. Robert Lin is the Clinical Coordinator of Orthotics at Newington Children's Hospital, 181 East Cedar Street, Newington, Connecticut 06111. Page Number(s) 130 - 136 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-5.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/1986_04_130/1986_04_130-6.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 Adaptive Seating in Pediatrics Creator An entity primarily responsible for making the resource Robert S. Lin, C.P.O. * Susan S. Lin, O.T.R. *