5 20 371 https://staging.drfop.org/files/original/900c406bee3adcda50bf8b6267359ead.pdf df82042fb3ac474e9dedb922d4912194 https://staging.drfop.org/files/original/fe114a930bf052972f072f3dceff189a.jpg baf11ca27502acca8baaf54e3ca55687 https://staging.drfop.org/files/original/2bea6a4071dcb885ee29cf80b031c21d.jpg 495cb08e3d3b7f57cf3c08c8ab99bd81 https://staging.drfop.org/files/original/6ce3fbdbe8f4750a79fc8b18340555b4.jpg 863124825991da3ae0b5ba0c515a41e1 https://staging.drfop.org/files/original/022c06bc2eadf40c0f1e04c53578a7a1.jpg b890e5d134886cf5f9630c735ed31b4d https://staging.drfop.org/files/original/488da4aeb82fd8a32ad0e2ca277a641f.jpg bce900c1fcc880b0989b617b2ee94ea5 https://staging.drfop.org/files/original/3bf5f22ba09b4acc4594ca080bb9a838.jpg 95b37754f135d90549bda9247fbc0e23 https://staging.drfop.org/files/original/3d8f97204bb2bb16ed9d02d6d9f40501.jpg 03284aa41c6c0b02c4a6f995614ac73b https://staging.drfop.org/files/original/d634c2d774e6dd2826a9839c7f153913.jpg d5757b210e0771bb37226bdf6cc6bbe1 https://staging.drfop.org/files/original/362e4848532095e03dc40255afdfc1f2.jpg 42bc04ccce92bc21e883090f6981081a https://staging.drfop.org/files/original/bd7d7e55042feb7315cc9b240e582e1a.jpg 5cebe71dc1c91759df3936df3c824f98 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_025.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 25 - 34 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Army Medical Biomechanical Research Laboratory Porous Laminate Patellar-Tendon-Bearing Prosthesis</h2> <h5>Clyde M. E. Dolan, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>In warm or humid climates, the problem of heat and perspiration within a nonporous plastic laminate prosthesis covering a substantial area of the body is particularly troublesome. The accumulation of sweat in a patellar-tendon-bearing (PTB) socket or a shoulder cap, combined with the inability of the laminate to permit evaporation or diffusion of water vapor, frequently causes mild to severe discomfort and even skin lesions sufficiently severe to require that the use of the prosthesis be suspended. Moreover, when a rubber (Kemblo) and leather liner is used, the sweat may cause it to deteriorate.</p> <p>Initial efforts of the U.S. Army Medical Biomechanical Research Laboratory (AMBRL) to produce porous plastic laminates for prosthetic applications were well received when applied to upper-extremity devices; <a></a> but, when the same technique was applied to PTB prostheses, the strength and durability of the material proved to be inadequate <a></a> In addition, problems of low porosity, nonreproducibility, and increased fabrication time were cited as serious deficiencies in the technique. <a></a></p> <p>In 1966, AMBRL reported on the development of an epoxy porous laminate which when fabricated according to the instruction manual <a></a> offered the following claimed advantages over prior techniques utilizing polyester resins:</p> <ol> <li>The new laminates were two and one-half times stronger under laboratory test conditions.</li><li>The new technique produced laminates which were twice as porous as prior versions.</li><li>The fabrication procedure was simpler, required only one curing temperature, and could be reproduced more reliably.</li></ol> <h3>Description of the Technique</h3> <h4>Stump-Casting Procedures</h4> <p>The stump-casting and cast-modification procedures are essentially the same as those taught in the various prosthetics educational programs. However, the positive stump model is prepared for a suction lamination. This technique, which involves the use of a vacuum pump to make the PVA bag conform to the socket contours, is familiar to many pros-thetists but is not a routine procedure in the fabrication of a PTB socket with soft insert.</p> <h4>Fabrications Procdedures</h4> <p>The procedures for fabricating a porous epoxy laminate PTB socket with a soft distal end differ from those used in the polyester lamination system as follows: the utilization of Silastic Elastomer 385 and Foam Elastomer 386 to form the soft distal end, and the procedure of impregnating the Banlon and nylon stockinette with a predetermined quantity of resin mixture consisting of epoxy EPON, Versamid, pigment, and methylene chloride.</p> <p>Preimpregnation of the stockinette and evaporation of the solvent prior to layup result in a stronger, more porous socket.</p> <h3>Finishing Procedures</h3> <p>Standard finishing procedures are not used because they would reduce the porosity of the socket. A procedure in which indexing pins are used to align the porous shank with the socket is detailed in the 1963 AMBRL instruction manual <a></a> and is incorporated in the NYU revision of the 1966 AMBRL manual. <a></a></p> <p>The one variation from the AMBRL procedure that was introduced in the finishing process by NYU was the use of polyurethane as a buildup material over the socket instead of A.C. polyethylene wax (steps 51 and 52 in the 1966 AMBRL manual). Polyurethane foam was believed to offer the prosthetist a faster method for accomplishing the external buildup over the socket. The foam also permits the use of power equipment for shaping, which the wax does not.</p> <h3>Preliminary Evaluation</h3> <p>A preliminary evaluation completed at NYU in March 1967 <a></a> critically considered the epoxy porous laminate procedure in the following respects on the basis of four fittings on below-knee amputees: the fabrication process, amputee reactions, durability, and laboratory tests. The fittings were carried out in the New York metropolitan area during a period of very hot, humid weather in the summer of 1966, which afforded ideal conditions for investigation of amputee reactions to socket porosity.</p> <p>In summary, the conclusions of the preliminary evaluation were:</p> <p>That the May 1966 AMBRL instruction manual was generally clear and easy to follow. However, the finishing procedures lacked the completeness of those set forth in the June 1963 AMBRL manual. A revision of the former was prepared, incorporating details of this part of the technique. The procedures were consistent with accepted prosthetics practice, and no unusual equipment was necessary.</p> <p>That the actual time required for fabrication was approximately one and a quarter hours longer than that required for fabrication of the conventional PTB prosthesis. The bench time can be reduced somewhat if the suction hose is inserted into the oven, eliminating the necessity of setting up the undercut areas of the stump model prior to placement of the socket in the oven for curing.</p> <p>That the coloring and the finish of the experimental prostheses were uniform, and the porosity was highly acceptable. Since no socket liner is used in this procedure, but rather a soft distal end, the amputee's tolerance to a "hard" socket was incidentally investigated. None of the amputee subjects in this preliminary evaluation noted any adverse reaction to the lack of a soft insert. All reported a significant reduction in discomfort associated with perspiration during the period of wear, remarking that the stump socks were much less saturated at the end of the day.</p> <p>That the experimental prostheses were significantly lighter in weight, with an average reduction of 32 per cent. The prostheses showed no signs of breakdown or clogging of the pores over a six- to 12-month period of wear, and showed excellent retention of original conformation. All are still being worn satisfactorily after 18 months.</p> <p>On the basis of this preliminary evaluation, the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development recommended that a field study be initiated to evaluate the porous laminate technique on a broad sample of juvenile subjects.</p> <h3>Scope and Objectives of the Field Study</h3> <p>Six clinics (Atlanta, Birmingham, Durham, Memphis, New Orleans, and Orlando), all located in hot, humid climates in the southern and southeastern sections of the United States, were invited to send a prosthetist representative to a three-day course in the fabrication of the AMBRL porous laminate PTB prosthesis, conducted at New York University in May 1967. Each clinic agreed to fit five subjects during the summer of 1967 with porous PTB prostheses fabricated by or directly under the supervision of the prosthetist attending the course.</p> <p>The field study was designed to evaluate the AMBRL porous laminate used in the following respects:</p> <ol> <li>Fabrication procedures.</li><li>Subjective reactions (comfort and cosmesis).</li><li>Medical considerations (stump hygiene and skin condition).</li><li>Durability and adjustments.</li></ol> <h3>The Sample</h3> <p>The sample consisted of 20 subjects-11 males and nine females between four and 20 years of age. Five were from Atlanta, three from Birmingham, three from Durham, two from Memphis, and seven from New Orleans. There were seven right and ten left below-knee amputees, two bilateral amputees (one right below-knee and left Syme's; one bilateral below-knee), and one unspecified. Eleven of the amputations were congenital, ten acquired, and one unspecified. All subjects were experienced prosthesis wearers, the prior prosthesis having been worn for seven months to three years.</p> <p>The types of prostheses worn by these subjects prior to the study are listed as follows:</p> <table> <tbody><tr> <td> <p><b>PTB sockets</b></p> </td> </tr> <tr> <td> <p>With side joints and lacer, without liner</p> </td> <td> <p>   3</p> </td> </tr> <tr> <td> <p>With supracondylar cuff, with liner</p> </td> <td> <p>   8</p> </td> </tr> <tr> <td> <p>With supracondylar cuff, without liner</p> </td> <td> <p>   6</p> </td> </tr> <tr> <td> <p>Syme's prosthesis</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Other or unspecified</p> </td> <td> <p>   3</p> </td> </tr> <tr> <td> <p> </p> </td> <td> <p> </p> </td> </tr> <tr> <td> <p><b>TOTAL: </b></p> </td> <td> <p><b>  22</b></p> </td> </tr></tbody></table> <h3>Methodology</h3> <p>At least, five clinic visits by each amputee subject were required for the appropriate evaluations. An outline of the procedures follows.</p> <h4>First Visit (Screening and Prescription)</h4> <p>At the first visit, clinic personnel discussed the purpose of the study with patient and parents, indicating the type of data that would be requested. A porous laminate PTB prosthesis was to be prescribed at this time. For purposes of uniformity, all experimental limbs were to use supracondylar suspension. General biographical information was recorded, as well as subjective comments concerning the previously worn prosthesis.</p> <h4>Second Visit (Delivery)</h4> <p>The porous laminate prosthesis was delivered at the second visit, and initial reactions of the subject and the clinic team were recorded. The prosthetist's report was initiated and retained by the prosthetist for submission at the termination of the study, as a means of recording fabrication and maintenance problems.</p> <h4>Third Visit (One Month Postdelivery)</h4> <p>The child's stump was examined to ascertain if any dermatological changes had occurred which might be attributable to the porous socket. Subjective reactions to the experimental prosthesis and reactions of the subject to the prosthesis as compared with the previously worn prosthesis were recorded.</p> <p>At this time the experimental prosthesis was rendered nonporous by the application of Saran Wrap, duplicating the procedure used in the preliminary evaluation at NYU. The prosthesis was then worn under these conditions for a two-week period of hot weather.</p> <h4>Fourth Visit (After Wear with Saran Wrap)</h4> <p>The stump was examined for dermatological changes. Any differences reported by the subjects as a result of eliminating socket porosity were assessed. The Saran Wrap was then removed.</p> <h4>Fifth Visit (After Six Weeks' Wear of the Porous Prosthesis without Saran Wrap)</h4> <p>Subjective and comparative reaction were once more elicited. The prosthetist's report was submitted.</p> <h3>Field Study Results</h3> <p>During the NYU course of instruction in this technique, one prosthetist was adversely affected by the epoxy resin. The difficulty had been noted occasionally in earlier studies. The developer has recognized the potential hazard, and appropriate handling precautions must be carefully observed. <a style="text-decoration:none;">*</a></p> <p>The epoxy resins (EPON 815) and curing agents (T-l) and, to a lesser extent, Versamid 140, are primary skin irritants. When in contact with the skin for a sufficient period of time, these materials are capable of producing a contact dermatitis in most individuals. In a relatively few hypersensitive workers, they can produce an allergic type of dermatitis in a relatively short period of time.</p> <p>Intermittent skin contact with these materials will not usually cause a dermatitis among normal workers; however, because of the occasional hypersensitive individual who cannot always be identified in advance, the precautionary measures suggested above should be used at all times.</p> <p>In addition to the foregoing precautions, good general ventilation is highly recommended.</p> <p>The first case of dermatitis usually indicates that proper handling procedures are not being observed, although in a very hypersensitive individual this is not necessarily true. The dermatitis should be treated promptly, and the source of contact should be ascertained and eliminated. The rash may be alleviated in most instances by soaking with warm Burow's Solution for 15-30 min., three or four times daily. Rashes that do not respond to treatment should be seen by a physician</p> <p><i>Based upon Handling Precautions for the Resin-Solvent System Used for Preparing Porous Laminates, an intramural memorandum issued by AMBRL in May 1967.</i></p> <h4>Fabrication Procedures</h4> <p>Telephone contacts with the participating prosthetics facilities during the course of the field study indicated that, with one exception, the fabrication procedures posed no serious problems. One facility was unable to duplicate the procedures because of difficulties with equipment. (Adequate temperature control is mandatory for successful preparation; this facility's oven temperature could not be reliably maintained for precuring the layup material.) Prosthetists' fabrication reports were received from five of the participating clinics.</p> <p>All reports indicated that two or three additional hours were required to fabricate a porous PTB prosthesis. Phases of the process cited as time-consuming were the weighing, processing, and curing; breakouts and reassembly; finishing; and the preparation of the soft distal end.</p> <p>No criticisms were made of the instructions contained in the manual. The process, however, was evidently more demanding than the conventional technique. Close attention to accuracy and detail is essential for successful preparation of the porous laminate.</p> <p>The increased fabrication time and effort, the need for some special materials, and the necessity for adequately ventilated work areas may result in some cost increases. One clinic expressed concern about the attitude of the local state agency in this respect, and one prosthetist suggested that the increased cost be borne in mind when the prescription is written.</p> <h4>Reactions of Subjects and Clinic Personnel</h4> <p>The experimental limbs were generally considered superior to the previously worn prostheses in several respects. Initial reactions to the porous prostheses, elicited immediately after delivery, are shown in <b>Table 1</b> and <b>Table 2</b>. After a one-month period of wear, corresponding reactions of the subjects and the clinics were recorded; these results appear in <b>Table 3</b> and <b>Table 4</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Examination of <b>Table 2</b> and <b>Table 4</b> (comparative reactions) indicates few changes from the positive first impression as wear increased, with a trend toward more emphatic positive comments.</p> <p>One month after delivery, the patient, his parents, and the clinic were asked their preference between the previously worn prosthesis and the experimental prosthesis. The results are shown in <b>Table 5</b>. In addition, the clinics were asked if they would prescribe a porous laminate prosthesis for other patients. Three clinics said "Yes," one said "No," and one said "Probably."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After four weeks of wear, the prostheses were covered with Saran Wrap to eliminate the porosity of the sockets while leaving the prostheses intact. No change was made in fit, weight, alignment, or other factors that might affect reactions. The subjects were asked to wear the experimental limbs under these conditions for a two-week period of hot weather. Seventeen subjects reported data for this test period. The majority indicated that perceived heat within the socket increased and that perspiration became a problem (introducing dermatological problems and discomfort). <b>Table 6</b> lists the reactions of the subjects regarding the test period utilizing the Saran Wrap.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Comparison of <b>Table 6</b> with <b>Table 2</b> shows a significant change in the perception of heat within the socket. Of those subjects offering opinions, 90 per cent considered the experimental prosthesis very satisfactory or satisfactory prior to the application of Saran Wrap, and 10 per cent considered it unsatisfactory. With the Saran Wrap, only 27 per cent reported the prosthesis satisfactory, and 73 per cent considered it unsatisfactory or very unsatisfactory-certainly a very dramatic reversal of reactions on the part of the wearers.</p> <p>Since no changes were introduced in fit, weight, or alignment, it was not expected that perception of socket comfort would change significantly under the test conditions, except to the extent that comfort might be affected by heat in the socket. Prior to the test period 95 per cent reported satisfactory reactions to comfort, while 5 per cent considered the prosthesis unsatisfactory; with the use of Saran Wrap, 83 per cent considered the experimental limb satisfactory and 17 per cent unsatisfactory.</p> <p>An uninterrupted six-week wear period followed the study of the effects of the Saran Wrap covering. At this time, subjects and clinic teams were asked to submit a non-comparative assessment of the experimental prosthesis and a separate questionnaire comparing the experimental prosthesis to the one worn before the field study. The results appear in <b>Table 7</b> and <b>Table 8</b>. These data were received regarding 17 experimental prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After a three-month period of wear, subjects and clinics were asked to indicate preferences as to the type of prosthesis to be worn in the future (<b>Table 9</b>). When clinics were asked if they would recommend the porous laminate prosthesis for other patients, three said "Yes," one said "No," and one said "Possibly."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Medical Considerations</h4> <p>A definite decrease in stump hygiene difficulties was specifically reported for two subjects in the study, leading to a recommendation by one clinic that the porous laminate be considered in cases presenting dermato-logical problems. There were no instances of deterioration of stump condition that could be related to the porous laminate, although socket adjustments were required in some cases.</p> <h4>Durability and Adjustments</h4> <p>Two clinic chiefs and their prosthetists expressed doubt that the porous laminate prosthesis would be sufficiently durable for patients who give their prostheses extremely heavy use. No such problems were encountered in an 18-month follow-up of the adult patients participating in the original NYU study of the epoxy porous prosthesis. The developer implies that adequate strength can be provided with this technique, even for heavy subjects, although only limited supporting data for this contention are available.</p> <p>One prosthesis fitted with side joints and thigh corset, which compromised the requested supracondylar suspension, showed repeated breakdown. If side joints are to be provided, the porosity of a substantial socket area must be sacrificed in order to provide adequate strength. Consequently, porous lamination may not offer as significant an advantage for these patients. In view of this problem, reservation of the porous laminate procedure for the PTB-type of fitting without side joints may be indicated. This point merits further investigation.</p> <p>One prosthesis was reported to have de-laminated between the insert and the outer wall. However, it appears that this complaint referred to a failure of the bond between socket and shell and not to delamination <i>per se. </i>Two other prostheses showed marked wear during the period of study, although no functional problems were encountered.</p> <p>Adjustments are more difficult to perform on the porous laminate socket, since it is impossible to fill in an area without sacrificing porosity. It is also more difficult to relieve an area. Because the finished laminate is so much thinner than conventional products, reducing the area may render it too weak for normal use.</p> <h4>Discussion</h4> <p>The high level of acceptance of the experimental prosthesis is supported by repeated references to three principal factors.</p> <p>"Increased comfort" is a broad term which encompasses, both directly and indirectly, the decreased weight of the porous limbs compared to the previously worn prostheses, decreased perspiration (with concomitant dermatological improvement) and reduction of heat within the socket, and the added comfort of the soft distal end.</p> <h4>Weight</h4> <p>To confirm the subjective impression of lighter weight, the weights of previously worn prostheses and experimental prostheses were compared. <b>Table 10</b> indicates the percentage of weight reduction for the 14 prostheses where such data were available. It can be seen that the average reduction is approximately 25 per cent.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Perspiration and Heat</h4> <p>Approximately one-third of the reasons cited for the preference of the porous laminate for future use related to the diminution of perspiration and the perception of the experimental limb as cooler. The results of the two-week test period (experimental socket covered with Saran Wrap) dramatically illustrate the importance of socket porosity in this regard.</p> <h4>Soft Distal End</h4> <p>In their preliminary testing, both the developer and New York University found no serious problems occasioned by the change from an insert to a hard socket with soft distal end. The observation was borne out in the field study during which the incidental investigation of the soft distal end elicited several positive comments (one clinic, although recommending a standard laminate in the future fitting of a patient to provide greater durability, would recommend that the new prosthesis incorporate the soft distal end procedure).</p> <h4>Amputee and Clinic Reactions</h4> <p>Patients and their parents were almost unanimous in their acceptance of the porous prosthesis (nearly 95 per cent of the patients and their parents preferred the experimental technique), whereas the clinics exhibited much less enthusiasm. At the close of the study, only two of the five clinics would definitely prefer the porous laminate for future use. It is important to note that the two clinics which recommended the porous laminate for future use accounted for the fitting of 11 of the 17 subjects who completed this phase of the study. Reluctance to prescribe the porous laminate resulted in extremely limited samples from the three clinics who preferred the standard technique.</p> <p>Two of the clinics rejecting the porous laminate for the future use of the patients fitted in the study might, however, recommend the porous prosthesis for <i>other </i>patients. Therefore, only one clinic categorically rejected the experimental prosthesis.</p> <p>Several suggestions may be advanced to help resolve this apparent discrepancy of opinion. During the study, as early as one month postdelivery, four reports were received which indicated dissatisfaction with the appearance of the experimental limbs. The poor appearance was specifically related to difficulties in keeping the comparatively rough surface clean. It was noted that the porous prostheses tended to appear dirty after only a short period of use, with one experimental prosthesis being rejected for this reason. Interrogation cf adult patients involved in the preliminary laboratory study showed that the prostheses are in fact difficult to clean and that they gather varying amounts of dirt, but none of the patients spontaneously complained of this problem. It might be expected that children would be less sensitive to this problem than adults.</p> <p>A further explanation for the clinics' less emphatic endorsement may lie in the increased cost factors (due to two to three hours' increase in fabrication time and materials), the need for some specialized equipment, and the occasional allergenic reactions of shop personnel to the uncured resin-solvent system. Therefore, the prosthetists' reluctance to utilize the technique may have been transmitted to the clinics.</p> <h3>Summary</h3> <p>The AMBRL porous laminate technique as applied to the PTB prosthesis was evaluated over a three-month period on 20 children at five juvenile amputee clinics in the southern section of the country. Essential aspects investigated were the fabrication process, subjective reactions, medical considerations, adjustments, and durability.</p> <p>The data indicated that porous laminate PTB prostheses were generally well accepted by patients and parents but less so by clinic personnel. The developer's claims of reduced perspiration, added comfort, decreased der-matological problems, and lighter weight were generally corroborated; weight reduction was the most consistently reported advantage.</p> <p>Increased fabrication time and some increase in the complexity of the fabrication process were cited as problems. Cosmetic characteristics elicited both favorable and unfavorable remarks; the propensity of the porous laminate to collect and trap dirt particles caused some dissatisfaction, while the textured appearance of the porous laminate was preferred in some instances.</p> <p>Concern was expressed regarding the durability of the porous laminate, particularly when applied to a prosthesis which was subjected to arduous use, although the experimental evidence was apparently insufficient for such concern.</p> <p>Based upon patients' and parents' preference for the experimental limbs, including instances of improvement in stump condition, it appears that the porous laminate PTB is a significant and worthwhile addition to prosthetics technology. Other applications of the porous laminate may also be recommended, particularly for those patients with substantial body areas enclcsed within a socket, with severe perspiration problems, or where a lightweight prosthesis is indicated. Shoulder caps, transthoracic sockets, above- and below-elbow sockets, or hip-disarticulation and hemipelvectomy applications may be considered. Informal observations of several upper-extremity fittings have again indicated that the porous laminate offers distinct advantages in terms of decreased perspiration and weight.</p> <p><b>References:</b></p> <ol> <li>Dolan, Clyde M. E., <i>The AMBRL porous laminatepatellar-tendon-bearing prosthesis</i>, New York University, Prosthetics and Orthotics, Post-Graduate Medical School, March 1968.</li> <li>Hill, James T.,<i>A manual for the preparation of above and below elbow porous prostheses</i>, TechnicalReport 6204, Army Prosthetics Research Laboratory, Washington, D.C., January 1962.</li> <li>Hill, James T., and Fred Leonard, <i>Porous plasticlaminates for upper-extremity prostheses</i>, Artif. Limbs, Spring 1963, pp. 17-30.</li> <li>Plumb, Robert E., and Fred Leonard,<i> Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</li> <li>Plumb, Robert E., and John J. Urban, <i>Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, MR-62-62, Army Prosthetics Research Laboratory, Washington, D.C., November 1962.</li> <li>Plumb, Robert E., James T. Hill, and HenryMouhot, <i>Instruction manual for preparing a porous epoxy PTB socket with soft distal end</i>,Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966.</li> <li>Plumb, Robert E., James T. Hill, and HenryMouhot,<i> Instruction manual for preparing a porous epoxy PTB socket with soft distal end</i>, Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966 (as amended by New York University).</li> <li>New York University, Prosthetic and OrthoticStudies, School of Engineering and Science, <i>Preliminary evaluation of AMBRL porous laminate patellar tendon-bearing prosthesis</i>, May 1965.</li> <li>New York University, Prosthetic and OrthoticStudies, Post-Graduate Medical School,<i>Preliminary evaluation: AMBRL porous laminate PTB prosthesis</i>, March 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Disposable gloves should be worn when handling all resins and solvents. Face shield or goggles are advisable when pouring or mixing the resins.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">New York University, Prosthetic and OrthoticStudies, Post-Graduate Medical School,Preliminary evaluation: AMBRL porous laminate PTB prosthesis, March 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Plumb, Robert E., James T. Hill, and HenryMouhot, Instruction manual for preparing a porous epoxy PTB socket with soft distal end, Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966 (as amended by New York University).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Plumb, Robert E., James T. Hill, and HenryMouhot, Instruction manual for preparing a porous epoxy PTB socket with soft distal end,Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic and OrthoticStudies, School of Engineering and Science, Preliminary evaluation of AMBRL porous laminate patellar tendon-bearing prosthesis, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Plumb, Robert E., and John J. Urban, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, MR-62-62, Army Prosthetics Research Laboratory, Washington, D.C., November 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T.,A manual for the preparation of above and below elbow porous prostheses, TechnicalReport 6204, Army Prosthetics Research Laboratory, Washington, D.C., January 1962.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Hill, James T., and Fred Leonard, Porous plasticlaminates for upper-extremity prostheses, Artif. Limbs, Spring 1963, pp. 17-30.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Clyde M. E. Dolan, M.S. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, NYU Post-Graduate Medical School, 317 East 34th St., New York, NY. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-04.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-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 The Army Medical Biomechanical Research Laboratory Porous Laminate Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Clyde M. E. Dolan, M.S. * https://staging.drfop.org/files/original/1d1ceef5e0e7ae1a01db4bf1a14f920a.pdf 15dde9b5748aae3e70554e693a2ccc35 https://staging.drfop.org/files/original/7341a1c789bf50c28c6f291e6ce1b8f1.jpg a3415062e2c78119f25ba9e99a91aab7 https://staging.drfop.org/files/original/58d7d562a2d2d25b6b29f764f5d0cfb4.jpg 9323149b8c303a17391f937f755ab79f https://staging.drfop.org/files/original/91b42dd18f1fc3412b1263cdc9856b74.jpg 977982cad4750c82718536539f96a0c1 https://staging.drfop.org/files/original/6a553c553328022c82face981f32bc08.jpg 7be62c5f05196a9b3fcee0f6702c980c https://staging.drfop.org/files/original/be77138d9c5e8b93c403e5150d85485f.jpg b0ac7e722904c5644175eb02eb4e1fda https://staging.drfop.org/files/original/f9cc0bf598af3d0a6e01e53df4364432.jpg 43756341fd355ef896d2d087e0f4aa7d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_011.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 11 - 16 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_011.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_011.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Independent Control Harnessing in Upper Extremity Prosthetics</h2> <h5>Colin A. McLaurin, B.A.Sc. <a style="text-decoration:none;">*</a><br />Fred Sammons, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>Functionally, the well-designed and well-constructed body harness for an upper-extremity prosthesis serves a twofold purpose: first, it helps to hold the prosthesis in place; second, it transmits body power for operation of the prosthesis. </p> <p> For shoulder-disarticulation amputees and for high above-elbow amputees, the provision of an adequate functional harness presents a challenging problem particularly with respect to power transmission and control. The problem is especially difficult in the case of shoulder-disarticulation amputees because of the lack of a control source from humeral motion, which is the major source of power and control in the case of above-elbow amputees. The typical prosthesis for shoulder-disarticulation amputees utilizes shoulder motions and chest expansion. </p> <p>In the present limited state of the art of prosthetics, there are three minimal operations to be controlled in an upper-extremity prosthesis: lifting of the forearm, operation of the terminal device, and management of the elbow lock. </p> <p> Here in the United States, the usual harnessing method for shoulder-disarticulation and above-elbow amputees utilizes the so-called "dual-control" system.<a></a> Lifting of the forearm of the prosthesis and operation of the terminal device are so linked mechanically that a single control motion (shoulder motion in the case of shoulder-disarticulation amputees arm flexion in the case of above-elbow amputee) produces either operation, dependending on weather the wlbow is locked or unlocked.</p> <p> In shoulder amputees, operation of the elbow lock must be managed by various special arrangements; for example, elevation of the shoulder, expansion of the chest, or use of the chin to nudge the elbow-lock control. In above-elbow amputees, operation of the elbow lock in a dual-control system depends upon extension of the humerus and depression of the shoulder. </p> <p> In a triple-control system, operation of the terminal device is separated from lifting of the forearm of the prosthesis. Triple control has been a recognized method of harnessing upper-extremity amputees for many years, and standard harness patterns providing triple control can be found quite readily in prosthetics literature.<a></a> However, triple-control harnessing in actual application is seldom seen in the United States, although it is used extensively in Germany and elsewhere. A possible reason for lack of use in the States is that in early trials it was difficult for the patients to operate the controls independently. </p> <p>Recent experiments at Xorthwestern University in fitting bilateral shoulder-disarticulation amputees have resulted in a harnessing system that provides acceptable function using standard components. Success with some five or six cases renewed interest in "independent-control" harnessing for above-elbow amputees. </p> <p> In describing this experimental harnessing for bilateral shoulder-disarticulation amputees and above-elbow amputees, the term "independent control," rather than "triple control," is used in order to avoid confusion with the standard harness patterns for triple control. </p> <h4> Bilateral Shoulder-Disarticulation Amputees </h4> <p> The limited availability of control sites constitutes a serious restriction on the effectiveness of a harnessing system for bilateral shoulder-disarticulation cases. Shoulder motions are available on both sides, and chest expansion can be utilized. However, there may be only sufficient control motions to obtain acceptable function from one prosthesis. In this event, activities which require the use of two hands, such as eating with a knife and fork, are necessarily precluded. </p> <p> Major consideration is given to operation of the terminal device and lifting the forearm of the prosthesis. In addition, the elbow lock must be operated and the functions of wrist and shoulder positioning should be supplied. </p> <p> Although there is but one prosthesis, two shoulder sockets are used. On the side of the amputee on which the prosthesis is suspended, the socket must, provide weight-bearing at the top. This socket may be fitted well down toward the lower edge of the rib cage in order to provide good stability. The other socket, or shoulder cap, is designed specifically to provide independent control of the terminal device, and it is made as small and as light as possible. (<b>Fig. 1</b> and <b>Fig. 2</b>) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Shoulder disarticulation on the right and humeral neck amputation on the left. Amputation followed electrical burns. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Bilateral amelia with scoliosis and short left leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> Shoulder Joint </h5> <p> A passively adjustable shoulder joint is essential for ease in putting on a coat, for positioning the prosthesis so that it does not interfere when sitting in an armchair, and for positioning the prosthesis for eating, writing, and similar tasks. Humeral abduction and flexion may be combined in a single axis joint. The friction plate shown in (<b>Fig. 2</b>) includes two wedge-shaped discs ("Wilson-Riblett wedges") which can be rotated during the preliminary fitting to provide the optimum plane of motion for the shoulder joint (<b>Fig. 3</b>). When this is obtained, thev are locked into position. The amount of friction can be regulated by a self-locking nut and washer which hold the assembly together. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Schematic drawing showing principle of "Wilson-Riblett wedges." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> Forearm Lift </h5> <p> Because the weight-bearing socket has been extended downward over the rib cage, the chest strap may be positioned around the center of the rib cage where maximum excursion can be obtained. The harness pattern shown in <b>Fig. 1</b> uses chest expansion in series with scapular abduction of the prosthesis-litted side to lift the forearm The forearm lift cable terminates in a swivel fitting at the lift tab. Since excursion is usually limited, the lift tab should be positioned close to the elbow joint. II this is not possible, a pulley may be titled to double the effect of the excursion. But. of course, such an arrangement doubles the input toree requirement In <b>Fig. 2</b>. the forearm lift cable is fitted internally in a special groove cut in the locking quadrant ol the elbow unit </p> <h5> Terminal Device </h5> <p> With the chest strap fastened about the middle ot his rib cage, the amputee is free to move the scapula of his nonprosthesis-bcaring shoulder. Thus, a small shoulder cap. carefully lilted to the scapula, can provide independent control of the terminal device. An anterior elastic strap is usually required to hold the shoulder cap in position. In <b>Fig. 2</b>, the available excursion was limited, and therefore a step-up pulley was necessarv in order to achieve full opening of the terminal device, </p> <h5> Elbow Lock </h5> <p> Since operation of the elbow lock requires a relatively small amount of excursion and force, there are several ways in which it can be accomplished. The patient shown in <b>Fig. 1</b> originally was fitted with a cable which ran from the elbow lock, around a pulley high on the shoulder, and thence down to a waist belt, so that shoulder elevation was used, alternately, to lock or to unlock the elbow. Later, this was replaced by the nudge control (<b>Fig. 1</b>), which the amputee preferred. </p> <p> For the patient shown in <b>Fig. 2</b>, the prominent acromioclavicular joint was utilized by cutting a hole in the anterior part of the socket and positioning a lever so that forward motion of the clavicle moved the lever forward and downward to develop tension in the elbow-lock cable. </p> <h5> Wrist Unit </h5> <p> A standard passive wrist-rotation unit, which permits pre-positioning by the amputee, was provided in both cases (<b>Fig. 1</b> and <b>Fig. 2</b>). </p> <p> For many tasks, such as toilet care, wrist flexion is important. Flexion can be provided by building it into the prosthetic forearm (<b>Fig. 2</b>), or by using a nudge control and Bowden cable to operate the lock on a standard wrist-flexion unit (<b>Fig. 1</b>). In the latter case the lock for the wrist-flexion unit is operated by relative motion between cable and housing. In this application the cable is stationary and the housing pushes to open the lock. To achieve this, the cable guides must be drilled out to allow the housing to slide freely. The inner cable passes through a hole drilled in the locking lever on the wrist-flexion unit and is anchored to a post screwed to the cover of the wrist unit (<b>Fig. 4</b>). When the wrist unit is unlocked by pressure on the nudge control, tension in the terminal-device cable will cause the wrist to flex. If the terminal-device cable is relaxed, gravity will cause the wrist to extend. Thus a measure of active wrist flexion is obtained. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Modifications of wrist-flexion unit for use with nudge control. Refer to Figure 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Capabilities and Limitations </h4> <p> The harnessing arrangement just described provides reasonably acceptable prosthetic function without the use of perineal straps. Independent control of the terminal device apart from operation of the elbow allows maximum opening of the terminal device in all positions of elbow flexion and improves the performance rate, since it is not necessary to lock the elbow before using the terminal device. Also, there is no tendency for the terminal device to open when the elbow is being flexed. </p> <p> The amputee who is a skilled foot user may be able to put on or take off the prosthesis without assistance, particularly if Velcro straps are used (<b>Fig. 2</b>). If the amputee is not a skilled foot user, assistance is required in fastening the chest strap snugly. </p> <p> The prime objective in fitting this type of prosthesis to a severely disabled amputee is to provide at least a minimum of self-sufficiency in public. Problems of selfdressing are complex, and their solution can scarcely be achieved without the use of external power and devices which have not yet been developed. </p> <h4> Above-Elbow Amputees </h4> <p> The same three minimal operations (namely, operation of the terminal device, lifting of the forearm, and management of the elbow lock) must be controlled in the prosthesis for a unilateral above-elbow amputee. To avoid restriction of the sound arm, the axilla loop of the harness should provide stabilization only. Hence the shoulder motions available for prosthetic use are those that remain on the amputated side. These are scapular abduction, humeral flexion, and humeral abduction. It is conceivable that humeral extension and humeral abduction could be harnessed, but an entirely different harnessing configuration would be required. As in the case of the shoulder-disarticulation amputee, shoulder elevation can be used only in conjunction with a perineal strap or a firm waistband. Most above-elbow amputees can separate scapular and humeral motion, and the harnessing described here is specifically designed to utilize this independent control. </p> <p> In this harnessing system, lifting of the forearm of the prosthesis is activated by scapular abduction. The anchor point is a ring held in the center of the back by the axilla loop. The reaction point is attached high on the socket, so as to be independent of humeral flexion. If the reaction point is placed centrally near the top edge of the socket, rotation is minimized and humeral abduction can be used to increase the excursion. The cable is passed through the reaction point and terminates in a swivel at the forearm lift tab, the length and position of which should be carefully adjusted to make full use of the available excursion. (The cable housing at the reaction point serves only as a cable guide.) The suspension strap and elbow-lock strap are attached as shown in <b>Fig. 5</b>, the configuration being essentially the same as that used in the Northwestern University dual-control ring-type harness. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Congenital above-elbow amputee fitted with independent control. Scapular abduction is used for forearm lift. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Humeral flexion and abduction are harnessed to provide operation of the terminal device. Experiments indicate that the harness pattern shown in <b>Fig. 5</b> is preferable to that in which the control cable is attached solely to the harness ring. A Bowden cable is used, with the housing anchored on the humeral section and on the forearm in a manner similar to that of a standard below-elbow fitting, so that operation of the terminal device is independent of flexion of the elbow. </p> <p> Optimum results are obtained when the shoulder motions are used in combination. Maximum lift of the forearm is achieved when the humerus is abducted at the same time that the scapula is abducted. This means that the elbow is held close in to the body as the forearm is lifted-a motion that is not ideal for certain tasks, such as switchboard operation. Scapular abduction also tends to affect the terminal-device cable. Thus, when the elbow is held in full flexion, there may be some tension induced in the terminal-device cable, making it difficult to hold the hook closed without locking the elbow. Conversely, the hook is very easy to open fully in this position. </p> <p> Three amputees have been fitted with this type of harness and have been wearing it routinely for several months. In addition, one bilateral amputee has been fitted with dual control on one arm and independent control on the other. All the subjects had been users of prostheses. They learned the basic controls with about an hour's training and became proficient at the end of a week. </p> <p> This harnessing provides excellent terminal-device function throughout the full range of elbow flexion, without locking or even stabilizing the elbow. Since the terminal device is independent of the forearm lift, there is no tendency for the hook to open when the forearm is being raised. However, near the point of full flexion, the interaction of the harness straps does require considerable effort to avoid opening the hook. Moreover, the force available for lifting the forearm is adequate only for the lightest loads. </p> <p> After several months' wear, one of the amputees rejected the harness and was refitted with a different type of independent control (<b>Fig. 6</b>). The operation of the terminal device was left unchanged, but the forearm-lift and elbow-lock straps were interchanged so that shoulder depression was used to raise the forearm, and scapular abduction to operate the lock. This seemed to provide greater force for lifting the forearm, provided the humerus is not flexed more than about 20 deg. Operation of the terminal device appeared to be slightly improved. The amputee is still wearing the prosthesis routinely. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Same amputee as shown in Figure 5 fitted so the shoulder depression is used to lift the forearm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li><p>Pursley, Robert J., <i>Haness patterns for upper-extremity prostheses</i>, Artificial Limbs, September 1955, p. 26. </p> </li> <li><p>Pursley, Robert J., <i>Harness patterns for upper-extremity prostheses</i>, Chap. 4 in <i>Orthopaedic appliances atlas</i>, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </p> </li> <li><p>Taylor, Craig L., <i>The biomechanics of control in upper-extremity prostheses</i>, Artificial Limbs, September 1955, p. 4. </p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Pursley, Robert J., Haness patterns for upper-extremity prostheses, Artificial Limbs, September 1955, p. 26. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Chap. 4 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, September 1955, p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Pursley, Robert J., Haness patterns for upper-extremity prostheses, Artificial Limbs, September 1955, p. 26. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Chap. 4 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, September 1955, p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Sammons, B.A. </b></td></tr><tr><td class="clsTextSmall">Research Therapist, Northwestern University Prosthetics Research Center, Chicago, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Colin A. McLaurin, B.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Project Director, Northwestern University Prosthetics Research Center; Research Associate, Department of Orthopedic Surgery, Northwestern University, Chicago, Ill</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-15.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-16.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-17.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-18.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-19.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-20.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 Independent Control Harnessing in Upper Extremity Prosthetics Creator An entity primarily responsible for making the resource Colin A. McLaurin, B.A.Sc. * Fred Sammons, B.A. * https://staging.drfop.org/files/original/7b641cc2c5efff0b13ea00554ff0524c.pdf 7625f33cbc3d4cfb83ec80cc57916490 https://staging.drfop.org/files/original/2b460a57bd7e3cefefc865722303cf8f.jpg f61aec4f5e8a68c88c0f3a7934ceba87 https://staging.drfop.org/files/original/158699aa9b82e6f73a8a2b652cb7d6fd.jpg fbdb3216dca3e4ba5c6f63d3222e452b https://staging.drfop.org/files/original/a68325f5b73646b5b593a8acb1bbd837.jpg f36901c352aad3d7bb8795ed8f2a6646 https://staging.drfop.org/files/original/cc30670084ad14b7609684a6454ac848.jpg 56d45a2b3659d1499e21a5da9829a307 https://staging.drfop.org/files/original/233ef95f73081b8f7c73a4ef388b3eae.jpg deffb0023ad714487dbd06e45b858dc0 https://staging.drfop.org/files/original/4696142a132cee2456d1fdc6faeb4ca9.jpg 89c9bf5a3b883b4293bb308ede78dbd4 https://staging.drfop.org/files/original/5bffdfe2ad0da8b9f5cc1981f71cf7c3.jpg fddc2597a8f63495c8c21845fe13d0a5 https://staging.drfop.org/files/original/d4520c3e41c8750ce3b30ffd8da8e2e5.jpg 71f93afbfae1921384420fd2c1e67617 https://staging.drfop.org/files/original/4fe5adb111706602874b94494623dc2d.jpg b885f7d3eededf4598d34efa04ba7d66 https://staging.drfop.org/files/original/8efb8897726cd8dd75a4539c0b6b2463.jpg e7714a18bbc9e8eacf2f3a4f34b3a9eb https://staging.drfop.org/files/original/0c9233c7ec883b727ccba3e73ba7b4db.jpg f5bcc44ab3a4478f32af9bf11055980c https://staging.drfop.org/files/original/03d2e12c78b332580cb171eb3d225e8f.jpg 83b50125b9d6bb8baff6767c478c78dc DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_022.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 22 - 28 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Evolution of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>Colin A. McLaurin, BASc. <a style="text-decoration:none;">*</a><br /></h5> <p>Not many people are amputees. Still fewer people are prosthetists. Not many amputees are hip-disarticulation cases. Hence, not many prosthetists are interested in hip-disarticulation prostheses except when occasion demands. That just about sums up the history of hip-disarticulation prosthetics.</p> <p>A more intensive look at the picture reveals two more or less standard approaches to the problem, but usually there are as many variations as there are limbshops. The accompanying illustrations (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, and <b>Fig. 6</b>) indicate the practice, if not the principle, of conventional fitting, together with some of the variants. A study of the principles of conventional fitting is even more revealing. The guiding one seems to be this: Take one standard above-kn ee leg and build on to it until it can be strapped to the amputee. The practice certainly bears this out. Even the term "tilting-table prosthesis" suggests working from the leg up to the stump, instead of beginning with the amputee, who properly should be the focal point in any attempt at rehabilitation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Saucer-type prosthesis for hip disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Tilting-table prosthesis for hip disarticulation, basic design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Variations in tilting-table prostheses: strap-and-roller medial support. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Variations in tilting-table prostheses: latch-type medial support, cross-sectional view. Above, standing; below, sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Variations in tilting-table prostheses: hip joint below socket. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Variations in tilting-table prostheses: track-and-roller joint. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This back-handed approach to problems is not something unique among limbfitters. The plumber is more interested in joining pipes than he is in the water requirements of a household. The airplane pilot is more concerned with the trim of the aircraft than with the comfort of the passengers' seats. The prosthetist's main interest lies in making a leg he can fit on the customer, and in so doing he has shown a considerable amount of ingenuity. Perhaps had the variations not been local in nature, more progress could have been made. Many fitters have come surprisingly close to the Canadian-type prosthesis, and no doubt others actually envisioned the basic principles without achieving the mechanical design.</p> <p>Generally speaking, the hip-disarticulation case has been considered very unfortunate when compared with other above-knee cases. Perhaps some of this attitude is owing to the fact that a great many cases are not of traumatic origin and that therefore the life expectancy is short. In any event, the result is that the amputee is not encouraged to expect much from his prosthesis. The usual complaints are mechanical in nature-rattling in the joints and the need for frequent repair. Accordingly, most innovations in the prostheses have been directed toward solving these mechanical problems, and more by chance than by design functional advantages evolved.</p> <p>Conventional hip-disarticulation prostheses are usually classified into two main categories, the saucer type and the more common tilting-table type.</p> <h4>The Saucer-Type Prosthesis</h4> <p>The saucer type of prosthesis, shown in <b>Fig. 1</b>, is essentially a standard above-knee leg with a saucer-shaped socket on top of the thigh. Suspension is by means of a single-axis joint and pelvic band and may include fore and <!--Page 23--> aft straps that pass over the shoulder. This type is most suitable for short-femur amputations because adequate stability is difficult to achieve without the additional bone structure. In accord with common practice with above-knee legs, the hip joint is placed well forward, thus providing some measure of stability. A lock may or may not be used at the hip joint. If a lock is used, it is of the semiautomatic type. A lever is pressed to release the lock for sitting, and the lock engages automatically on full extension. The lock provides stability (at some loss of function), but it offers mechanical difficulties because all the loads are fun-neled through the relatively small joint.</p> <h4>The Tilting-Table Prosthesis </h4> <p>Although not so simple or as light as the saucer type, the tilting-table prosthesis is more generally used because of the additional support. <b>Fig. 2</b> shows a typical prosthesis. A socket, usually of leather, is made to fit the stump and attached by a belt around the pelvis and often with a strap over the shoulder. The socket is articulated on the thigh section with a metal joint lateral to the acetabulum. Again the joint may or may not have a semiautomatic lock. Without a lock, the wearer has little control over the limb, most of the stability during the stance phase being afforded by friction between the socket and the thigh section.</p> <p>Because it is extremely difficult to make a hip joint strong enough to bear the entire load, contact between the socket and the medial edge of the thigh section is essential in weight-bearing, and this expedient is of course equally important when a lock is used. <b>Fig. 3</b> and <b>Fig. 4</b> illustrate two methods <!--Page 24--> that have been tried. In <b>Fig. 3</b>, a strap is fastened to the socket and passed under rollers attached near the medial brim of the thigh. These rollers also take the downward thrust of the socket, and a metal track may be attached to the socket for the rollers to bear upon. <b>Fig. 4</b> illustrates a dead-center latch mechanism. When the hip joint is fully extended, the latch flips by dead center and secures the socket to the thigh. A hip lock is necessary with this arrangement.</p> <p><b>Fig. 5</b> illustrates a fairly common departure in design. The walking function is identical, but the hip joint has been lowered to a position beneath the socket where a full-width bearing may be made much lighter. Because of the position of the joint directly below the center of gravity, however, a lock must be used. Along with the usual inconveniences and mechanical difficulties, this type also has distinct disadvantages in sitting. The thigh section is much shorter than normal, and the bulk of the joint raises the socket about an inch above chair height.</p> <!--Page 25--> <p><b>Fig. 6</b> shows a rather interesting deviation. This design uses a track-and-roller mechanism in which the center of rotation is a few inches lower and anterior to the acetabulum. The actual model seen by the writer was heavy and crude in construction so that binding of the rollers on the tracks prevented free motion, but it is worth noting since in principle it is almost identical to the present Canadian type, and it seems to be designed with a view toward improving function.</p> <h4>The U.S. Navy Hydraulic Prosthesis</h4> <p>At the close of World War II, the U. S. Navy designed and fitted an hydraulic prosthesis with the primary purpose of improving function. <b>Fig. 7</b> illustrates the main features of the device. The very large ball-bearing hip joint was made strong enough to bear all the weight, thus obtaining a free joint. An extension controlled the motion about the knee joint. The cylinder in turn was controlled by a valve which was either automatically or manually actuated. Normal motion about the hip joint allowed the piston to move slowly, as in an automobile shock absorber, and the knee joint was thus permitted to flex and extend with some damping. But fast rotation about the hip joint (as in stumbling) caused the valve to close and thus stabilized the knee. The manual control also closed the valve and locked the knee in any position. There were two disadvantages of this device- cost and weight. In addition, the application of hydraulics to prosthetics usually introduces problems of noise, leakage, and occasional erratic behavior.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Navy hydraulic prosthesis for hip disarticulation, schematic. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Influence of Materials</h4> <p>A review of prosthetics practice in the hip-disarticulation case would be incomplete without reference to materials. The shank and thigh members are usually of wood covered with rawhide as in standard above-knee legs, but because of the saving in weight aluminum-alloy members are preferable when available. Steel is the almost exclusive medium for hip joints and locks, but in the Navy hydraulic prosthesis aluminum alloy was used to save weight. Sockets are usually made of two layers of leather, with Celastic core for stiffness. Aluminum alloy and monel (an alloy of copper and nickel) have been quite successful. They are usually lighter, more sanitary, and easier to attach to the joints. Plastic laminates are light, strong, sanitary, and easily molded to complex shapes, and it is not surprising to find them successfully used in hip-disarticulation sockets. It was the ease of <!--Page 26--> fabrication that made possible the plastic socket with the wrap-around pelvic band (page 33).</p> <p>Generally speaking, the materials and the mechanical designs were chosen with a view toward solving the mechanical problems, and it was with this thought in mind that design study was begun at Sunnybrook Hospital in Toronto. The highlights of this study are worth noting as an illustration of how an indirect approach to a problem can achieve results.</p> <h4>Evolution of the Canadian Design</h4> <p>The primary objective at Sunnybrook was to construct a hip-disarticulation prosthesis that would avoid the stress concentrations in conventional locks and to provide a simple method for releasing the locks. The first experimental prosthesis employed a four-link mechanism, as shown in <b>Fig. 8</b>. The links were about 4 in. wide to provide adequate lateral strength. The socket was plastic and the thigh section aluminum alloy. It was intended that a posterior strap be used to lock the leg in full extension, but initial trials indicated adequate stability without a lock owing to the fact that at or near full extension the effective hip center was well forward of the center of gravity and because the posterior brim of the thigh prevented hyperextension. In order to achieve simplicity in assembly and to increase mechanical rigidity, the forward link was lengthened and made strong enough to support all the main loads (<b>Fig. 9</b>). The rear link thus acted only as a guide and could be made light and adjustable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: four-link mechanism. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: modified four-link mechanism. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One difficulty remained-there was a chopping action between the top of the thigh and the socket such that serious pinching could result. Owing to the geometry of the linkage system, the gap between the thigh and the socket was present whenever the thigh was neither fully flexed nor fully extended.</p> <p>The next step in the evolution was to extend the front link to include the knee joint and to replace the rear link with a simple rubber stop to prevent hyperextension. This final configuration, shown in <b>Fig. 10</b>, permitted the use of a single broad joint without locks. At first it was felt that the position of the stop would be critical, and accordingly the first unit included a stop that could easily be adjusted by the amputee. It was soon found that this feature was not critical and that <!--Page 27--> initial adjustment by shimming or grinding was adequate. The most apparent difficulty was the tendency for too long and too slow a stride, and thus the elastic webbing was added to restrain hip flexion. Cosmetic appearance was improved by a floating thigh cover (<b>Fig. 11</b>) made of horsehide and attached to the socket only. A foam-rubber liner was glued to the horsehide to give it stiffness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: final design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: floating thigh cover for cosmesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Apart from the mechanical simplicity of the new prosthesis, functional advantages soon became apparent. Little effort was required in the swing phase, and a full stride was easily obtained. Previously, with a locked hip joint, hip flexion was simulated either by pelvic rotation or by motion of the socket on the stump. The resultant gait was usually jerky and tiring, although some amputees had learned to walk surprisingly well. Since the amputee is actually "sitting" in the socket, complaints of discomfort were not common, but obtaining adequate security in the socket was a different matter.</p> <p>Too seldom have the bony prominences of the ilium been used for secure fitting. Usually a broad, leather pelvic belt, as in <b>Fig. 2</b>, was used for lateral support and a shoulder strap was added to prevent the socket from dropping down during the swing phase. The excessive weight of many prostheses necessitated the shoulder strap. The ischial seat is nearly always available for direct weight-bearing, and the areas for taking pressure elsewhere are large. If the socket is extended in the form of a band across the back of the pelvis and around to the opposite iliac crest, then three points of the innominate bones are firmly gripped, as shown in <b>Fig. 12</b>. Since these <!--Page 28--> three points are well spaced, excellent lateral stability is obtained. It is undesirable to have the socket extend above the iliac crests since doing so causes restriction and discomfort. Adequate vertical support can be obtained by ensuring a close fit in the area between the crests and the anterior-superior spine of each ilium.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Anterior view of socket-waistband showing three points where the skeletal structure is firmly gripped. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Conclusion</h4> <p>The Canadian-type prosthesis has been fitted to many amputees at various centers and over a period of several years. Stability with the free hip and knee joints is adequate if correct alignment is attained and if some gait training is provided. In a fall, the prosthesis is usually safer, since the joints collapse and prevent vaulting. One amputee has sustained several falls without injury to himself or the prosthesis. There are, however, several improvements possible in walking characteristics of the prosthesis. The elastic check-strap prevents excessive hip flexion, but some means should be provided for cadence control. Without restraining forces at the knee and hip, the leg tends to walk at its own pace as determined by its pendulum properties. Correctly applied friction or hydraulic devices could enhance the swing characteristics so that various speeds and strides could easily be attained. Furthermore, stability at the knee joint depends upon hyperextension. This means that knee flexion requires effort. A knee which would provide adequate stability at heel contact and yet flex easily when required would offer a big advantage. No doubt several years hence the present device will seem crude and clumsy; in the meantime it provides a light, strong, and relatively efficient prosthesis.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Colin A. McLaurin, BASc. </b></td></tr><tr><td class="clsTextSmall">Assistant Director, Prosthetics Research Center, Northwestern University, 401 E. Ohio St., Chicago; formerly Research Engineer, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-012.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 Evolution of the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Colin A. McLaurin, BASc. * https://staging.drfop.org/files/original/69dcd7caf7126245f67c576a23eed259.pdf b7b6157c3a00c22ce04eab5fcbcd9bd3 https://staging.drfop.org/files/original/cd52e34d44c4e57526a5fce138f7f698.jpg 7a198c7f047f773bbc6304cfba3cf5ca https://staging.drfop.org/files/original/5d7294a2a8e341f658d1da509204af9b.jpg 7bd95a76b3d734667480ec0dfa10627e https://staging.drfop.org/files/original/41aca07379059375c3292b724c20ad74.jpg 1d4152198663676bd39749aa3927f9a9 https://staging.drfop.org/files/original/67da595e2b69a4eddfa254d7f3e4af1b.jpg 37ef26f3aa707b94fe6ce8c247500085 https://staging.drfop.org/files/original/9b09d3285dd63986158fb6ad3ff17829.jpg 1834799a9a45cb6e9a6a14ebdaeaf347 https://staging.drfop.org/files/original/01becc70231689f01d3e23078ca3d426.jpg a30c1c89e6080e63e83f5a4d21259851 https://staging.drfop.org/files/original/c837aee0438447ad78993b03f0c6c200.jpg a8318e44f6a4c5f16bad1e856293ce4f https://staging.drfop.org/files/original/b42005d371ab6bcdfafd2938aebf111f.jpg e14968ee1a57f38cdb7f3d3f58869784 https://staging.drfop.org/files/original/6d838654a7a10c9c607154be00da4967.jpg 6487b2156f041d65856f1b7fbd7fce04 https://staging.drfop.org/files/original/c721165ea01198ee6aef4e31acd0fdac.jpg f2e09c1ac6e6f04fc5b0a5eb66bcbd18 https://staging.drfop.org/files/original/86e71ac88dc77c0fe807c5821fd82c2a.jpg c276be77977e747e8b61adff1578acb7 https://staging.drfop.org/files/original/594db7f923eba326a0a22d4a72240941.jpg 37b19234f934f0937579f96fc8254bfe https://staging.drfop.org/files/original/7911660ec28bd9831354b1be9725eb7d.jpg 83d75d5dd8bf9a0f175a066cfac8db09 https://staging.drfop.org/files/original/2ce46311925780543b5f166aae06734c.jpg 20250700f961fbca04d3a509217ae6f4 https://staging.drfop.org/files/original/51f64afd51e21f05fcb8be1cf6b566a6.jpg 78db7332d104e619ea0153d0faf72faa https://staging.drfop.org/files/original/67dbcbc2d6e97fce74975c8e5425df4d.jpg 9c9248069a2f1eeb39d500e952d2092d https://staging.drfop.org/files/original/d9cb0275b460dcb93313cf0a93e01dc4.jpg 1b87da727d718119cf9f5981c3028001 https://staging.drfop.org/files/original/bbe231086fad6f1a5604ed09094d496d.jpg 284ec9e3ade0dccb3ab0c62ed1ae442e https://staging.drfop.org/files/original/72335cd71fe5e3195663463b7ff672df.jpg 6e71c69d6cb6b4d01362c92378c81350 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_022.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 22 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Anatomy and Mechanics of the Human Hand</h2> <h5>Craig L Taylor, Ph.D. <a style="text-decoration:none;">*</a><br />Robert J. Schwarz, M.D <a style="text-decoration:none;">*</a><br /></h5> <p>It is obvious to all that the human hand represents a mechanism of the most intricate fashioning and one of great complexity and utility. But beyond this it is intimately correlated with the brain, both in the evolution of the species and in the development of the individual. Hence, to a degree we "think" and "feel" with our hands, and, in turn, our hands contribute to the mental processes of thought and feeling.</p> <p>In any mechanism, animate or inanimate, functional capabilities relate both to structural characteristics and to the nature of the control system available for management of functions singly or in multiple combinations. Just so with the human hand. Analysis of normal hand characteristics therefore requires an understanding of both sensory and mechanical features. Of course whole volumes have been written on hand anatomy, and it is not possible in a short article to describe all elements in detail. It is helpful, however, to review the basic construction of bones and joints and of the neuromuscular apparatus for governing motions and forces. Twenty four muscle groups, controlled by the various motor and sensory nerve pathways, with their rich potentialities for central connection, and acting upon a bone and joint system of great mechanical possibilities, give to the hand its capacity for innumerable patterns of action.</p> <h3>The Functional Structure of the Hand</h3> <h4>The Bones</h4> <p>The bones of the hand, shown in (<b>Fig. 1</b>), naturally group themselves into the carpus, comprising eight bones which make up the wrist and root of the hand, and the digits, each composed of its metacarpal and phalangeal segments (<b>Table 1</b>). The carpal bones are arranged in two rows, those in the more proximal row articulating with radius and ulna. Between the two is the intercarpal articulation. The bony conformation and ligamentous attachments are such as to prevent both lateral and dorsal volar translations but to allow participation in the major wrist motions (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Bones and articulations of the hand, including the interosseus muscles. A, volar view; B, dorsal view. For nomencla ture, see Tables 1 and 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. Bones and Joints of the Hand and Wrist </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Angles of rotation about the wrist. A, extension (or dorsiflexion); B, flexion (or volar flexion); C, radial flexion; D, ulnar flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In each of the digits, the anatomical design is essentially the same, with exceptions in the thumb. Metacarpals II through V articulate so closely with the adjacent carpal bones of the distal row that, although they are capable of some flexion and extension, independence of motion is very limited. The metacarpal shafts are arched to form the palm, and the distal ends are almost hemispherical to receive the concave curvature of the proximal ends of the first phalanges.</p> <p>The metacarpophalangeal joint exhibits a pattern seen also in the interphalangeal joints. As shown schematically in (<b>Fig. 3</b>), the virtual center of rotation lies approximately at the center of curvature of the distal end of the proximal member. The lateral aspects of the joint surfaces are narrowed and closely bound with ligaments, so that lateral rotation is small in the metacarpophalangeal joints and lacking entirely in the phalangeal articulations. Hence, the latter are typical hinge joints. The thumb differs from the other digits first in that the second phalanx is missing and, second, in that there is greater mobility in the carpometacarpal articulation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Section through radius, lunate, capitate, and the bony structure of digit III, showing virtual centers of rotation of each segment upon the next more proximal one. When the fist is clenched, the prominence of the knuckles is formed by the head of the more proximal member of each articulation. For nomenclature, see Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Muscles and Tendons</h4> <p>Most of the muscles of hand and wrist (<b>Table 2</b>) lie in the forearm and, narrowing into tendons, traverse the wrist to reach insertions in the bony or ligamentous components of the hand. Generally, the flexors (<b>Fig. 4</b>) arise from the medial epicondyle of the humerus, or from adjacent and volar aspects of the radius and ulna, and then course down the inside of the forearm. They are, therefore, in part supinators of the forearm (<b>Fig. 5</b>).The extensors (<b>Fig. 6</b>) of wrist and digits originate from the lateral epicondyle and parts of the ulna, pass down the dorsal side of the forearm, and thus assist in pronation. The thumb shares in the general flexor extensor scheme, but its extensors and abductors originate from mid and distal parts of radius and ulna.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Flexors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Forearm design as related to hand mobility. By virtue of this arrangement, the hand can be rotated through 180 deg., palm up to palm down, with the elbow flexed. With the arm fully extended, participation of shoulder and elbow allows the hand to be rotated through almost 360 deg., palm up to palm up. U, ulna; R, radius; P, pronation; S, supination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Extensors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tendons of wrist and hand pass through bony and ligamentous guide systems, as shown schematically in (<b>Fig. 7</b>). Flexor tendons pass through a "tunnel" bounded dorsally by carpal bones, laterally by the greater multangular and the projection of the hamate, and volarly by the tough transverse carpal ligament. Similarly, the dorsal carpal ligament guides the extensor tendons, and a system of sheaths serves as a guide for flexor and extensor tendons through the metacarpal and phalangeal regions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The anatomy of prehension. Schematic sections through digits I and III show essential relations of muscles and bones. The letters LG indicate the presence of ligamentous guides which channel close to the wrist the tendons of muscles originating in the forearm. Guide line X—X indicates relative position of carpal bases of thumb and fingers. For rest of nomenclature, see Tables 1 and 2. From Taylor.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The intrinsic muscles of the hand, <i>i.e., </i>those with both origin and insertion confined to wrist and hand (<b>Fig. 8</b>), are, with the exception of the abductors of thumb and little finger, specialized for the adduction of the digits and for opposition patterns such as making a fist, spherical grasp, and so on.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Volar intrinsic muscles of the hand. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Palmar and Digital Pads</h4> <p>The volar aspect of the palm and digits is covered with copious subcutaneous fat and a relatively thick skin so designed in a series of folds that it is capable of bending in prehension. The folds are disposed in such a way as to make for security of grasp, while the underlying fat furnishes padding for greater firmness in holding. Because, however, slipping of the skin over the subcutaneous fat would lead to insecure prehension, the folds are tightly bound down to the skeletal elements, much as mattresses and upholstered furniture are quilted or otherwise fastened to prevent slippage of the filler.</p> <p>In the hand, the volar skin is tied down by white fibrillar tissue connecting the sheaths of the flexor tendons to the deep layer of the dermis along the lateral and lower edges of the palmar fascia. The folds therefore vary with the relative lengths of the metacarpal bones and with the mutual relations of the sheaths of the tendons and the edge of the palmar fascia.</p> <p>The sulci, or furrows, are emphasized because the subcutaneous fat in any given area is restricted to the interval between the lines along which the skin is tied down. Thus pressure upon any individual montic ulus cannot displace the underlying soft tissue beyond the boundaries established by the fibrillar connections. The relative size of any particular eminence is an indication of the size of the muscle involved and of its relative development through usage, with the exception that the size of the hy pothenar eminence depends in part upon the prominence of the pisiform.</p> <h4>The Dorsal Integument</h4> <p>Unlike the volar surface, the dorsal side of the hand is covered with thin, soft, pliable skin and equally mobile subcutaneous tissue, both capable of yielding easily under tension. Because in flexion of the fingers and in making a fist the covering on the back of the hand must be able to stretch from wrist to fingernails, the dorsal skin is arranged in numerous minute redundancies, which, in the fiat of hand, are manifest in the typical transverse wrinkles, particularly over the phalangeal articulations. Special adaptations in the dorsal skin of the thumb accommodate the distinctive rotational planes of that digit about its carpometacarpal articulation. In the normal, healthy hand, the degree of redundancy in any given area is just such that all wrinkles are dispatched when the fist is clenched. Swelling in any area, dorsal or volar, inhibits flexion extension of the part affected.</p> <h4>Nerve and Blood Supply</h4> <p>Three principal nerves serve the muscles of the hand (<b>Fig. 9</b>). Nerve supply is indicated, except for minor variations and exceptions, in (<b>Table 3</b>). Each of these major nerve trunks diverges into countless smaller branches ending in the papillae of the palmar pads and dorsal skin, and the whole neuromuscular system is so coordinated in the brain that motor response to stimuli is ordinarily subconscious and reflex. Thus an object slipping from the grasp is automatically gripped more firmly, but not so firmly as to damage the hand itself. Noxious stimuli are rejected automatically, as when the fingers are withdrawn from an object uncomfortably hot.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Nerves supplying the hand. Top to bottom, ulnar nerve, median nerve, radial nerve. See Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The wrist and hand receive their blood supply from the radial and ulnar arteries, which run parallel with the bones concerned, enter the hand through the flexor "tunnel," and then join through a double arch system (<b>Fig. 10</b>). Small branches from the arches serve the digits. The major venous system comprises the basilic and cephalic veins superficially placed on the volar surface of the forearm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Blood supply to the upper extremity. A, above, medial view of the elbow. A, bottom, dorsal veins of the hand. B, superficial veins of the arm. C, arteries of the arm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Resting Hand Pattern</h3> <p>The resting hand assumes a characteristic posture, a feature easily seen when the hand hangs loosely at the side. The resting wrist takes a mid position in which, with respect to the extended forearm axis, it is dorsiflexed 35 deg. (<b>Fig. 11</b>). It is worth noting that this is the position of greatest prehensile force (<b>Fig. 12</b>, bottom). The mid position for radial or ulnar flexion appears to be such that the metacarpophalangeal joint center of digit III lies in the extended sagittal plane of the wrist (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The resting hand pattern. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12 Effect of forearm-hand angle upon wrist flexion and extension forces and upon prehension forces. Above, relationship between forearm-hand angle and maximum forces of wrist flexion and extension measured at the carpometacarpal joint. Heavy lines, flexion (volar flexion); light lines, extension (dorsal flexion). Solid lines, averages; dotted lines, standard deviations. Unpublished data, UCLA, 15 male subjects. Below, relationship between forearm-hand angle and maximum prehension force measured between thumb and opposing index and middle fingers grasping a 1/2-inch block. Right hand, eight normal male subjects. Solid line, average; dotted lines, standard deviations From a UC report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Typically, the conformation of fingers and thumb is similar to that shown for palmar prehension (<b>Fig. 13</b>), the fingers being more and more flexed from index to little finger. The relations between thumb, palm, and fingers are such as to permit grasp of a 1.75 in. cylinder crossing the palm at about 45 deg. to the radioulnar axis. Bunnell<a></a> considers this "an ancestral position ready for grasping limbs, weapons, or other creatures."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Six basic types of prehension, as defined by Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fixed Hand Adaptations</h3> <p>In thrusting or striking actions and the like, the hand may assume fixed and rigid postures while functioning with the arm in support. These represent nonspecialized functions in which the hand serves merely as an adapted "end of the arm." The various forms include the flat of hand, the clenched fist, the knuckle and digital support postures, and so on.</p> <h3>Wrist Mechanics</h3> <p>The wrist joint, composed of the radiocarpal and intercarpal articulations (<b>Fig. 1</b>), has an elliptical rotation field with the major axis in the dorsal volar excursion, the minor in the ulnar radial. No significant torsion occurs. Bunnell<a></a> gives the angular excursions about the radiocarpal and intercarpal articulation as shown in (<b>Table 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. Angular Extent of Wrist Flexions" </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rotation within the carpal bones during these movements is too complicated for brief treatment. Not only do the rotations occur at several articulating surfaces, but the virtual axes of rotation lie distal to the contact surfaces owing to gliding motions in the convex concave structure of the joints. Idealization of the motions into those of a simple lever, rotating about a fixed center, as implied in diagrams such as <b>Fig. 2</b>, can be justified only as a convenient approximation.</p> <p>The muscles traversing the wrist include those inserting into the carpus and metacarpus and those mediating flexion and extension of the phalanges. The latter contribute to the wrist action, particularly under loads. In such cases, the finger muscles develop reaction against the object held (or within the hand itself if the fist is clenched) and add their forces to wrist action. The forces, action, and grouping of these muscles are given in <b>Table 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. <br /> ^a From Fick. <a></a> <br /> ^b The palmaris longus, absent in about 15 percent of cases, is omitted from the summed Fick forces of volar flexion.<br /> ^c Averages from measurements of maximum forces normal to the hand, applied at the metacarpophalangeal joint, on 15 young males at the University of California at Los Angeles (unpublished data). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Prehension Patterns</h3> <p>It is evident equally from a study of the muscle bone joint anatomy and from observation of the postures and motions of the hand that an infinite variety of prehension patterns is possible. For purposes of analysis, however, it suffices to describe the principal types. Seeking a logical basis for defining the major prehension patterns, Keller et al.<a></a> found that the object contact pattern furnishes a satisfactory basis for classification. From &gt;photographic observation of the prehension patterns naturally assumed by individuals when (a) picking up and <i>(b) </i>holding for use common objects used in everyday life, three types were selected from among those originally classified by Schlesinger.<a></a> These, appearing in (<b>Fig. 13</b>), are palmar, tip, and lateral prehension, respectively. The frequency with which each of these types occurred in the investigation cited is given in (<b>Table 6</b>). While the relative percentages differ in the two types of action, the order of frequency with which the prehension patterns occurred is the same.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. Frequency or Prehension Patterns </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Mechanical Anatomical Basis or Prehension Patterns</h3> <p>It is convenient to analyze digital mechanics in terms of flexion extension variations in the digits, thumb postures, and variations in the radioulnar axis.</p> <h4>Individuation of Digital Flexion Extension</h4> <p>Insertion of flexor and extensor muscle systems into several major segments along the proximal distal axis provides a variety of flexion extension patterns in the digits. In <b>Fig. 7</b>, the essential components are shown schematically for digits I and III. With these attachments, fixation of carpal and metacarpal segments by cocontraction of flexor and extensor carpi muscles provides a firm base for independent movements and fixations of the phalangeal segments. Individual flexions of the second and terminal phalanges stem from separate flexor muscle (<b>Fig. 13</b>). The counterbalancing digital extensor inserts into the two most distal phalanges and, on contraction, rigidly extends the entire finger. Coordinated action between extensor and flexor groups, however, permits fixed intermediate positions of each segment of the system.</p> <p>Two common postures of this system may be pictured. In palmar prehension (<b>Fig. 13</b>), the carpal and metacarpal segments commonly fix the wrist in moderate extension, while the digital configuration, mostly metacarpophalangeal flexion coupled with only slight phalangeal flexion, indicates action of the long flexors, strongly modified by the lumbricals and interossei, which are in position not only to contribute to the metacarpophalangeal flexion but also to maintain the phalangeal xtension. In tip prehension, the action of muscles upon carpal and metacarpal bones is similar, but distributed flexion in all phalangeal segments indicates predominant flexor activity.</p> <h4>Thumb Versatility Patterns</h4> <p>The versatility of the thumb lies, first, in the variety of its flexion extension patterns and, second, in the adjustable, rotatory plane in which flexion extension can take place. The first of these is directly analogous to the digital system for the other four fingers, in that for any given metacarpal position there are numerous possible positions of the phalanges. The second effect is due to the relative mobility of the carpometacarpal joint, which allows the thumb to act in any plane necessary to oppose the digits. The principal oppositions are semidirect, as seen in palmar, tip, and spherical prehensions. Actually, in these cases the plane of the thumb action is inclined 45 to 60 deg. to the palmar plane. In lateral prehension, the plane is approximately parallel to the palmar plane.</p> <h4>Variations in the Radioulnar Axis of the Hand</h4> <p>A third principal mode of variation concerns cross hand alignments. Thus the metacarpophalangeal joints may be drawn into line, and with abducted thumb a flat hand position is assumed. At the other extreme, the hand is cupped for spherical prehension (<b>Fig. 13</b>) as the opponens muscles of thumb and little finger, aided by other adductors and flexors, act to pull these digits toward each other. Similar alignment occurs when a fist is made.</p> <h3>Hand Movements</h3> <p>The large number of muscles and joints of the hand obviously provides the equipment for numerous and varied patterns of movement. Not so evident, but equally important in determining complexity and dexterity of motion, are the large areas of the cerebral cortex given over to the coordination of motion and sensation in the hand. Thus, in the motor cortex the area devoted to the hands approximately equals the total area devoted to arms, trunk, and legs.<a></a> This circumstance ensures great potentiality for coordinated movement and for learning new activities. Similarly, the sensory areas are large, so that they determine such advanced functions as stereognosis, the ability to recognize the shape of an object simply by holding it in the hand. The great tactile sensitivity of the hand is, of course, in large part due to the rich supply of sense organs in the hand surface itself. The threshold for touch in the finger tip, for example, is 2 gm. per sq. mm., as compared to <i>33 </i>and 26 for the forearm and abdomen respectively.<a></a></p> <p>The three major types of movement described by Stetson and McDill<a></a> are in part represented in the hand. They include fixation movements including cocontractions; movements ranging from slow to rapid with control of direction, intensity, and rate; and ballistic movements.</p> <h4>Fixation Movements</h4> <p>In all of the types of prehension described, the hand assumes a fixed position. If the prehended object is unyielding, reactions to the flexion forces are afforded by the object. If the object is fragile, or the hand empty, the hand is maintained in any required prehensile posture by cocontractions of the opposing muscle groups.<a style="text-decoration:none;">*</a></p> <p>The characteristics of balanced muscular action when supporting in the hand loads which produce moments at the wrist have been studied electromyographically by Dempster and Finerty.<a></a> In general, when average potential amplitudes are used to characterize the electrical activity of the muscle, the curves of load action potential are linear. Frequencies range from 35 to 65 per sec. but bear no clear cut relationship to load. Typically, each of the muscles traversing the wrist was found to function as agonist, lateral stabilizer, or antagonist as the moment load was shifted from direct opposition at zero deg. to the 90 deg. and then to the 180 deg. positions. The magnitude of the action potentials associated with each of these roles is approximately in the order 4:2:1.</p> <h4>Slow and Rapid Movements</h4> <p>In movements ranging from slow to rapid, with control of direction, intensity, and rate, there is always some degree of cocontraction to ensure control and to permit changes in force and velocity. A net force in the muscles causes motion. In this category is a long list of activities, such as writing, sewing, tying knots, and pressing the keys of musical instruments. Included are most actions involving differential or integrated motions of the digits.</p> <p>It is of interest to note that the full capacity for these motions is seldom developed by the average individual. With intensive practice, significant increases in the facility of manipulation, even with simple operations, may be achieved, although individuals differ markedly in the amount of training gain. The average individual has latent potential for development of skill, as shown by the feats of manipulation occasionally evidenced. Knot tying, cigarette rolling, and similar complex manipulations may be performed with one hand, as often demonstrated by accomplished unilateral arm amputees. According to Tiffin<a></a>, dexterity differences are correlated neither with mental ability nor with hand shape or dimensions, but Cox<a></a> points out that they have an important effect on the performance of industrial assembly operations.</p> <h4>Ballistic Movements</h4> <p>Ballistic movements are rapid motions, usually repetitive, in which active muscular contractions begin the movement, giving momentum to the member, but cease or diminish their activity throughout the latter part of the motion. It is unlikely that, of themselves, the fingers utilize this type of motion to any marked degree. Barnes<a></a> reviews evidence that in repetitive work finger motions are more fatiguing, less accurate, and slower than are motions of the forearm. Consequently, in repetitive finger activities in which there is a ballistic element, such as piano playing, typing, and operating a telegraph key, wrist and elbow motions predominate while the fingers merely position themselves to strike the proper key.</p> <h3>Hand Dynamics</h3> <p>The hand muscles, their actions, and contractile forces are given in (<b>Table 5</b>) taken from Fick.<a></a> The total Fick force equals the sum mated forces of the individual muscles participating in the action. For each muscle the force is equal to the physiological cross section <i>(i.e., </i>the total cross section of the muscle taken normal to its fibers) multiplied by the force factor of 10 kg. per sq. cm., estimated by Fick to hold for human muscle. These forces are produced along the axis of the muscle and its tendon, but since the effective moment arm upon any of the wrist or hand joints is small, the <i>measured </i>isometric forces are only about 10 percent of the total force.</p> <p>Among the wrist actions, total forces and measured isometric forces assume the same rank order. The variation,. with wrist angle, of both flexor extensor forces in the wrist and of prehensile forces in the hand is of practical importance as well as theoretical interest. The prehensile force reaches a maximum at a wrist angle of about 145 deg. (<b>Fig. 12</b>, bottom). This is approximately the angle at which the maximum forces of wrist flexion and extension occur (<b>Fig. 12</b>, top). It is common experience that the wrist assumes this angle when very strong prehension is required. The lessened forces at wrist angles toward the extreme positions of flexion or extension are attributable to the well known force reductions in the isometric length tension curve as a muscle is markedly stretched or slackened.<a></a> The exception to this rule, seen in the augmented force of flexion at wrist angle 85 deg., apparently means that this degree of wrist extension does not stretch the flexor muscles beyond their force maximum.</p> <h3>Conclusion</h3> <p>This, briefly, constitutes the anatomical basis of hand mechanics, from which it can be seen that normal hand function is the result not only of a highly complex and versatile structural arrangement but also of an equally elaborate and fully automatic system of controls. As will be seen later (page 78), such considerations lay down the principal requirements and limiting factors in the design of reasonably successful hand substitutes. When, in the normal hand, any functional feature, either mechanical or sensory motor, is impaired, manipulative characteristics are reduced correspondingly. In the arm amputee, hand structural elements have been wholly lost, and the most delicate neuromuscular features, those in the hand itself, have been destroyed. Although the lost bone and joint mechanism can be simulated, adequate replacement of the control system defies present ingenuity. Lacking control comparable to that in the natural hand, present day artificial hands are necessarily limited in the mechanical details that can be utilized, which accounts for the fact that the regain in function currently possible in hand prostheses falls far short of duplicating the natural mechanism.</p> <h3>Acknowledgment</h3> <p>The anatomical drawings which accompany this article are the work of John Cassone, medical illustrator at the University of California, Los Angeles.</p> <p><b>References:</b></p> <ol> <li>Barnes, R. M., <i>Motion and time study</i>, Wiley, New York, 1937.</li> <li>Best, C. H., and N. B. Taylor, <i>Physiological basis of medical practice</i>, Williams and Wilkins, Baltimore, 1937. p. 1256.</li> <li>Best and Taylor, op. cit., p. 1418.</li> <li>Bunnell, Sterling, <i>Surgery of the hand</i>, Lippincott, Philadelphia, 1944.</li> <li>Cox, J. W., <i>Manual skill</i>, Cambridge University Press, 1934.</li> <li>Dempster, W. T., and J. C. Finerty, <i>Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study</i>, Am. J. Physiol., 150:596 (1947).</li> <li>Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke<i></i>, Dritter Teil, G. Fischer, Jena, 1911.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle</i>, Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Keller, A. D., C. L. Taylor, and V. Zahm, <i>Studies to determine the functional requirements for hand and arm prosthesis</i>, Department of Engineering, University of California at Los Angeles, 1947.</li> <li>Schlesinger, G., <i>Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen</i>, Springer, Berlin, 1919.</li> <li>Stetson, R. H, and J. A. McDill, <i>Mechanism of different types of movement</i>, Psych. Mono., 32(3): 18 (1923).</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity</i>, Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Tiffin, Joseph, <i>Industrial psychology</i>, Prentice-Hall, New York, 1947.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs</i>, 1947. Vol. II.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Barnes, R. M., Motion and time study, Wiley, New York, 1937.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Cox, J. W., Manual skill, Cambridge University Press, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Tiffin, Joseph, Industrial psychology, Prentice-Hall, New York, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Dempster, W. T., and J. C. Finerty, Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study, Am. J. Physiol., 150:596 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">There are many other examples of fixation stales, such as the open claw conformation of the fingers and the extended and rigid index finger for dialing a telephone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Stetson, R. H, and J. A. McDill, Mechanism of different types of movement, Psych. Mono., 32(3): 18 (1923).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Best, C. H., and N. B. Taylor, Physiological basis of medical practice, Williams and Wilkins, Baltimore, 1937. p. 1256.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Best and Taylor, op. cit., p. 1418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Predominance of palmar prehension in both activities accounts for adoption of this pattern in the design of modern artificial hands (page 86).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Keller, A. D., C. L. Taylor, and V. Zahm, Studies to determine the functional requirements for hand and arm prosthesis, Department of Engineering, University of California at Los Angeles, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Vol. II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert J. Schwarz, M.D </b></td></tr><tr><td class="clsTextSmall">Instructor in Otolaryngology, College of Medical Evangelists, Los Angeles; formerly Assistant in Engineering Research, University of California, l.os Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-13.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_022/table01.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_022/table02.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-17.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-18.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-20.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-21.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-22.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-24.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_022/table03.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-25.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-27.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-29.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-30.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_02_022/table04.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_02_022/table05.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_02_022/table06.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 Anatomy and Mechanics of the Human Hand Creator An entity primarily responsible for making the resource Craig L Taylor, Ph.D. * Robert J. Schwarz, M.D * https://staging.drfop.org/files/original/d3e07ca0af0348fd4c2e920c106b4c65.pdf 809d9e3993c31bb21b2a8dc9b7031253 https://staging.drfop.org/files/original/222baa00904d46e2a3f74ce88ede3447.jpg c7b121f400393dc467ed647aeacdac4e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_061.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 61 - 63 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_061.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_061.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience in Harnessing Extreme Arm Cases</h2> <h5>Craig L. Taylor, Ph. D. <a style="text-decoration:none;">*</a><br /></h5> <p>With recent developments in shoulder prostheses, including that for complete removal of the shoulder girdle, it is possible to fit all upper-extremity amputees with useful arm substitutes. But of course it does not follow that all patients with high amputations can obtain from the available harnessing resources a uniformly good level of prosthetic function. It is appropriate to review present experience with such cases in order to establish realistic guides for the fitter. Although there is only a limited number of upper-extremity amputees with multiple amputations or with amputations at very high levels, the UCLA Case Study<a></a> has accumulated a sufficient number to make tentative conclusions possible.</p> <p>Limitation in the potentialities of shoulder harness begins with the unilateral shoulder case of the disarticulation type. Unilateral humeral-neck amputees with an intact shoulder girdle have, in every case known, been able to manage the shoulder dual control, and with any of several elbow-lock arrangements they have been able to carry out all of the operations of the prosthesis. Further unilateral shoulder losses, or losses of both shoulders at various levels, entail such impairment of harnessable shoulder mobility that it is impossible to attain the operating effectiveness ordinarily to be expected from the major prosthetic controls. A review of several types of fittings and the results obtained indicates the nature of these limitations.</p> <h4>Unilateral Shoulder Amputees</h4> <p> In the unilateral shoulder amputee, limitation begins with the disarticulation because the leverage on the amputated side is then so reduced that biscapular shrug no longer gives the necessary excursion. With most men of average to large build, however, the results usually are satisfactory (<b>Table 1</b>). In the case of M.W., pelvic control was required. T.M., a large and broad-shouldered man, obtained good function despite large, but not complete, clavicle and scapula losses. With the fore-quarter case, P.H., the sound shoulder could not manage the full control, and the functional regain was decidedly marginal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bilateral Above-Elbow/Shoulder Combinations</h4> <p> No case of bilateral humeral-neck amputation has thus far come to notice, but the bilateral above-elbow/shoulder combination is comparatively frequent. Five cases of this type can be cited. All save one are at least moderately successful. The unsuccessful case, C.B., has a number of stump complications that have prevented a satisfactory result. Otherwise, good operation, one prosthesis at a time, is provided by harnessing modifications in which the elements of the shoulder-disarticulation harness from one side and of the figure-eight from the other are combined. It should be noted that in all these cases both shoulder girdles are intact, and there is in addition one humeral stump. Hence, shrug and arm-flexion controls can be managed normally.</p> <p>The first case of this type, L.S., is a young man, age 29, with a right above-elbow stump of 10 in. and a humeral-neck amputation on the left side. The musculature and mobility of both shoulders and of the right stump are good. Amputee L.S. is tall and slender but of moderately broad-shouldered build. He is fitted on the right with an above-elbow dual control, on the left with a modified shoulder-disarticulation harness with nudge control for elbow lock. He is rated as a good wearer and is independent in nearly all activities.</p> <p>The second case, C.B., is an elderly man, age 60. He has a right shoulder disarticulation and a left short humeral stump supplemented with a tibial graft. Neuromata in the shoulder area and tenderness about the tibial graft have made fitting difficult; trial fittings with numerous types of harness have not been successful. The age of the subject, recurrent shoulder pain, and habits of dependence have together prevented satisfactory results.</p> <p>Another case, M.C., is a young woman, age 36, with a right short above-elbow and a left humeral-neck stump, the latter supplemented with a tibial graft not yet ready for fitting. Meanwhile, amputee M.C. is operating well with the right prosthesis only. She has acquired skill in eating, drives a car, does housework, and is rated a good wearer generally. Future addition of the left prosthesis is uncertain.</p> <p>Amputee R.G. is a young man, age 31, with a right short above-elbow and a left humeralneck amputation. He is tall and rangy with broad shoulders. Bilateral pectoral muscle tunnels had been constructed, but they were eventually closed at the amputee's request. When last seen he was fitted with short above-elbow dual control on the right side and shoul-der-disarticulation dual control on the left. For a while the left elbow lock was operated by the pectoral tunnel, but the method of elbow-lock operation after removal of the tunnel is unknown. Over several years of observation this amputee was rated as a moderately good wearer and was independent in most personal activities.</p> <p>Finally, J.L. is a man, age 40, with a right above-elbow stump 9 in. long and a left amputation at the humeral neck. Of fairly tall and rangy body build with good shoulder and stump mobility, he was fitted with a right above-elbow dual control and a left basic shoulder-disarticulation harness, the left elbow lock being operated by a nudge control After fitting and training he attained a good level of performance and as far as is known continues to be a good wearer.</p> <h4>Bilateral Shoulder Disarticulation</h4> <p> The reduced shoulder width associated with the bilateral shoulder-disarticulation case so impairs scapular abduction and shoulder flexion that complete control of the prostheses is not possible. Full operation of the terminal device at elbow angles above 90 deg. cannot be managed with the dual control, and a lower level of operation must be accepted. The pelvic control remains a possibility, but this expedient has so many disadvantages of inconvenience, awkwardness, and discomfort that few if any amputees accept it for continuous use. Shoulder control can at best be unilateral only.</p> <p>Nevertheless, an acceptable level of function may result. For example, J.G. is an elderly man, age 63, with bilateral shoulder disarticulations. Of medium build and with rounded chest, he has to date been completely dependent on help from others. Fitting and care have been sporadic because of infrequent visits to the laboratory. He last was fitted unilaterally with a right prosthesis and a reaction cap on the left shoulder. Thus far the fit has been promising. At the last visit he had managed eating and other activities.</p> <p>With the congenital anomalies, amelia and phocomelia, control functions usually are considered as being the same as those for the shoulder-disarticulation case. Shoulder girdles are narrow because of the absence of humeral heads or owing to loose and nonarticulated rudimentary elements, so that basic shoulder control may not be adequate for bilateral function. In phocomelia, with both forearm and hand or only hand elements, additional help may often be obtained for secondary controls such as elbow-lock operation. In any event, these congenitals early develop "manipulation" with the feet, and these capabilities have not been matched, so far as is known, by any upper-extremity prosthesis.</p> <p><b>References:</b></p> <ol> <li>Gottlieb, M. S., <i>Final report of the UCLA upper extremity amputee case study, </i>Department of Engineering, University of California (Los Angeles), in preparation 1955.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Gottlieb, M. S., Final report of the UCLA upper extremity amputee case study, Department of Engineering, University of California (Los Angeles), in preparation 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_061/tmp48F-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Experience in Harnessing Extreme Arm Cases Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph. D. * https://staging.drfop.org/files/original/b76e176eea5ade74fc19b1a4179ee035.pdf 70fa24e8024de93a3dac3ead7a24a4c3 https://staging.drfop.org/files/original/8d4e4395448b88c9f47146d10e2bd761.jpg e7aecd53a8fb74f0db642462ee9eacbc DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_004.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 4 - 8 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Objectives of the Upper-Extremity Prosthetics Program</h2> <h5>Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The upper-extremity prosthetics program, under the sponsorship of the Advisory Committee on Artificial Limbs, National Research Council, has been a growing and evolving program from its inception in 1945. Its initial objectives were limited to time and motion study of amputees and to device invention and development. But from the vantage point of 1954 we may list many additional objectives that have been assumed according to the necessities of a national program dedicated to the welfare of the amputee. As new activities have been added, none of the original have been abandoned, although certain of the original ones have been reduced in relative emphasis and expenditure.</p> <p><b>Fig. 1</b> illustrates in schematic form the major phases of the upper-extremity program as they have waxed and waned over the years from 1946 to 1953. The scope and magnitude of these activities represent a program with few parallels in our peacetime economy. As is evident in <b>Fig. 1</b>, not all the activities were started (or even conceived) at the outset. But, as has been pointed out by Strong,<a style="text-decoration:none;">*</a> no one could predict at the outset the ramifications of a program dedicated to the tangible goal of putting new and improved prostheses on amputees. The appropriateness of this program under the auspices of the National Research Council was underscored by President Bronk, who praised the ACAL program as a fitting example of the service to the public welfare for which NRC was founded.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the upper-extremity prosthetics program, 1945-53. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fundamental Studies</h4> <p>The study of normal and amputee biomechanics underlies all improvement in prosthetic replacement. A continuous program of inquiry in this field is therefore essential. Although much of such research is undertaken without immediate practical goal, free inquiry brings to light ideas which find widespread application, as has already been demonstrated time and again. The continuous observation of arm motions and of prosthetic motions provides a nourishing bed of interest and information from which the application phases draw strength and purpose.</p> <p>The program of fundamental studies has featured research on normal motions, analyzed in terms of physical mechanics and in terms of industrial time and motion concepts. These investigations have built up a body of information on the patterns of motion, speeds, forces, and skills that is invaluable in conceiving, planning, and predicting the results of new developments. A special phase of this program has had to do with cineplasty, where the direct utilization of muscle force has remarkable potentialities for prosthetic replacement but where intimate knowledge of the mechanics of the muscle is required in order to obtain successful operation of the prosthesis. Knowledge of stump shrinkage, of finger forces, of external power controls, of accessory body mechanics, of mechanical stresses in the prosthesis during use—all these are fundamental to the proper assessment of normal and of amputee biomechanics.</p> <p>The objectives of the program of fundamental studies in the upper extremity may be summarized as:</p> <ol> <li>To study the performance of manipulative activities in normal individuals and to analyze the activities in terms of biomechanics and of time and motion criteria.</li><li>To compare the motions of amputees with pros-theses with similar motions of normals in order to define the erns of altered and substitute motions peculiar amputees.</li><li>To measure the forces and displacements of muscles and muscle groups in relation to cineplasty, harness controls, and external power controls.</li><li>To define the alterations in general body mechanics in amputees as a result of the asymmetrical loss body weight.</li></ol> <h4>Development of Prosthetic Devices</h4> <p>The "bread and butter" of the ACAL program is the development of improved prosthetic devices, and a major emphasis has always been placed upon this phase of the program. Development of each device originates in the need shown by fundamental studies or by experience with amputees. design, experimental fabrication, amputee test, and field evaluation are the successive steps through which each device must pass. The past and present development laboratories include Northrop Aircraft, Inc., the Army Prosthetics Research Laboratory, and the University of California at Los Angeles, but other agencies, such as New York University and many cooperating industry limbshops, function in the final evaluation phases.</p> <p>ACAL developments in prosthetic devices include new inventions and many adaptations of mechanisms and materials from other technical fields. Engineers have delved deep into the rich heritage of American technology to find applications of plastics, lightweight metals, and mechanisms that have immensely improved the structural and functional characteristics of upper-extremity prostheses. In short, the development objectives are:</p> <ol> <li>To invent, adapt, and apply new materials and mechanisms so as to add new functions, or to improve old functions of prostheses, seeking in the end to provide an armamentarium of devices to meet the needs of every amputee type.</li><li>To design and redesign prosthetic components for simplicity and ease of manufacture, and for durability, without loss of essential function.</li><li>To create a system of interchangeable components which may be singly prescribed for the individual amputee case, but which can be combined into a functionally integrated and an esthetically compatible prosthesis.</li><li>To incorporate cosmetic and anthropomorphic principles into basic design so that prostheses are not abnormally conspicuous and are pleasing from the standpoint of color, texture, and form.</li></ol> <h4>Industry Advisory Participation</h4> <p>From earliest days, ACAL has recognized the benefit that would accrue to its activities if the experienced "know-how" of the industry could be utilized in an effective way. To attain this goal, it was considered necessary to bring into the planning meetings of the ACAL group the counsel of leading prosthetists and limb manufacturers. Accordingly, three members of the limb industry were made members of the Upper-Extremity Technical Committee to serve at the national level, while in Los Angeles a local Industry Advisory Committee was set up to advise and aid the UCLA project. These cooperative ventures have proved to be of great mutual benefit, the objectives being briefly as follows:</p> <ol> <li>To learn from the industry the needs for device development, for advancement in prosthetics technology, and for improvement of amputee services.</li><li>To utilize the experience and judgment of members of the limb industry in determining policy and in planning cooperative ventures involving field application studies.</li></ol> <h4>Contributions to Prosthetics Technology</h4> <p>With the wealth of World War II technological development to draw upon, the ACAL program rapidly adopted new materials and practices, not only in the design and development of new prostheses but also in shop fitting and fabrication practices. Most outstanding of these innovations is the incorporation of plastics for prosthetic use. The principal laboratories under the program, APRL, Northrop Aircraft, Inc., and UCLA, have exemplified these uses, and their reports have been a source of information to the industry.</p> <p>The objectives are:</p> <ol> <li>To adapt new and different materials for use in fitting and fabrication.</li><li>To introduce into prosthetics practice methods of measurement and fabrication tending to improve quality of service and economic efficiency.</li></ol> <h4>Amputee Case Study</h4> <p>In the early stages, the ACAL program emphasized research and development on devices, and amputees necessarily were fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. It soon became apparent, however, that established practices in prescription, fitting, and training of amputees were highly variable and that, to round out consideration of all factors bearing on amputee rehabilitation, these practices themselves should become the subject of investigation. This objective was strengthened by the knowledge that no single design of prosthesis is superior for all amputees but rather that, of many types of equipment, the most suitable selection for a given amputee depends upon his individual personal, social, and occupational needs and desires. Accordingly, the Case Study Program was initiated at UCLA in 1950 and continued until 1952. The large amount of information on the 70 amputees in this study is being reduced for publication; much of it has been directly transferred into the Educational Program (see below).</p> <p>The case study of cineplastic amputees at APRL has followed in its major outline the procedures at UCLA, and much valuable information is being gathered on this important class of amputee.</p> <p>These programs serve an especially important role in bridging the gap between fundamental work in the laboratory and practice in the field. Prosthetics involves, in unique degree, a combination of science and technology with the practical arts. Every amputee is to some extent a special case. It has therefore been . necessary to incorporate the case-study phase in order to ensure the applicability of technical improvements.</p> <p>In concise form, the objectives of the Case Study Program may be stated as follows:</p> <ol> <li>To investigate the application of prostheses to a wide range of amputee types so that a rational procedure for prescription for the needs of the amputee can be formulated.</li><li>To test and develop the elements of physical and occupational therapy that apply to amputee rehabilitation and prosthetic use.</li><li>To discover the effect of occupation, education, recreational interest, and other personal factors of the amputee upon his prescription, fitting, and training.</li><li>To determine effective methods for evaluation of amputee service, not only pertaining to the quality of mechanical equipment but also to the results of training, to the end that the amputee obtains a truly functional prosthesis.</li></ol> <h4>Prosthetics Education</h4> <p>It has been a cardinal principle of the ACAL group that the products of its research, investigation, and development should be speedily disseminated to all technical and professional groups interested in applying such knowledge for the welfare of the amputee. The scope of these activities has steadily in-creased. Early discoveries were conveyed by means of technical reports which were primarily useful to the other member laboratories and to manufacturers within the industry. Later, as case study and other application phases of the program developed, the broader responsibility was assumed of supplying educational materials dealing with many aspects of technical and professional prosthetics service. Two volumes have been prepared. <i>Human Limbs and Their Substitutes</i> (McCraw-Hill, in press) supplies an authoritative reference on prosthetics, while the Manual of Upper-Extremity Prosthetics (University of California at Los Angeles, 1952) has been issued to serve as a shop guide for the practicing prosthetist.</p> <p>Valuable as the printed material has proved to be, it was found that the needs of the prosthetist for advanced training could not be met with sufficient rapidity and thoroughness. These craftsmen, lacking formal institutional training in their specialty, and with the highly variable backgrounds of apprentice training, displayed great need for direct instruction to bring "them up to the standard required by the new technology. Two other professional groups most concerned in amputee service, physical and occupational therapists and physicians and surgeons, were no less in need of learning the newer knowledge of prosthetics. This condition made it imperative to offer an accelerated advanced training in the theory and practical arts concerned in prosthetics.</p> <p>Accordingly, the Prosthetics Training Program was instituted at UCLA with the following objectives:</p> <ol> <li>To give for selected groups of prosthetists advanced training in the skills and knowledge needed to make and fit upper-extremity prostheses using many of the most recent refinements arising from research.</li><li>To give for selected groups of physical therapists and occupational therapists advanced training in the skills and knowledge needed to assist amputees in adjusting themselves physically, mentally, and vocationally to the use of the newer developments in upper-extremity prostheses.</li><li>To enable physicians and surgeons to expand their understanding of the possibilities and limitations of the more recent developments in prostheses and of some effective procedures for taking advantage of these developments.</li><li>To encourage the acceptance and practice of the "team approach" to the problem of prosthetic prescription, in which the physician or surgeon, as captain of the team, is assisted by professionally qualified physical therapists, occupational therapists, and prosthetists.</li></ol> <h4>Field Research Studies</h4> <p>To test the usefulness of the knowledge gathered during the ACAL research program, a field research project was instituted in Chicago during 1952. The intent was to determine whether the local rehabilitation people concerned with the problems of prosthetics-the physician, the therapist, and the prosthetist-would benefit from the new knowledge. Accordingly, a group of Chicago physicians, therapists, and prosthetists were invited to attend a "pilot" course in upper-extremity prosthetics at UCLA, the content of the course being based almost exclusively upon the research performed under the ACAL program.</p> <p>Upon completion of the training, a clinic-was established in Chicago, where a group of 50 amputees was processed in accordance with the information taught at UCLA. The status of each amputee was carefully evaluated both before and after clinic treatment. Results showed a dramatic and clear-cut improvement in the functional and psychological attributes of this group of amputees. Thus, initial field evaluation clearly demonstrated the practical usefulness of the research results when applied to amputees in the local situation.</p> <p>Upon completion of the Chicago study, and in close coordination with the educational program already described, nationwide field studies were instituted under the supervision of the Prosthetic Devices Study, New York University. The purposes of these studies, which are presently going on, are as follows:</p> <ol> <li>To ensure the proper application of the research findings to upper-extremity amputee cases throughout the country.</li><li>To provide the local clinics throughout the country with administrative and technical consultation so that assistance may be provided in the resolution of difficult problems.</li><li>To evaluate the effectiveness of these procedures when applied to amputees, in order to determine where problem areas still exist and thus to direct future research toward the resolution of these difficulties.</li></ol> <p>It is anticipated that, upon conclusion of the present field research program, studies will have been conducted in conjunction with clinics operating in some 40 of our largest communities.</p> <h4>Conclusion</h4> <p>As a result of the upper-extremity prosthetics program, arm amputees can now be provided with reasonably comfortable, functional prostheses. Studies indicate that between 80 and 90 percent of the arm amputees fitted during the UCLA Case Study Program and the Chicago Project continue to wear and use their prostheses. When this is compared with the 10-percent figure estimated for arm amputees throughout the country who wear prostheses, it appears that some measure of success has been achieved. But it is apparent to workers in this field that the progress made to date is merely a step in the proper direction and that we can expect continued improvement in all aspects of upper-extremity rehabilitation.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Bronk, D.W., President, National Academy of Sciences. Address to the Advisory Committee on Artificial Limbs, Annual Meeting, Washington, May 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Strong, F. S., Jr., The Artificial Limb Program: Five Years of Progress. Advisory Committee on Artificial Limbs, NRC, Washington, November 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering and Biophysics, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_004/January-1954-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Objectives of the Upper-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph.D. * https://staging.drfop.org/files/original/2af24d33498f903f19fea2c5675a74ef.pdf d4e6f2d65239910f25cf126d68e7c8dc https://staging.drfop.org/files/original/4d3ddcf7651fff9ec5dd9c3427c58e15.jpg 2749c27e2446e4f746ea4e1d8d08afea https://staging.drfop.org/files/original/eb71c2538c5e88109be6c357c40e60cd.jpg a33087cc766f88e31bed11c95885bb6e https://staging.drfop.org/files/original/92f0b57c8b3defb346a3497604e47f3f.jpg 603429119911e70056b4450ef18b92d0 https://staging.drfop.org/files/original/5f498a6651b7e9b8f1eec1ea73532e91.jpg 9fdf9004b81b54e8652950012ccb0165 https://staging.drfop.org/files/original/b041422d191f77298643b52ef852617e.jpg 17c5cb478f84c50ccb8cd4e0527884cd https://staging.drfop.org/files/original/7fe13473de8d4000ed8c8f18cd3c0b4d.jpg 2a4e79271e4ba7bbbe536c18ab728781 https://staging.drfop.org/files/original/2297ac77954f4047d113992c6d45458d.jpg 2cf1cf57dd83112d6fbeee8a32f2027e https://staging.drfop.org/files/original/e8e3e367a8c90615a071af926d0dcc43.jpg a5aa4351b6ee2371ba40f0cf38df6840 https://staging.drfop.org/files/original/aa16b41fd406f041938dd06c277015c2.jpg 649eaeff89a5184e2def9092077444fe https://staging.drfop.org/files/original/121e62ebcf3c71973c3482ab42e53c83.jpg 15b4270a6585a213d7aedf6a76d60520 https://staging.drfop.org/files/original/9a57f9be025587ccf0193133556036ad.jpg 168fdb2039020ed045f4a822c8e13c6b https://staging.drfop.org/files/original/d83a4fc2a02d05be889604c2340a00a2.jpg f4fc363ce2a8acfc59cc24e5042d33da https://staging.drfop.org/files/original/c60c52b30ad7a3259df529b2acf883a3.jpg 8ccb20f11781e2ba1dbbce79edefa8b0 https://staging.drfop.org/files/original/8a8b1b1c51d20c3232be371241d1e215.jpg 12ee4710b77effd0f0bd2c647a1b1aca https://staging.drfop.org/files/original/a876719fff8467e1a527e2a73d31a30b.jpg 2b985f3fea23eaa471be8fac044cb345 https://staging.drfop.org/files/original/6449892d298e50c73e338beea299bbc0.jpg ac35194aca22c469e31de504b9bed2b5 https://staging.drfop.org/files/original/5ed18cbfc520ac464095a32b721c6849.jpg 759e2b53115fae6bf241f4d450875a36 https://staging.drfop.org/files/original/076402ce0eaaee6760087a9c8a6b61a6.jpg 8100a1578a04f465b946f59287bb3d36 https://staging.drfop.org/files/original/ff64515284519fe251c8dd39ea00d384.jpg 74b1d12ca12689370d20ffc2f18789bd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_004.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 4 - 25 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of Control in Upper-Extremity Prostheses</h2> <h5>Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>In the rehabilitation of the upper-extremity amputee, structural replacement by prosthetic arm and hand is an obvious requirement, and it poses a comparatively easy task; functional replacement by remote control and by substitute mechanical apparatus is more elusive and hence infinitely harder. For the purposes of functional utility, remaining movements of upper arm, shoulder, and torso must be harnessed, and use must be made of a variety of mechanical devices which amplify remaining resources by alternators, springs, locks, and switching arrangements. The facility of control attained through this apparatus is the key to its ultimate value.</p> <p>The future of upper-extremity prosthetics depends upon an ever-increasing understanding of the mechanics of the human body by all who minister to the amputee-prosthetist, surgeon, and therapist alike. It must always be stressed that the final goal is an amputee who can function. Too often there is a tendency to put undue faith in the marvels of mechanism alone, when in fact it is the man-machine combination that determines performance. It is in this broad frame of reference that the biomechanical basis of upper-extremity control must be approached.</p> <h3>Prosthetics Anthropometry</h3> <h4>Surface Landmarks</h4> <p>If successful control is to be obtained, the various components of the prosthesis must be positioned with a good degree of accuracy.</p> <p>To do so requires reference points on the body, of which the most satisfactory are certain bony landmarks. Most of these skeletal prominences protrude to such an extent that location is easily possible by eye. Others require palpation, and this method should be used to verify observation in every case. The bones most concerned in upper-extremity anthropometry are the clavicle, the scapula, the humerus, the ulna, and the seventh cervical vertebra. Surface indications of protuberances, angles, or other features of these bones constitute the landmarks, the locations and definitions being given in <b>Fig. 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Bones and external landmarks in the upper extremity. Definitions: <i>seventh cervical vertebra, </i>most prominent vertebra in the neck region; <i>acromion, </i>extreme lateral edge of the bony shelf of the shoulder; <i>inferior angle of scapula, </i>lowest point on shoulder blade; <i>epicondyles, </i>lateral and medial bony points at the pivot of the elbow; <i>ulnar styloid, </i>projecting point on little-finger side of the wrist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Arm and Trunk Measurements</h4> <p>The typical male torso and upper extremity are shown in <b>Fig. 2</b>, which, together with <b>Table 1.</b>, was derived from average measurements on Army personnel.<a></a> Such an average form serves to establish harness patterns and control paths. The arm, forearm, and epicondyle-thumb lengths constitute the basis of sizing prostheses.<a></a> (In everyday language the word "arm" is of course taken to mean the entire upper extremity, or at least that portion between shoulder and wrist. In anatomical terms, "arm" is reserved specifically for the segment between shoulder and elbow, that between elbow and wrist being the "forearm." Although in the lower extremity the word "leg" commonly means the entire lower limb, whereas anatomically the "leg" is that segment between knee and ankle, confusion is easily avoided because we have the special word "shank." No such spare word is available to describe the humeral segment of the upper limb.-Ed). Arm length places the artificial elbow; forearm length locates the terminal device. The epicondyle-thumb length is an important over-all sizing reference because in the unilateral arm amputee it is customary to match hook length (and, in the case of the artificial hand, thumb length) to the length of the natural thumb <b>(Fig. 3)</b>.The bilateral arm amputee can be sized from body height by means of the Carlyle formulas<a></a>, which employ factors derived from average body proportions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic anthropometry of the male torso and <b>upper extremity. </b>See Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Correct lengths for upper-extremity prostheses. In the unilateral case, hook length is made to coincide with normal thumb length, as is also the thumb length of the artificial hand. For bilateral arm amputees, <i>A = </i>0.19 X (body height); <i>B + C </i>= 0.21 X (body height). After Carlyle (J). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional Anatomy</h4> <p>The human torso, shoulder, and upper extremity are exceedingly complex structures. In any dealing with these elements of anatomy, therefore, it is desirable to sort out from the mass of detail those features important to the particular area of study and application. Where prosthetic controls are concerned, the mechanism of movement is the central subject of consideration. This functional anatomy treats of the aspects of bone, joint, and muscle structure that together determine the modes and ranges of motion of the parts. It is a descriptive science, and while to escape dependence upon nomenclature is therefore impossible, the purpose here is to convey a basic understanding of the operation of the upper-extremity mechanisms without undue use of specialized terminology. In any case, the reader should have available basic anatomical references such as <i>Gray's Anatomy</i><a></a> or kinesiology texts such as those of Steindler<a></a> and of Hollinshead. <a></a></p> <h4>Elementary Motions of the Upper Extremity</h4> <p>The geometry of each joint is complex, and most movements involve an interaction of two or more joints. Consequently, a motion nomenclature based on joint movements would be unnecessarily complicated. More simply, the motion of each part upon its proximal joint may be described with respect to the principal planes which intersect at that joint. In this system, moreover, one may define a standard position in which the trunk is erect, the arms hang with their axes vertical, the elbows are flexed to 90 deg., and the wrist planes are vertical to assume the "shake-hands" position. <b>Fig. 4</b> presents the angular movements possible in the three planes of space. The shoulder-on-chest, arm-on-shoulder, and hand-on-wrist actions take place through two angles, as if moving about a universal joint. Geometrically, the arm motions are more precisely defined by a spherical coordinate system where the segment position is given by longitude and colatitude angles. For descriptive purposes, however, the anatomical nomenclature is commonly used. It should be recognized that, for multiaxial joints, flexion-extension and elevation-depression angles describe motions in the major orthogonal planes only, and intermediate angular excursions must be thought of as combinations of these motions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Simplified movement system in the upper extremity. Wrist flexion is omitted since ordinarily it is not involved in upper-extremity controls. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The simplified movement system depicted in <b>Fig. 4</b> is incomplete in many ways. Not included are such movements as twisting of the shoulder due to various scapular movements, anterior-posterior swings of the arm in positions of partial elevation, and the slightly conical surface of revolution of forearm flexion.(It deserves to be noted here that, taken literally, expressions such as "forearm flexion-extension," "arm flexion-extension," and "humeral flexion-extension" represent questionable nomenclature. To "flex" means to "bend." Limb segments do not bend very readily without breaking. Joints are <i>designed </i>for flexion. In the lower extremity, for example, one speaks not of "shank flexion" but of "knee flexion," not of "thigh flexion" but of "hip flexion." That is, one uses "flexion" or "extension" not with reference to motion of the distal segment but with reference to the more proximal joint. Although Webster accepts the expression "to flex the arm," he obviously uses the word "arm" in the everyday sense of meaning the entire upper extremity, or at least that portion between shoulder and wrist. Because this loose terminology in the upper extremity is so widely established, not only among workers in prosthetics, it is used throughout this issue of Artificial Limbs, with the understanding that "forearm flexion" means "elbow flexion," "arm flexion" and "humeral flexion" mean "flexion of the glenohumeral joint (and associated structures) " See page 9 <i>et seq.</i>-Ed.). These details may, however, be ignored in the interest of the simplicity of description that is adequate for the purposes of upper-extremity prosthetics.</p> <h4>The Shoulder Girdle</h4> <p><i>Skeletal Members and Joints</i></p> <p>The scapula and clavicle are the chief bones making up the shoulder girdle. Secondarily, the proximal portion of the humerus may be included, since the close interarticulation of all three bones at the shoulder joint gives a considerable degree of coordinated activity among them and also extends to the complex as a whole the actions of many of the muscles inserting on the individual members.</p> <p>Details of the skeletal anatomy involved are shown in <b>Fig. 5</b>. There are in the system two joints and one pseudo joint. In the sternoclavicular joint, the clavicle articulates with the sternum in a somewhat saddle-shaped juncture recessed in a concavity within the sternum. The biaxial surfaces permit movements in two planes. Ligaments crossing the joint prevent displacement of the clavicle anteriorly and laterally. The elevation-depression range is 50 to 60 deg., the flexion-extension range from 25 to 35 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Skeletal anatomy of the shoulder region, <i>a, </i>Anterior view. <i>b, </i>Posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the acromioclavicular joint, the distal end of the clavicle articulates with the scapula in an elliptical juncture which permits a ball-and-socket type of action. The acromioclavicular ligaments bind the joint directly. Strong ligaments from the clavicle to the coracoid process give important additional stabilization. The range of movement is small, being only about 10 deg. in the frontal and sagittal planes.</p> <p>The pseudo joint, the scapulothoracic, is a muscular suspension which holds the scapula against the thoracic wall but which at the same time permits translatory and rotatory movements. A large factor in maintaining this joint in position is barometric pressure, which is estimated to act upon it with a force of 170 lb.</p> <p><i>Muscles and Movements</i></p> <p>The complex arrangement of bony elements is rivaled by the involved nature of the muscles of the shoulder girdle and by the intricate ways in which they act upon it. The schematic view of <b>Fig. 6</b> presents the fundamentals. Elevation of the shoulder is seen to be brought about principally by elevators and downward rotators of the scapula, such as the upper trapezius, the levator scapulae, and the rhomboids. Although the rhomboids assist in elevation, they do not contribute to upward rotation. Depression of the shoulder is mediated by muscles inserted on the scapula, the clavicle, and the proximal end of the humerus. Anteriorly the lower fibers of the pectoralis major, the pectoralis minor, and the sub-clavius, and posteriorly the lower trapezius and latissimus, act as depressors.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Schematic kinesiology of the shoulder girdle. <i>L, </i>latissimus; <i>LS, </i>levator scapulae; <i>LT, </i>lower trapezius; <i>MT, </i>medial trapezius; <i>PM, </i>pectoralis major; <i>Pm, </i>pectoralis minor; <i>RM, </i>rhomboid major; <i>Rm, </i>rhomboid minor; <i>SA, </i>serratus anterior; <i>SC, </i>subclavius; <i>UT, </i>upper trapezius. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rotation of the scapula upward <i>(i.e., </i>right scapula, viewed from the rear, rotates counterclockwise) or downward <i>(i.e., </i>right scapula, viewed from the rear, rotates clockwise) is brought about by a special combination of the elevators and depressors. As shown in <b>Fig. 6</b>, two portions of the trapezius, together with the serratus, cause upward rotation. Conversely, the pectorals, the latissimus, and the rhomboids cooperate to cause downward rotation. As will be seen later (page 13), the mechanical principle of the couple applies in these rotatory actions upon the scapula.</p> <p>Flexion and extension of the shoulder involve as principal elements the abduction and adduction, respectively, of the scapula. The flexor muscles acting on the shoulder complex are the pectoralis major and minor, which swing the clavicle and acromion forward. The serratus anterior aids strongly by abducting the scapula. The extensors, placed posteriorly, include the latissimus, which pulls posteriorly and medially on the humerus, and the trapezius and rhomboids, which pull medially on the scapula.</p> <p>The forward and backward shrugging of the shoulders with abduction and adduction, together with some upward and downward rotation of the scapulae, constitutes a major control source. Even in above-elbow amputees who use humeral flexion for forearm lift and for terminal-device operation at low elbow angles (page 22), scapular abduction is utilized for terminal-device operation at large angles of elbow flexion <i>(e.g., </i>when the terminal device is near the mouth). In shoulder amputees, both these operations depend wholly upon scapular abduction augmented by upward rotation.</p> <h4>The Arm</h4> <p><i>The Humerus and the Glenohumeral Joint</i></p> <p>The humerus, together with its joint at the shoulder, comprises the skeletal machinery of the arm. As noted in <b>Fig. 4</b>, it is capable of flexion-extension, elevation-depression, and rotation upon its proximal joint. The glenoid cavity, a lateral process on the scapula, receives the spherical surface of the humeral head. The glenohumeral articulation is therefore of true ball-and-socket character. The fibrous joint capsule is remarkable in that it envelops the humeral head and the glenoid margins in complete but rather loose fashion, so that a wide range of movement is possible. To some extent barometric pressure, but to larger extent the musculature spanning the joint, is responsible for keeping the articular surfaces together in all angular positions. A group of muscles including the subscapularis, the supraspinatus, and the infraspinatus function principally in this holding action.</p> <p><i>Muscles and Movements</i></p> <p>The kinesiology of the arm is closely associated with that of the shoulder girdle, nearly all natural movements involving a coordinated movement between arm and shoulder. It is helpful, however, first to describe the pure movements of the arm. Schematics of the muscles acting upon the arm are presented in <b>Fig. 7</b>. Elevation is effected by the lateral deltoid and the supraspinatus, depression by the latissimus, the pectoralis major, the long head of the triceps, and the teres major. In both actions, the contributions of individual muscles differ according to the angle of the arm. And it should be noted that, with insertions near the pivot point of the humeral head, the rotatory moments are proportionately small, thus accounting for the large number of muscles necessary to give adequate joint torques. Arm flexion and extension are brought about by two groups of muscles. The biceps, the coraco-brachialis, the anterior deltoid, and the clavicular fibers of the pectoralis major mediate flexion, while the posterior deltoid, the long head of the triceps, the latissimus, and the teres major effect extension. Rotation of the arm depends upon muscles that insert on the surface of the humerus and then pass anteriorly or posteriorly around it to impart medial or lateral torsion. As would be expected, rotational forces are greatest when the arm hangs at the side; torque is reduced drastically when the arm is elevated over the head and the twisting angles of the muscles tend to disappear.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Schematic kinesiology of the arm. <i>AD, </i>anterior deltoid; <i>B, </i>biceps; <i>CB, </i>coracobrachialis; <i>IS, </i>infraspinatus; <i>L, </i>latissimus; <i>LD, </i>lateral deltoid; <i>PD, </i>posterior deltoid; <i>PM, </i>pectoralis major; <i>S, </i>subscapularis; <i>SS</i>, supra-spinatus; <i>T, </i>triceps; <i>TM, </i>teres major; <i>Tm, </i>teres minor. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Combined Arm and Shoulder Movements</i></p> <p>In most natural arm movements, such as arm elevation, arm flexion, forward reaching, and to-and-fro swings of the partially elevated arm, both arm and shoulder girdle participate. In full arm elevation of 180 deg., for example, 120 deg. are contributed by rotation of the arm on the glenohumeral joint, 60 deg. are contributed by upward rotation of the scapula.<a></a>In forward reaching, involving partial arm flexion, the shoulder flexes and the scapula abducts and rotates slightly. Properly managed, this motion, the common flexion control motion of both the above- and the below-elbow amputee (pages 19-22) can give marked gracefulness to prosthetic operation.</p> <h4>The Forearm</h4> <p><i>Skeletal Members</i></p> <p>The radius and ulna together constitute a forearm lever which can rotate about the elbow axis. By virtue of the arrangement at the proximal head of the radius and at the distal end of the ulna, the forearm can also carry out torsion about its longitudinal axis to produce wrist rotation. With the aid of the mobility at the shoulder and at the wrist, it is possible to place the hand in space in an almost unlimited number of positions. The skeletal anatomy of the elbow is shown in <b>Fig. 8</b>, the articulations being the ulno-humeral and the radiohumeral. Participating in forearm rotation is the radioulnar joint at the wrist.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The right elbow joint, viewed from in front. The thin capsular ligament is not shown. Note that the ulna, with its posteriorly projecting olecranon, forms a hinge joint with the humerus, while the head of the radius is free to rotate within the annular ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The ulnohumeral joint has an unusual structure. The complex surfaces of articulation between ulna and humerus are such that the axis of rotation of the forearm is not normal to the long axis of the humerus. As the elbow is flexed or extended, therefore, the forearm does not describe a plane. Instead, the ulna swings laterally as the elbow is extended, until at full extension the cubital angle is about 170 deg. Xevertheless, only small error is involved in considering the motion to be essentially that of a simple hinge with an axis of rotation perpendicular to ulna and humerus and allowing the ulna to swing through about 140 deg. of flexion.</p> <p>In the radiohumeral joint, the slightly concave proximal end of the radius articulates with the hemispherical capitulum placed somewhat laterally on the anterior surface of the distal end of the humerus. The radius is free to move with the ulna through the complete range of flexion and, in addition, to rotate with forearm pronation and supination. In the radioulnar joint, the distal end of the ulna forms a curved surface against which the radius opposes an articulating concavity. As the forearm goes through a pronation-supination range of about 170 deg., the radius "swings like a gate" about the distal end of the ulna.</p> <p><i>Muscles and Movements</i></p> <p>As shown in <b>Fig. 9</b>, the musculature for providing forearm flexion and extension is comparatively simple, while that for pronation-supination is somewhat more involved. Flexion of the forearm is effected principally by the biceps, originating on the scapula and inserting on the radius, and by the brachialis, spanning the elbow from humerus to ulna. Secondarily, the brachioradialis and other muscles, originating distally on the humerus and coursing down the forearm, contribute to flexion. Extension is largely the function of the triceps, originating on both the scapula and humerus and inserting on the leverlike olecranon process of the ulna. A small extensor action is added by the anconeus.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Schematic kinesiology of the forearm. <i>A, </i>anconeus; <i>B, </i>biceps; <i>BR, </i>brachialis; <i>BrR, </i>brachioradialis; <i>PT, </i>pronator teres; <i>PQ, </i>pronator quadratus; <i>Su, </i>supinator; <i>T, </i>triceps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rotation of the forearm is a function of many muscles. Some, such as the supinator, evidently are designed for the purpose, while others, as for example the finger flexors, have different principal functions, the contribution to forearm rotation being only incidental. <b>Fig. 9</b> presents the major rotatory muscles only. Supination is mediated by the brachioradialis, the supinator brevis, and the biceps, pronation by the pronators quadratus and teres. Of great importance to upper-extremity prosthetics is the fact that rotation of the forearm is a function of total forearm length. With successively shorter stumps, not only are the rotation limits of the radius and ulna reduced, but also the contributions of muscles are eliminated as their insertions are sectioned.</p> <h4>Musculoskeletal Mechanisms</h4> <p>The upper extremity having been considered from the standpoint of functional and descriptive anatomy, attention may now be turned to a more mechanical view of its operations. Typical elements of mechanism in the upper extremity include joints (bearing surfaces), joint-lining secretions (lubricants), bones (levers and couple members), tendons (transmission cables), and muscles (motors). The arrangement of these elements makes up a complex machinery capable of such diverse activities as precise orientation in space, performance of external work, fine digital manipulations, and so on.</p> <h4>Typical Joint Mechanics</h4> <p>The elbow joint embodies the essential structures of diarthrodial joints. The bearing surfaces are covered with a thin layer of articular cartilage that is continuous with the synovial membrane lining the whole joint capsule. Subsynovial pads of fat serve to fill up the changing spaces that occur during movement of the joint (<b>Fig. 10</b>). It is believed that these fatty deposits serve as "pad oilers" to maintain the continuous film of synovial fluid over the articular surfaces.<a></a> This fluid contains mucin (a glycoprotein which serves as a lubricant for the joint) and other material constituting a nutritional medium for the articular cartilage. Considerable uncertainty exists concerning the method of formation and distribution of the fluid to the joint, but its mechanical function is clear and the normal joint performs as a well-oiled bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Typical change in joint spaces with flexion-extension, as revealed by the elbow. Redrawn from Steindler <i>(17), </i>after Fick. <i>A, </i>Gap of the medial border of the olecranon surface with elbow in extreme extension. <i>B, </i>Gap of the lateral border of the olecranon in extreme flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bones and Their Mechanical Function</h4> <p>The bones of the upper extremity, besides forming a support for soft tissue, provide a system of levers which makes the arm an important mechanism for the performance of gross work, such as lifting, slinging, and thrusting. The arm bones serve further as positioners of the hand, in which other, finer bones constitute the intricate articulated framework of the manipulative mechanism. Two main features of bones merit discussion here-their internal composition and construction and their external shape and adaptations that permit them to serve as members of mechanical systems.</p> <p><i>Internal Structure</i></p> <p>There is much evidence that the gross internal structure of bone is eminently suited to withstand the mechanical stresses placed upon it by the compressive loads of weight-bearing, by the tensions of tendons and ligaments, and by the lateral pressures of adjacent tissues.<a></a>The nature and orientation of the trabeculae in cancellous bone have, for example, long been held, in theory, to provide the maximum strength along the lines of major stresses. This idea, originally suggested by von Meyer, has been championed by many, including Koch, who carried out a stress analysis on the femur.<a></a> Objections to the von Meyer theory have dealt largely with the frequent and incautious extension of the concept. It is now believed that genetic and growth factors determine the essential form and dimensions of bone. Mechanical stresses serve secondarily to mold and modify it to give added strength where stresses are greatest. One must grant from even a superficial examination of the internal structure of bone that Nature has done an admirable job of designing for maximum strength with minimum weight.</p> <p><i>Members of Mechanical Systems</i></p> <p>The second principal feature of bones, that of serving as rigid members in a complex of mechanical systems, is the one that has engaged the most attention. It is surprising that the simple lever concepts of Archimedes have persisted in anatomy and kinesiology texts to the present day. Thus, the forearm-flexor system is said to act as a third-class lever, the extensor system as a first-class lever. Although these assertions are of course true, both of these systems are, in the more complete language of Newtonian mechanics, parts of force-couple systems in which equal and opposite components of force are transmitted through the bones and joints (<b>Fig. 11</b>). Elft-man<a></a> has emphasized this view. The magnitude of the couple is given by the product of the force (either of the equal but opposite forces) and the distance between them, which also is numerically equal to the torque of the muscle force. The concept of the couple calls attention to the existence of the equal and opposite forces in joints and emphasizes the loads placed upon them by muscular work. Another and more complicated application of the couple is seen in scapular rotation. Here, as described by Inman <i>el al.</i><a></a> and as shown in <b>Fig. 12</b>, the pull of the lower fibers of the serratus anterior upon the scapula is such as to give it upward rotation, while the thrust of the clavicle, acting through the acromioclavicular joint, holds a pivot for the rotation. Simultaneously, the pull of the upper trapezius fibers causes the clavicle to undergo angular rotation about the sternoclavicular joint. The result is that, at least through the first 90 deg. of arm elevation, the motion is shared by coordinated angular rotations of scapula, clavicle, and humerus. As a basic part of this rotatory action, the scapula acts as the moment arm of a force couple, the trapezius and serratus providing components of force which are equal and opposite.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Force couples at the elbow. Tensile forces in biceps and brahialis are associated with equal, opposite, and parallel forces through the joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Muscle forces acting on the shoulder, anterior view. The trapezius, acting diagonally, gives a supportive component. <i>Fy</i>,<i>, </i>and a horizontal component, <i>Fx, </i>which together with the opposite force from the serratus, 5, comprise an upward rotatory force couple on the scapula. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Tendons and Muscles</h4> <p>The specific functions of tendons are to concentrate the pull of a muscle within a small transverse area, to allow muscles to act from a distance, and in some instances to transmit the pull of a muscle through a changed pathway. The mechanical importance of this tissue is nowhere more evident than in the arm, where a large degree of versatility of motion in the segment distal to each joint is preserved by "remoting" the action of muscles through slender, cablelike tendons over joints. By this means lines of pull are brought near the joint axes, thus providing a lever arm consistent with the tensile force of the muscle at all joint angles and also giving at low joint angles an increased angular motion for a given linear contraction. Other advantages of remoting the muscles are seen in the forearm and hand. In order to afford the variety and complexity of interdigital movements, many independent muscle units are necessary, and critical space problems are avoided because muscles such as the common flexors and extensors of the fingers are placed at some distance up the forearm.</p> <p>The predominant function of tendon as a tension member in series with muscle, which is a tension motor, is seen in early growth stages. An undifferentiated cellular reticulum of connective tissue is everywhere found in embryonic tissue. The parent cells are fibroblasts; they elaborate and extrude the collagenous material of which white fibers are made. <a></a> At this point the presence of mechanical tensions in the tissue influences the rate, amount, and direction of the resultant fiber formation. At maturity the tendon is composed almost entirely of white collagen fibers, closely packed in parallel bundles, to form a cablelike strand. It is contained within a sheath which forms a loose covering lubricated continuously by a mucinous fluid to reduce friction with surrounding tissues.</p> <p>Mutual adjustment of the characteristics of muscle and tendon is shown in many respects. The musculotendinous juncture varies with the arrangement of the muscle fiber. It shows a simple series arrangement for fusiform muscles like the biceps, or it comprises a distributed attachment zone by continuation of the tendon into intramuscular septa where pinni-form fibers may insert (<b>Fig. 13</b>). In some unexplained way the relative lengths of muscle and associated tendon are so composed that the shortening range of the muscle is that necessary to move the segment distal to the joint through its maximum range.<a></a> The capacity to adapt the ratio of muscle length to tendon length has been demonstrated in an experiment in which the pathway of the tibialis anterior tendon in the rabbit was shortened. The result was that the tendon shortened while the muscle lengthened to regain the normal joint range.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Muscle fiber patterns. <i>A, </i>Fusiform. <i>B, </i>Bipinniform. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The relative strengths of muscle and of tendon also show an approximate compatibility, the tensile strength of tendon, measured at from 8700 to 18,000 lb. per sq. in.<a></a>, being greater than that for muscle. Strength tests of excised muscle-tendon systems show that failure commonly occurs in the belly of the muscle, or at the musculotendinous juncture, or at the bone-tendon juncture, but never exclusively in the tendon itself. Analysis of clinical cases indicates that muscle is still the site of failure even when it is maximally tensed.<a></a> It is clear, then, that of the muscle-tendon combination the tendon is normally always the stronger.</p> <h4>Forearm-Fexor Mechanics</h4> <p>The forearm-flexor system is well suited to serve as an example of biomechanics because the bone-joint system comprises a simple uniaxial hinge while the flexor muscles, though five in number, can be reduced to a single equivalent muscle whose geometry and dynamics can be specified from measurement data. <b>Fig. 14</b> illustrates the lever system on which the equivalent muscle acts. The angle between the axis of the muscle and that of the forearm bones, <i>i.e., </i>the "angle of pull," theoretically ranges from 0 deg. at full extension to 90 deg. at 100 deg. of elbow angle, and since the moment arm is continuously proportional to the sine of the angle of pull the mechanical advantage of the lever also is proportional to it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Forearm-flexor mechanics. Insert gives the geometry of the idealized flexor system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are of course departures from this idealized geometry. For one thing, the angle of pull and the elbow angle are not exactly equal. Moreover, at small elbow angles the torque component does not actually drop to zero because the muscles must always pass over the elbow joint at some finite distance from its center. Finally, the force-length curve<a></a> of the equivalent muscle must also be taken intoaccount in expressing the effective torque. For these and other reasons, actual torque measurements take precedence over theoretical calculations, and the composite curve of <b>Fig. 14</b> has been plotted from the results of a number of investigators. Whereas the moment arm peaks at an elbow angle of 100 deg., the muscle force is declining throughout the elbow-flexion range, and the net effect, as reported by Miller ,<a></a> is a maximum torque of about 625 lb.-in. at from 80 to 90 deg. Clarke and Bailey<a></a> found a peak of about 400 lb.-in. at between 70 and 80 deg., and the author has obtained 550 lb.-in. just under 90 deg. in a group of subjects. Wilkie's data give a value of about 525 lb.-in. at 80 deg., measured on himself.<a></a> These variations can be explained as resulting from the effect of a limited sampling of an inherently variable characteristic. Greater consistency probably could be obtained in a larger series of measurements.</p> <h4>Maximum Torques in Major Aactions</h4> <p>Because they express the fundamental output characteristics, and because they are most easily measured, the muscle torques about the major joints represent the most significant and practical aspects of the statics and dynamics of the musculoskeletal system. Not only is muscular power a concept of uncertain validity but also it is very difficult to measure. The combined effect of muscle and lever, however, can easily be measured in many subjects, so that statistical stability can be achieved in the results. Because muscle agonists change length with joint angle, and because they are thus caused to work on different parts of their length-tension diagrams, joint torques vary as a function of joint angle. As demonstrated by Clarke<a></a>, this phenomenon, shown in <b>Fig. 14</b> for the forearm-flexor system, holds more or less for all major actions about the joints. But these details may be neglected in summarizing the maximum torques throughout the upper-extremity system (<b>Table. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Functional Role of Sockets</h4> <p>The socket is the foundation of the upper-extremity prosthesis. It obtains purchase upon the most distal segment of the remaining member and should be stable, though comfortable, in its fit with this member. The socket must bear weight both axially and in all lateral directions. It is the attachment member for mechanical components and for control guides and retainer points. Hence the socket must be a sound structural member as well as a custom-fit, body-mating part. Finally, the socket extends the control function of the member to which it is fitted, giving movement and direction to the prosthesis. In any discussion of prosthetic controls, therefore, the starting point is the socket.</p> <p>The requirement of formability and strength in sockets has been met satisfactorily by the introduction of polyester laminates.<a></a> These materials permit close matching of the stump impression, and variations in strength can be introduced by increasing the number of laminate layers. The double-wall construction<a></a> provides a stump-fitted inner wall, with an outer wall that can be designed to structural uniformity and cosmetic requirement. Sizing to achieve this aim has now been reduced to standard practice. <a></a> Finally, the texture and coloring of the plastic laminate can be controlled to achieve satisfactory cosmetic results.</p> <h4>The Below-Elbow Socket</h4> <p>The peculiar feature of the forearm, that pronation-supination is a function of the whole forearm length, places a special limitation on the below-elbow socket. Although for stability in flexion the whole remaining forearm stump is best sheathed in the socket, to do so prohibits forearm rotation. In the case of the longer below-elbow stumps, therefore, some sacrifice in stability can be afforded in the interest of retaining forearm rotation. The proximal portion of the socket is fitted loosely to give freedom for forearm rotation while the distal portion is fitted snugly to provide a stable grip. <b>Fig. 15</b> shows the amount of forearm rotation available at various levels of the natural forearm and that remaining in below-elbow amputees of various types. Because of torsion of the flesh, however, and because of slippage between the skin and the socket, effective socket rotation is lost in stumps which are only 50 percent of forearm length. The effective socket rotation remaining in the wrist-disarticulation case is only about 90 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Below-elbow amputee types, based on average forearm length, epicondyle to styloid. After Taylor <i>(18).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Further adaptations of below-elbow sockets to suit the functional requirements at the various levels are shown in <b>Fig. 16</b>. In the long below-elbow stump, the elliptical cross-section of the forearm near the wrist permits a "screw-driver" fit of the socket to yield the maximum in rotational stability. With the shorter stumps, the possibility of effective rotation is reduced and is lost completely at about 50 percent of forearm length. At this level, the problem of forearm rotation is outweighed by that of providing flexion stability. Dependence upon a rigid or semirigid hinge system is necessary in the short below-elbow stump, and finally, in the very short stump, effective forearm flexion is so reduced that a split socket with step-up hinge becomes a necessity.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Schematics of below-elbow prostheses. For each type, an insert gives the cross-sectional anatomy 1 in. from the end of the stump. Sections are taken from the normal anatomy of the forearm. Sockets, hinges, cuffs, and suspensions are for <i>a, </i>single socket; <i>b, </i>rotation type; <i>c, </i>double-wall socket; and <i>d, </i>split socket. After Taylor <i>(18).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The goal of below-elbow socket design is to regain as completely as possible the control function of the forearm, which includes <i>(a) </i>positioning of the hand by forearm flexion and <i>(b) </i>hand rotation by means of pronation-supination. In the below-elbow prosthesis, adequate forearm flexion is obtained rather easily; rotation is limited to the potential available in the longer stumps. Manual wrist rotation, of course, supplements the remaining natural rotation. In the below-elbow prosthesis, then, control of the terminal device in space depends in fair measure upon the role of the socket in preserving the residual flexion and rotation of the below-elbow stump.</p> <h4>The Above-Elbow Socket</h4> <p>Unlike the below-elbow case, the above-elbow stump presents no problem of diminishing rotation with diminishing stump length because arm rotation is confined wholly to the gleno-humeral joint. Socket design for the above-elbow case is therefore related principally to the requirement of fitting the stump closely so that the humeral lever can be fully effective in controlling the prosthesis. <b>Fig. 17</b> shows the minor variations corresponding to above-elbow type, including the elbow disarticulation. Sockets for the latter must take account of the bulbous end of the stump. They must provide snug fit around the epicondyle projections but maintain sufficient room in the region just above, where the stump cross-section is reduced, to permit insertion of the stump in the socket. In both the elbow-disarticulation and the standard above-elbow cases, the upper margin of the socket is terminated below the acromion for freedom of movement at the shoulder. In the short above-elbow case, the socket is carried up over the acromion to obtain additional stabilization and suspension from the shoulder, as required by the very limited stump area. The control function of the above-elbow socket is twofold. As in the below-elbow case, the socket extends the slump to the next more distal joint and thus gives range and direction to this component upon which the positioning of the still more distal segments depends. But in addition to this feature, the above-elbow socket also has a power function. Through its attachments to shoulders and torso, it provides the forces and displacements needed to produce forearm flexion, terminal-device operation, and elbow lock. To fulfill these functions, the socket must have stable purchase on the stump in both flexion and extension. Hence, for elbow-disarticulation and above-elbow types, the socket should continue to the axillary level; for short-above-elbow amputees, it should come up over the acromion (<b>Fig. 17</b>). Finally, medial and lateral rotation of the socket are necessary for further functional positioning. Close fit and good suspension are required to give stability in these actions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Schematics of above-elbow sockets, including elbow disarticulation. For each type, an insert gives the cross-sectional anatomy at the indicated level. Dashed lines show stump contour and inner wall of the socket. Standard and short above-elbow cases have a double-wall socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Shoulder Socket</h4> <p>In the range of amputation sites from transection of the humeral neck to complete removal of the shoulder girdle, the socket form changes from shoulder cap to thoracic saddle. As displayed in <b>Fig. 18</b>, the bearing area increases as the remaining shoulder elements are reduced; similarly, the amount of "build-out" needed to preserve shoulder outline increases with increasing amputation loss. With disarticulations and all more extreme losses, sectional plates may be introduced at the axillary parasagittal plane. This arrangement makes it possible to fabricate the prosthesis in two sections, a matter of considerable advantage to the limbmaker, and it also affords the functional advantage of a preposition swivel of the humeral section upon the saddle section to simulate flexion-extension of the arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematics of shoulder sockets. Solid lines show residual bony structure, dashed lines the body contour and inner wall of the socket. Disarticulation and forequarter sockets may be two-piece with sectional plates at <i>a.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The functional aspects of the shoulder socket are to some extent secondary to the structural; yet there are certain definite functional ends to be served. Shoulder and scapular mobility in elevation, flexion, and extension should be preserved to the highest possible degree. In humeral-neck and shoulder-disarticulation cases, aid can be given to the shrug control (biscapular abduction), and at least a small range of motion can be given to the elbow, but of course no such function can be expected in forequarter or partial-forequarter amputees.</p> <h4>Major Arm and Shoulder Controls</h4> <p>The common method of operation of upper-extremity prostheses is by means of shoulder harness which provides suspension and which also transmits force and excursion for control motions. In this manner such operations as forearm flexion-extension, terminal-device operation, and elbow lock are managed. <b>Fig. 19</b> presents the essential features of the major harness controls. In principle, each effective control must begin with a point stabilized on shoulder or torso, pass over a voluntarily movable shoulder or arm part, and thus provide relative motions with respect to the origin. At the movable point, the control cable enters the Bowden-type housing, which transmits the relative motion independent of movements of the distal segments. Controls may be used singly or in combination, depending upon the level of amputation, amputee preference, and other practical considerations.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Major harness controls. The points stabilized by harness (x) are beginning points for the control cable, which passes into a Bowden-type housing at movable points (¦). The relative motion is transmitted via the Bowden cable to distal points on the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Besides the relative motions between various segments of the human body, still another source of energy for operation of upper-extremity prostheses can be made available by the surgical procedure known as cineplasty, <a></a> in which a skin-lined tunnel is fashioned in the belly of a muscle group. In various experimental programs conducted both here and abroad, muscle tunnels have been made in the forearm flexors, the forearm extensors, the biceps, the triceps, and the pectoralis major.</p> <p>Of all the various combinations tried, the biceps tunnel in below-elbow amputees has proved to be the most successful. Failure of other cineplasty systems has been due in some cases to inability of designers to overcome the mechanical problems involved in harnessing the energy thus provided and in other cases to the inherent properties of the particular muscle group concerned. In the below-elbow case, use of the biceps tunnel eliminates the need for shoulder harness and permits operation of the prosthesis with the stump in any position. It has given excellent results in many instances and has been made available to those beneficiaries of the Veterans Administration who can make effective use of the procedure.<b>Fig. 21</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Coordinated control motions for elbow lock. Simultaneously the humerus is both extended <i>(a) </i>and abducted <i>(b) </i>while the shoulder is depressed (c) and the trapezius is bulged <i>(d) </i>by downward rotation of the scapula. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cineplasty tunnel in the biceps of the average male will provide sufficient force and excursion to operate modern terminal devices-an average maximum force of 50 lb. and 1 1/2 in. of useful excursion. It is not unusual for some individuals to be able to build up the force available to a value in excess of 100 lb., but such a high force normally is not required.</p> <h4>The Nature and Operation of Ccontrol Systems</h4> <p><i>The Below-Elbow Single-Control System</i></p> <p>The single control for the below-elbow amputee is powered by arm flexion to provide terminal-device operation. This control motion, used by the above-elbow amputee also, depends upon a coordinated flexion of the humerus and abduction of the scapula on the amputated side; little shoulder activity is required on the sound side. It is substantially the same motion as that used in normal unilateral reaching. The displacements of humerus and scapula are additive, so that the resulting motion is quite natural. With full Bowden-cable transmissions of power from arm cuff to forearm socket, there is no influence of elbow angle, and the operation is mastered easily by all amputees with stumps of 35 percent or more of normal forearm length.</p> <p><i>The Below-Elbow Dual-Control System</i></p> <p>(Although the terminology commonly used to describe the several control systems could well afford to be better systematized, it is adopted here because it is now so well established throughout the field of prosthetics. One <i>may </i>think of "dual control" as meaning that two control sources are involved in the provision of all necessary functions, but according to convention it means that two functions, specifically elbow flexion and terminal-device operation, are provided by a single control source, the third function, elbow lock, if needed, being managed by an additional control source. Yet "triple control" (page 22) in the accepted sense means not that three functions are furnished by a single control source but that three control sources are used to provide three functions, one for each.-Ed.)</p> <p>In harnessing below-elbow stumps shorter than 35 percent of normal forearm length, it generally is necessary to use an auxiliary type of lift to help the amputee flex the forearm. This procedure is applicable to a split-socket type of prosthesis. It merely is an adaptation of the above-elbow dual-control system (page 22) using a lever loop positioned on the forearm section so that arm flexion may be utilized to assist in forearm lift. The cable housing is split and assembled so that when the arm is flexed the elbow will flex. The elbow hinge has no locking mechanism, the short below-elbow stump being used to stabilize the forearm. Normally, sufficient torque is available about the elbow axis to give adequate stability in all usable ranges.</p> <p>In prescribing for a new amputee with this level of amputation, it might be advisable first to have the amputee try a split-type prosthesis without the below-elbow dual-control system. If, at time of initial checkout, the amputee cannot lift his forearm, or if he complains of painful contact with his stump, then of course the dual system is indicated. After the assist lift has been worn for some time, the remaining muscles of the stump may have hypertrophied, in which case the amputee might be able to discard the dual system and convert to the below-elbow single control.</p> <p><i>The Below-Elbow Biceps-Cineplasty System</i></p> <p>Force and excursion provided by the biceps muscle tunnel are harnessed by inserting into the tunnel a cylindrical pin of a nontoxic material and attaching a cable to each end of the pin. As in the other types of control systems, the Bowden-cable principle is employed to maintain a constant effective distance between the source of energy and the mechanism to be operated, regardless of relative motions occurring between body segments. In order that conventional terminal devices may be employed, it is necessary to join the two cables before attachment to the mechanism. Several devices for making this coupling are available commercially.</p> <p>Suspension of the socket is provided by an arm cuff, which is attached to the socket by any of the various hinges normally used in fabrication of below-elbow prostheses. The arm cuff is fashioned in such a manner that forces tending to pull the prosthesis from the stump are absorbed by the condyles of the elbow rather than by the muscle tunnel.</p> <p><i>The Above-Elbow Dual-Control System</i></p> <p>In above-elbow amputees, the humeral stump furnishes the motive power for the three operations of the prosthesis-flexion of the forearm, operation of the terminal device, and management of the elbow lock. The first two operations are so linked mechanically that a single control motion, arm flexion, produces either terminal-device operation or forearm flexion, depending on whether the elbow is locked or unlocked (<b>Fig. 20</b>). Although the control motion by arm flexion in the above-elbow case is similar to that described for the below-elbow amputee, there are several differences. Because the cable passes through a lever loop on the forearm to give torque about the elbow, it is affected by elbow position. As the forearm is flexed, arm-flexion excursion is used up, and the excursion needed to operate the terminal device must come from scapular abduction (shrug), as in shoulder cases. Typically, the above-elbow amputee manages a full range of free forearm flexion by a normal arm-flexion movement. But in the elbow-angle range of from 90 to 135 deg., with elbow locked for terminal-device operation, he must call upon supplementary excursions from biscapular abduction. With the terminal device at the mouth, practically all operation depends upon shoulder shrug.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Operation of above-elbow and shoulder dual controls. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the above-elbow dual-control system, operation of the elbow lock depends upon humeral extension and associated coordinations. When the forearm has been flexed to the position desired, the elbow lock is engaged by the arm-extension movement. Skill is needed to maintain tension on the arm-flexion cable so that the arm does not drop during the locking control motion. Well-trained amputees elevate the arm moderately to compensate for the humeral extension and thus maintain the elbow angle. The extension control motion is complex. The humerus is simultaneously extended and elevated so that it moves obliquely to the side. During this phase, the point of the shoulder must be stabilized, or even moved forward, and the trapezius is bulged by downward rotation of the scapula (<b>Fig. 21</b>).<b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Location of the proximal retainer for both above- and below-elbow cases. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Above-Elbow Triple-Control System</i></p> <p>The triple-control system has been devised to separate terminal-device operation from forearm lift. When the dual-control system is used, the amputee must select, by the use of the elbow lock, either terminal-device operation or forearm lifting. By separating forearm flexion and terminal-device operation, the triple control makes it possible for the terminal device to be controlled by an independent body motion. Although in general an above-elbow amputee fitted with triple control has an elbow lock, a few such cases are able to separate prehension from forearm flexion without use of the lock.</p> <p>A control cable from the terminal device is so attached and positioned that biscapular abduction or merely shoulder shrug will operate the terminal device through its full range of prehension. To lift the forearm the amputee uses arm flexion. Elbow-lock operation is accomplished in the same manner as in the dual-control system, that is, by arm extension.</p> <p>It is apparent that this arrangement will work best with a comparatively stable socket and a relatively long above-elbow stump. The chief advantage of the triple-control system is that at full forearm flexion the terminal device may still be operated through its complete range.</p> <p><i>The Shoulder Dual-Control System</i></p> <p>In the absence of the humeral lever, the shoulder becomes the major power source, biscapular abduction controlling both forearm and terminal device in the dual-control system. The control path courses horizontally across the scapulae, and either opposite-axilla loop or basic chest-strap harness (page 46) captures the action satisfactorily. The combination afforded by the dual principle also is illustrated in <b>Fig. 20</b>.</p> <p>The shoulder amputee has a special difficulty in obtaining the combination of full forearm flexion and terminal-device operation because, unlike the above-elbow amputee, who can add the excursions of humeral flexion and scapular abduction, he must obtain all movement from biscapular abduction. Shoulder amputees with broad shoulders and wide chests usually achieve this action satisfactorily; others must accept the limitation of partial terminal-device operation at full forearm flexion. Partial-shoulder and fore-quarter amputees must depend upon the sound shoulder entirely, and in this case the action range of the terminal device typically is limited to not more than 90 deg. of forearm flexion.</p> <p>In shoulder amputees, operation of the elbow lock must be managed by various special arrangements. The waist control, utilizing shoulder elevation; the perineal strap, based on relative motion between shoulders and pelvis; the nudge control, requiring either manual or chin operation; extreme shoulder flexion on the sound side; and extension of the shoulder on the amputated side complete the array of known feasible possibilities. It is evident that with this class of amputees control motions will be slower and deliberately sequential. They are therefore necessarily more noticeable and awkward.</p> <p><i>The Shoulder Triple-Control System</i></p> <p>The harness required for the triple-control shoulder-disarticulation system consists of a chest strap for forearm flexion, a waist strap to operate the elbow lock, and an opposite-shoulder loop for prehension. The amputee must have excellent scapular abduction and must be able to separate it from extreme opposite-shoulder shrug, and he must have available good shoulder elevation on the amputated side. The chief advantage of the triple control in the shoulder-disarticulation case is identical to that of the triple control in the above-elbow case, namely, that the terminal device may be operated fully in the vicinity of the mouth. To operate the prosthesis from an extended position, the amputee first produces biscapular abduction, thus raising the forearm. Then, with the forearm held in place, he elevates the shoulder on the amputated side to lock the elbow. To operate the terminal device, he then flexes the sound shoulder. Excursion for terminal-device operation is thus unaffected by forearm flexion.</p> <p>Unfortunately this system must be restricted to humeral-neck and shoulder-disarticulation cases. For lack of sufficient excursion on the amputated side, it is unlikely that a forequarter amputee would be able to use triple control.</p> <h4>Mechanical Application of the Major Controls</h4> <p>To elucidate practical amputee biomechanics, it is necessary to refer to several aspects of the connecting mechanism between amputee and prosthesis in the power-transmission system. Of first importance are the proximal retainers, which are located at the point where the cable from the shoulder harness enters the cable housing. These retainers are the beginning points of the transmission systems indicated in <b>Fig. 19</b>. In both below- and above-elbow cases, the proximal retainer is positioned in accordance with the ratios shown in <b>Fig. 22</b>. For all above-elbow stumps of greater than 50 percent of acromion-to-epicondyle length, the proximal retainer point is placed slightly lower than half way down the arm, the reason being that the control passes naturally through this point in its course from opposite shoulder, across the scapula, and thence to the lever loop on the forearm shell. The humeral lever power is quite adequate at this point (<b>Table 3</b>), and no practical advantage is gained by a lower placement. With above-elbow stumps less than 50 percent as long as the normal arm length, acromion to epicondyle, the proximal retainers must be placed at the level of the stump end in order to prevent undue tipping of the socket, as would occur if forces developed beyond the end of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In shoulder cases, the control path is directed horizontally at approximately the midscapular level and brought to the arm section at the axilla. The control motion is purely biscapular abduction, and consequently the proximal retainer is placed on the prosthesis at the midscapular level. The resulting force and excursion are given in <b>Table 3</b>.</p> <p>Arm-extension forces are potentially quite high, as also shown in <b>Table 3</b>. Because only 2 to 6 lb. of force and 1/2 in. of excursion are required to operate an elbow lock, normally there is a generous power excess. The principal concern in harnessing arm-extension control is to obtain operation with minimal movement and thus to avoid awkwardness.</p> <h3>Conclusion</h3> <p>The central purpose of this article has been to outline the biomechanical basis of control in upper-extremity prostheses. Consequently, emphasis has been placed upon the normal and residual functional anatomy and kinesiology underlying this service. The particularized biomechanics of prosthesis control has been defined, and the limitations incurred in amputations at high levels have been stressed. The major message is that a thorough understanding of the motions of control available to each type of patient is necessary to the proper prescription, fitting, and training of the upper-extremity amputee. Thus only can full advantage be taken of the improved functional features to be found in modern arm components.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasly, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Carlyle, L. C, <i>Using body measurements to determine proper lengths of artificial arms, </i>Memorandum Report No. 15, Department of Engineering, University of California (Los Angeles), 1951.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Clark, W. E. Le Gros, <i>The tissues of the body; an introduction to the study of anatomy, </i>3rd ed., Clarendon Press, Oxford, 1952.</li> <li>Clarke, H. Harrison, and Theodore L. Bailey,<i>Strength curves for fourteen joint movements, </i>J. Assoc. Phys. &amp; Ment. Rehab., 4(2):12 (1950).</li> <li>Cronkite, Alfred Eugene, <i>The tensile strength of human tendons, </i>Anat. Rec, 64:173 (1936).</li> <li>Elftman, H , <i>Skeletal and muscular systems: structure and function, </i>in <i>Medical Physics, </i>O. Glasser <i>el al., </i>eds., Vol. I, p. 1420, Year Book Publishers, Inc., Chicago, 1944.</li> <li>Haines, R. W., <i>On muscles of full and of short action,</i> J. Anat., 69:20 (1934).</li> <li>Hollinshead, W. H., <i>Functional anatomy of the limbs and back; a text for students of physical therapy and others interested in the locomotor apparatus, </i>Saunders, Philadelphia, 1951.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Inman, V. T , J. B. deC M. Saunders, and L. C. Abbott, <i>Observations on the function of the shoulder joint, </i>J. Bone &amp; Joint Surg., 26:1 (1944).</li> <li>Koch, John C, <i>The laws of bone architecture, </i>Am. J. Anat., 21:177 (1917).</li> <li>Lewis, Warren H., ed., <i>Gray's anatomy of the human body, </i>24th ed. revised, Lea and Febiger, Philadelphia, 1942.</li> <li>McMaster, Paul E., <i>Tendon and muscle ruptures; clinical and experimental studies on the causes and location of subcutaneous ruptures, </i>J. Bone &amp; Joint Surg., 15:705 (1933).</li> <li>Miller, D. P., <i>A mechanical analysis of certain lever muscles in man, </i>Ph.D. dissertation, Graduate School, Yale University, New Haven, Conn., 1942.</li> <li>Newman, R. W., and R. M White, <i>Reference anthropometry of Army men, </i>Report No. 180, Quartermaster Climatic Research Laboratory, Lawrence, Mass., 1951.</li> <li>Steindler, Arthur, <i>Kinesiology of the human body tinder normal and pathological conditions, </i>Charles C Thomas, Springfield, Ill., 1955.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasly, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952.</li> <li>Unpublished data, UCLA.</li> <li>Wilkie, D. R., <i>The relation between force and velocity in human muscle, </i>J. Physiol., 110:249 (1949).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasly, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 19.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasly, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clarke, H. Harrison, and Theodore L. Bailey,Strength curves for fourteen joint movements, J. Assoc. Phys. &amp;Ment. Rehab., 4(2):12 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Wilkie, D. R., The relation between force and velocity in human muscle, J. Physiol., 110:249 (1949).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clarke, H. Harrison, and Theodore L. Bailey,Strength curves for fourteen joint movements, J. Assoc. Phys. &amp;Ment. Rehab., 4(2):12 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Miller, D. P., A mechanical analysis of certain lever muscles in man, Ph.D. dissertation, Graduate School, Yale University, New Haven, Conn., 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">McMaster, Paul E., Tendon and muscle ruptures; clinical and experimental studies on the causes and location of subcutaneous ruptures, J. Bone &amp;Joint Surg., 15:705 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cronkite, Alfred Eugene, The tensile strength of human tendons, Anat. Rec, 64:173 (1936).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Haines, R. W., On muscles of full and of short action, J. Anat., 69:20 (1934).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Inman, V. T , J. B. deC M. Saunders, and L. C. Abbott, Observations on the function of the shoulder joint, J. Bone &amp;Joint Surg., 26:1 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Elftman, H , Skeletal and muscular systems: structure and function, in Medical Physics, O. Glasser el al., eds., Vol. I, p. 1420, Year Book Publishers, Inc., Chicago, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Koch, John C, The laws of bone architecture, Am. J. Anat., 21:177 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Steindler, Arthur, Kinesiology of the human body tinder normal and pathological conditions, Charles C Thomas, Springfield, Ill., 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Hollinshead, W. H., Functional anatomy of the limbs and back; a text for students of physical therapy and others interested in the locomotor apparatus, Saunders, Philadelphia, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Steindler, Arthur, Kinesiology of the human body tinder normal and pathological conditions, Charles C Thomas, Springfield, Ill., 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Lewis, Warren H., ed., Gray's anatomy of the human body, 24th ed. revised, Lea and Febiger, Philadelphia, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Carlyle, L. C, Using body measurements to determine proper lengths of artificial arms, Memorandum Report No. 15, Department of Engineering, University of California (Los Angeles), 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Newman, R. W., and R. M White, Reference anthropometry of Army men, Report No. 180, Quartermaster Climatic Research Laboratory, Lawrence, Mass., 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-2.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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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.&nbsp;<a style="text-decoration: none;">*</a><br />Robert C. Grotz, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Joanne Klope Shamp, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>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.</p> <p>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."</p> <p>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.</p> <p>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:</p> <ol> <li> <p>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.</p> </li> <li> <p>Selection of a material with adequate flexibility, durability, and shape retention under conditions of continual deformation during ambulation.</p> </li> <li> <p>Ease of donning for the one-handed patient.</p> </li> </ol> <h3>Design Rationale</h3> <p>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"><b>Fig. 1</b></a>). Within the total contact design are incorporated the following forces:</p> <ol> <li> <p>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"><b>Fig. 2</b></a>).</p> </li> <li> <p>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"><b>Fig. 3</b></a>).</p> </li> <li> <p>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"><b>Fig. 3</b></a>). This facilitates straight plane dorsiflexion.</p> </li> <li> <p>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"><b>Fig. 4</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.jpg"><b>Fig. 5</b></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"><b>Fig. 5</b></a>).</p> </li> <li> <p>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"><b>Fig. 6</b></a>).</p> </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"><b>Fig. 7</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg"><b>Fig. 8</b></a>).</li> </ol> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-07.jpg">Figure 7.</a> Medial view, left foot<br /></strong><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg">Figure 8.</a> Lateral view, left foot</strong><br /> <h3>Prescription Rationale</h3> <p>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.</p> <p>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"><b>Fig. 9</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-10.jpg"><b>Fig. 10</b></a>, and<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-11.jpg"> <b>Fig. 11</b></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.</p> <strong><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.</strong><br /><br /><strong><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</strong><br /><br /><strong><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.</strong><br /> <p>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.</p> <p>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.</p> <h3>Clinical Experience</h3> <p>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.</p> <h3>Fabrication</h3> <p>Polypropylene was chosen as the thermoplastic currently exhibiting the best conformance to the desired qualities, when used in the fabrication process described.</p> <h3>Casting Procedure</h3> <p>The casting technique is similar to that described in <i>Lower Limb Orthotics, A Manual</i><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></p> <p>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.</p> <h3>Modification Of The Positive Model</h3> <p>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.</p> <ol> <li> <p>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"><b>Fig. 12</b></a>).</p> </li> <li> <p>Medial aspect of the calcaneus extending to the plantar surface of the longitudinal arch <em>without</em> 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"><b>Fig. 13</b></a>).</p> </li> <li> <p>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"><b>Fig. 14</b></a>).</p> </li> <li> <p>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"><b>Fig. 6</b></a>).</p> </li> <li> <p>Smooth entire cast.</p> </li> </ol> <p>If an accurate negative cast and positive model were created, no further modifications are necessary.</p> <h3>Vacuum-Forming Process</h3> <p>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"><b>Fig. 15</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-16.jpg"><b>Fig. 16</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-17.jpg"><b>Fig. 17</b></a>) to create strengthening corrugations in the orthosis after molding.</p> <p>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.</p> <h3>Trimlines</h3> <p>The orthosis is removed from the positive model using a cast cutter and is sanded to finish according to the following trimlines:</p> <ol> <li> <p>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").</p> </li> <li> <p>Length of the plantar extension is terminated 6mm. proximal to the metatarsal heads for comfort.</p> </li> <li> <p>The lateral trimlines (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-18.jpg"><b>Fig. 18</b></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"><b>Fig. 18</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-19.jpg"><b>Fig. 19</b></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.</p> <p>Note that flexibility is enhanced by the narrowing anteriorly and posteriorly as the lateral side meets the heelcup.</p> </li> <li> <p>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"><b>Fig. 19</b></a>).</p> </li> <li> <p>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"><b>Fig. 20</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.jpg"><b>Fig. 21</b></a>).</p> The plantar extension (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.jpg"><b>Fig. 21</b></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> <p>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.</p> <h3>Discussion</h3> <p>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.</p> <p>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.</p> <p>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.</p> <h3>Summary</h3> <p>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.</p> <p>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.<br /><br /><em><b>*Joanne Klope Shamp, C.P.O. </b>Joanne Klope Shamp, C.P.O., is with the Shamp Pros-thetic-Orthotic Center in Norton, Ohio.<br /><br /><b>*Robert C. Grotz, M.D. </b>Robert C. Grotz, M.D., is Medical Director for Edwin Shaw Hospital in Akron, Ohio<br /></em></p> <p><em><b>*Cyndi Ford, P.T. </b>Cyndi Ford, P.T., is with the Edwin Shaw Hospital in Akron, Ohio.</em></p> <h3>Additional Reading</h3> <ol> <li> <p>Bobath, B. "The Application of Physiological Principles to Stroke Rehabilitation—A Special Report," <i>The Practitioner</i>, December, 1979, Vol. 223, 793-4.</p> </li> <li> <p>Ibid, "The Treatment of Neuromuscular Disorders by Improving Patterns of Coordination," <i>Psychotherapy</i>.</p> </li> <li> <p>Bobath, B. and Bobath, K., "The Importance of Memory Traces of Motor Efferent Discharges for Learning Skilled Movement," <i>Developmental Medicine and Child Neurology</i>, 1974, p. 16, pp. 837-8.</p> </li> <li> <p>Cherry, D.B., "Review of Physical Therapy Alternatives for Reducing Muscle Contracture," <i>Physical Therapy</i>, Volume 60, Number 7, p. 877, July, 1980.</p> </li> <li> <p>Effgen, S., "Integration of the Plantar Grasp Reflex as an Indicator of Ambulation Potential in Developmentally Disabled Infants," <i>Physical Therapy</i>, Volume 62, Number 4, pp. 433-35, April, 1982.</p> </li> <li> <p>Freedman and Herman, "Inhibition of EMG Activity in Human Triceps Surae Muscles During Sinusoidal Rotation of the Foot," <i>Journal of Neurology, Neurosurgery and Psychiatry</i>, 1975:38, pp. 336-45.</p> </li> <li> <p>Knutsson, E. et al., "Different Types of Disturbed Motor Control in the Gait of Hemiparetic Patients," <i>Brain</i>, 1979:102, p. 405.</p> </li> <li> <p>Lehmann, J.F., "Biomechanics of Ankle-Foot Orthoses: Prescription and Design," <i>Archives of Physical Medicine and Rehabilitation</i>, Volume 60, May, 1979, p. 200.</p> </li> <li> <p>Ibid, "Plastic Ankle-Foot Orthoses: Evaluation of Function", <i>Archives of Physical Medicine and Rehabilitation</i>, p. 402.</p> </li> <li> <p>Ibid, "A Biomechanical Evaluation of Knee Stability in Below-Knee Braces," <i>Archives of Physical Medicine and Rehabilitation</i>, p. 688, December, 1970.</p> </li> <li> <p>Manfredi, Sacco and Sideri, "The Tonic Ambulatory Foot Response," <i>Brain</i>, 1975: 98, pp. 167-80.</p> </li> <li> <p>Perry, et al., "Determinates of Muscle Action in Hemiparetic Lower Extremity," <i>Clinical Orthopaedics and Related Research</i>: p. 131, March-April, 1978.</p> </li> <li> <p>Walters, R.L., "The Enigma of 'Carry Over'," <i>International Rehabilitation Medicine</i>, 1984:6, pp. 9-12.</p> </li> <li> <p>Watemabe, I. and Obubo, J., "The Role of Plantar Mechanoreceptor in Equilibrium Control," <i>Ann-NY-ACAD-Science</i>, 1981: 374, pp. 855-64.</p> </li> <li> <p>Weiz, S., "Studies in Equilibrium Reaction," <i>Journal of Nervous and Mental Disorders</i>: 88, 1938, p. 150.</p> </li> </ol> <p><b>References:</b></p> <ol> <li>Yates, G., "A Method for Provision of Lightweight Aesthetic Orthopaedic Appliances," <i>Orthopaedics</i>: Oxford, 1:2, pp 153-162, 1968.</li> <li>Lehneis, H.R., "New Concepts in Lower Extremity Orthotics," <i>Medical Clinics of North America</i>, 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," <i>Physical Therapy</i>, 62:4 pp. 453-455, 1982.</li> <li>Bobath, B. and Bobath, K., <i>Motor Development in Different Types of Cerebral Palsy</i>, 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," <i>Foot and Ankle</i>, p. 145, 1983.</li> <li>Duncan, W., "Tonic Reflexes of the Foot," <i>Journal of Bone and Joint Surgery</i>, July, 1960.</li> <li>Sarno, J.E. and Lehneis, H.R., "Below-Knee Orthoses: A System for Prescription," <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 54, p. 548, December, 1975.</li> <li>Rehabilitation Engineering Center, Moss Rehabilitation Hospital. <i>Lower Limb Orthotics: A Manual</i>, 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/33ac5f83c3b345c7f45c737170f43aa0.pdf 7e4f270c0b93c37ded6218cb290d8afb Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_003.pdf Text Any textual data included in the document <h2>A Personal Experience</h2> <h5>Cynthia L. Cuchna&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Most people would say, "It would be terrible to be born with a birth defect." Well, I know firsthand that it really isn't so terrible. I have been blessed with family and friends who have not let me feel that my disability should get in the way of reaching my goals. My parents have never let me use my handicap as a way of getting out of responsibilities. I have the same responsibilities around the house as my sisters and if I don't take care of them I am equally disciplined just as my sisters would be if they didn't do their share of the work. I feel my oldest sister, Sherri, has helped me the most in believing that I am just as capable as anyone else in doing things for myself. If I would ask her to get me a book or a glass of water or something, Sherri would probably say something like, "Get it yourself, you aren't helpless!" I wouldn't want it any other way between us.</p> <p>People have asked me if I feel my sisters are allowed to go more places and do more things than me. I don't feel that I've missed out on any of the experiences my sisters have had. I go to football games, movies, go shopping, and go to the local disco just like my sisters.</p> <p>The only problem I have is that most of my friends live too far away from me to just "drop by" whenever they feel like it. My friends are my classmates from the high school I had to attend, which is outside my local school district and is the only school in the county capable of handling my special problems. We can't even call one another very often because it is long distance.</p> <p>Hospitals have been a vey important part of my life, since I was in and out of them quite frequently when I was young. I never really minded going into the hospital because the doctors and nurses were always nice and I knew they would take good care of me. Along with hospitals comes bills. Our family has never been eligible for financial aid because my parents always made "too much money." I know that at times it has been tough for my parents to make ends meet because I am such an "expensive kid." Sometimes I feel guilty about having my parents pay such big bills just because of me.</p> <p>I have been in braces ever since I was four years old. I know that they have helped me considerably, but I often have negative feelings about my braces. There was a time when I was unable to wear my braces due to pressure sores. I like being out of them because my clothes weren't torn by the locks on my braces and I liked getting dressed faster. I thought I looked prettier without all of that plastic and metal sticking out of my clothes. I am finally starting to realize that I look better in them because they make me straighter. I don't look like I'm a "pretzel" when I'm in them. I have greater mobility in them, which enables me to do things and go places that I couldn't in my wheelchair. Even though the negative feelings may resurface in the future, I plan on wearing my braces a lot more than I have for the past two years.</p> <p>When I go out to a movie or go shopping, sometimes people stare at me. This has never really bothered me. It just shows me that they are interested in my disability and are curious to see how my braces, crutches and/or wheelchair works. I especially like it when little children come up to me and ask, "What happened to you?" I am glad that children aren't afraid to ask questions. I wish that adults would open up and ask, because I would be more than willing to tell them about anything they would want to know.</p> <p>My plans for the future are to graduate from college with a degree in psychology. I think that I would like to be a school psychologist because I love children. I know that the road ahead will have some rough spots, but I know that I can make it with the love and support of my family behind me.</p> <em><strong><b>*Cynthia L. Cuchna </b></strong>Cynthia Cuchna was born with spina bifida on March 21, 1966. Now she is 18 years old and is entering her first year of college.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Personal Experience Creator An entity primarily responsible for making the resource Cynthia L. Cuchna * https://staging.drfop.org/files/original/db74232ff919eba50ae953fc5d8e15df.pdf 4106376d5c34e536f4d1f88cbe77c124 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_001.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Still a Long Way to Go</h2> <h5>D. S. McKenzie, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It is probably a common experience to those of us who work in the field of artificial limbs to receive odious comparison between the relatively primitive prostheses and the sophisticated hardware deriving from space technology, nuclear physics, and the like. The implication usually is that, if similar expenditure on research were made in our field, similar dramatic advances would be made. I do not think that the problem is as simple as this reasoning would imply, and there is some evidence to support my view. I am told that, once upon a time, a great American aviation company undertook to develop an artificial arm and that, some years and a million or two dollars later, they reverted with relief to the relatively simple matter of designing aircraft.</p> <p>And yet we must acknowledge that the externally powered upper-extremity prostheses of today are poor things. It is very doubtful indeed whether the unilateral arm amputee can obtain from them any functional or emotional gain over that deriving from the conventional body-powered prosthesis; indeed, in some respects there may be a loss. It is even doubtful whether any bilateral amputee with measurable humeral stumps would be improved, except perhaps by making it possible to superimpose an additional degree of freedom such as pronation-supination on the existing body-powered prostheses. Indeed, I would go so far as to say that the amelics and bilateral shoulder-disarticulation patients would be better off functionally if they only had sufficient sites available for harnessing with sufficient power and excursion for body-powered control. Currently available externally powered limbs are acceptable to these patients only because a little function is better than none at all. How little that is, is exemplified by the readiness with which the children with upper-extremity amelia and normal lower limbs revert to using their feet for prehension and manipulation.</p> <p>It is of more than passing interest to attempt to analyze why these things should be so, and I think there are a number of reasons.</p> <p>First, the power-weight ratio of available actuators and power storage components is still not advantageous enough for us to provide truly acceptable responses.</p> <p>Second, we have not yet discovered enough control sites capable of providing a sufficient number of degrees of freedom to position the hand or terminal device in space, to put it in the optimum attitude in relation to each task to be performed, and still leave an adequate reserve for prehension.</p> <p>The problem of simulating normal prehension has not been solved, nor, in my opinion, has a truly acceptable compromise been attained. Most writers agree that a well-designed hook is more functional than any of the many so-called functional hands, and yet few would claim that the hook contributes anything to cosmetic restoration or that it is likely to be emotionally satisfying to more than a small proportion of patients. Various ingenious hands purport to provide a selection of different types of grasp, such as the power grasp, precision grasp, "three-jaw chuck," and so forth, and some even achieve this. But none of them, nor of the hooks for that matter, is capable of manipulation within the grasp. This results in the exasperating experience for the user that any object he picks up is seldom immediately in a position of function; he is unable to manipulate it into such a position and has to resort to inelegant procedures such as transferring the object to the mouth and back to the hand again. Furthermore, many tasks that we do are achieved by manipulation-screwing, modeling, squeezing, and a host of others--which, for the amputee, have to be done by energy-consuming gross arm movements or even gross body movements, and he cannot feel what he is doing. It is not surprising that the unilateral amputee elects to use his remaining hand, and the amelic his toes.</p> <p>The foregoing difficulties apply in the main both to externally powered and body-powered prostheses, and I have said little about sensory feedback, a degree of which is available to the users of the latter systems. The control cable offers a built-in position servo, while a great deal of information about the forces applied at the output can be derived from the reactions of the harness against the body and those of the socket on the stump. When external power is used, these afferent channels either cease to exist or are severely attenuated, and it becomes necessary to consider the provision of artificial sensory loops which in their turn introduce difficulties in interpretation.</p> <p>We are thus confronted with what I believe to be the main barrier to progress in externally powered prostheses-the man-machine interface. This should be taken to mean not only the physical attachment of the prosthesis to the wearer, but also the boundary through which all command signals from the biological system of the wearer must pass to the mechanical system of the prosthesis and through which all information relating to the output of the prosthesis must return to the biological system if the wearer is to make the best use of such information to modulate performance.</p> <p>It is on these channels of communication that the effective control of externally powered devices depends. I am quite certain that we do not know enough about their mechanism to exploit them to best advantage. No one has yet attempted to measure the "goodness" of the channels-for example, in terms of communication theory-and yet I believe that effective systems design would follow on such data as surely as night after day.</p> <p>One of the greatest virtues of biological systems is that they are highly adaptive. The human control system-and in particular the computer as represented by the central nervous system-is no exception to this. The pattern of manual activity which we require in order to enjoy a full life is so infinitely variable that I have very serious doubts whether any form of programmed operation within the prosthetic system will satisfy a user for any length of time. The concept of programming the trajectory of the terminal device so as to limit the decision-making demand upon the user to commanding the system to move it from <i>A </i>to <i>B </i>is open to this criticism. Even if provision were made for the user to override the program and revert to voluntary control, I suspect that the switch would soon be left permanently in the override position. In any event, the case for this sort of programming seems to me to be accepting that the interface is inevitably poor in a communications sense. It may be that a better understanding of the interface will make this an unduly pessimistic view.</p> <p>Reverting to the adaptive properties of the biological system in general, and of the central nervous system in particular, it seems to me that significant progress in externally powered limbs will be made only when it becomes possible to link the central nervous system "on line" with the prosthetic control system. Servo loops crossing the interface would make an integrated and adaptive system. It might be said that a start had already been made on this by exploiting the myoelectric discharges for control. In such an integrated system, however, the command signal is being derived by tapping the middle of the efferent loop. Such sensory information as returns by afferent channels is derived from the muscles and their tendons. Essentially, this is a backwater of the main stream of the afferent channel of the man-machine complex. It follows that information about the output of the man-machine system can only be inferred rather than known. In my view, Simpson's position-controlled servos and Bottomley's pressure-demand pneumatic valve have more prospects of achieving a truly adaptive output and might be regarded as among the first breaches in the man-machine interface.</p> <p>Taking all these matters into consideration, besides many other difficulties which I will not discuss for reasons of space, we are in no position to be complacent about externally powered arms. Indeed, the state of the art is so relatively primitive that the only overriding indication for prescribing them at this time is bilateral high-level amputation or the equivalent-only a handful of patients out of the total upper-extremity case load of any prosthetic service and an even smaller proportion of the total case load. The difficulties are so great, and the amount of fundamental information lacking is so formidable, that one is continually surprised at the surge of interest in the field and the amount of effort that is going into it. Indeed the budget for prosthetics research and development in Great Britain for next year envisages that over 30 per cent of the total expenditure will go to work on external power. From what I saw when I visited the United States in May 1967, I would think that a similar proportional expenditure is being made there. Taking into account the tiny number of immediate beneficiaries-although admittedly they are among the most severely disabled-it is proper to take stock and consider whether this level of expenditure of money and effort is justified. Have we got our priorities right? Of course, there is much common ground in the orthotics field, and many developments arising from purely prosthetics requirements would have direct application here. This would increase the number of potential beneficiaries, but they would still be a small proportion of the total disabled population. I think the justification as well as the reason for the interest in the subject is the fact that we believe the possibility of introducing a new order of function to <i>all </i>upper-extremity amputees lies in external power and possibly to lower-limb amputees as well.</p> <p>May I use these pages to make a plea, if not that hardware development should cease, at least that some of the effort should be put into fundamental research into problems such as those I have indicated? Indeed, all of us already engaged in such work should devote sufficient time to discovering what the patient really needs, rather than to providing him with what we think he ought to need.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>D. S. McKenzie, M.D. </b></td></tr><tr><td class="clsTextSmall">Director, Ministry of Health, Biomechanical Research and Development Unit, Roehamp-ton, London, S.W. 15, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Still a Long Way to Go Creator An entity primarily responsible for making the resource D. S. McKenzie, M.D. * https://staging.drfop.org/files/original/5a1dda96e4178cd06649ab215cbbe0d5.pdf 916f9e9ed1caca96356f3a227150715d https://staging.drfop.org/files/original/8636aa4e4c5c07d52b8abe2b11b37b34.jpg d84ef6ba41e554dcba230d9df535077a https://staging.drfop.org/files/original/5b4a9dbd8c695c2a35af0d77111fe2c1.jpg 8fbbd755ed8145a65a43809e70417f90 https://staging.drfop.org/files/original/8487fa7a9496454abdd425b5a0d7785f.jpg f87e785df8826fce7f9b25bbfa02d214 https://staging.drfop.org/files/original/6d91bb58231e3290cbcf8e2dd6de2830.jpg 8c72ee75f68585c21747347b7c6d1307 https://staging.drfop.org/files/original/1b17acd6b2b5de624697430d6894d59e.jpg a0c575e50cf69d22a6c74b5be9757d31 https://staging.drfop.org/files/original/07792a7c6f21b09b088faf9389ca2610.jpg da7f539b8006bf431baa7e3e5b8122f7 https://staging.drfop.org/files/original/11eb68ee39aa5ebeb200cda4a27eeebc.jpg 20f231014dcb6fa69b27864fb3ffa898 https://staging.drfop.org/files/original/197c2d8a6200d52ac28aef88fcc77fdd.jpg 801b1962726d6ad8ef106424aca27645 https://staging.drfop.org/files/original/afdc0eb1a348faf2d0c27285bcbb337e.jpg fd18d6f8a478bd70ef313e66aa24f6d3 https://staging.drfop.org/files/original/2250f8e6296a64f9cab5e169d1c2b241.jpg 516066b6193dbe1c2a6b992facb1be90 https://staging.drfop.org/files/original/6a4612dbdc98238350b49fd1d433b615.jpg 198d5a4e6535b9269b942902bc83a6d6 https://staging.drfop.org/files/original/013bbfd894737f6f6987e68067760431.jpg f272ceb4a5cfc69133ef0090cd118908 https://staging.drfop.org/files/original/6b60e9da47923de26b69a07869eb13ed.jpg 889d26201fbd7450b4346f43c42da7ee https://staging.drfop.org/files/original/b6a47343d2d4db601a1452d432a910bb.jpg d57c642323cf7ae5fe5d51d3c25f34e0 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_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.&nbsp;<a style="text-decoration: none;">*</a><br />W.J. Hartvikson&nbsp;<a style="text-decoration: none;">*</a><br />H. Anton&nbsp;<a style="text-decoration: none;">*</a><br />E. Hommonay, C.P.O.(C)&nbsp;<a style="text-decoration: none;">*</a><br />N. Russell, C.P.(C)&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>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.</p> <p>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.</p> <p>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.</p> <h3>Clinical Investigation</h3> <p>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 (<b>Fig. 1</b>).</p> <strong><a href="/files/original/8636aa4e4c5c07d52b8abe2b11b37b34.jpg" target="_blank" rel="noopener">Figure 1</a>. The age range was from 24 to 72 years.</strong><br /> <p>The weight of the patients ranged from 95 pounds to 195 pounds and their height ranged from 5'1" to 6'4".</p> <p>Amputation dates ranged from 1930 to 1986, with over half of the respondents having been injured since 1975.</p> <p>On average, each patient had 3.75 surgical procedures, with a range from 1 to 24.</p> <p>The length of time from amputation to prosthetic fitting was, for the most part, under one year (<b>Fig. 2</b>).</p> <strong><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.</strong><br /> <p>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.</p> <p>The length of time for use of the Seattle foot ranges from one month to two years with an average of 8.5 months (<b>Fig. 3</b>).</p> <strong><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.</strong><br /> <p>The Seattle foot was fit on 29 below-knee amputees and two above-knee amputees.</p> <p>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.</p> <p>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.</p> <p>When questioned about the effect of the Seattle foot on changing gait, 87% felt it was better and 13% felt it was the same.</p> <p>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.</p> <p>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.</p> <p>Balance and endurance on the prosthesis was felt to be easier by about 61% of the respondents and smoothness was better in 87%.</p> <p>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.</p> <p>Walking and running was easier for 67% of the respondents (48% of the patients jogged). Of the 61% who dance, 74% found it easier.</p> <p>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.</p> <p>The greatest advantages with the Seattle foot were reported to be a more natural and smooth action, resulting in an improved gait (<b>Fig. 4</b>), better ability to handle stairs and uneven ground, and improved abilities in sports.</p> <strong><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.</strong><br /> <p>The cosmetic design and the anatomical detail were appreciated by 97% of the respondents.</p> <p>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.</p> <p>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.</p> <p>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. <b>Fig. 5</b>, <a href="/files/original/07792a7c6f21b09b088faf9389ca2610.jpg" target="_blank" rel="noopener"><b>Fig. 6</b></a>, and <a href="/files/original/11eb68ee39aa5ebeb200cda4a27eeebc.jpg" target="_blank" rel="noopener"><b>Fig. 7</b></a> graphically demonstrate the comparison.</p> <strong><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.<br /></strong><br /> <h3>Laboratory Investigation</h3> <p><i>Electrogoniometric Evaluation</i></p> <p>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.</p> <p>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.</p> <p>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"><b>Fig. 8</b> </a>and <a href="/files/original/afdc0eb1a348faf2d0c27285bcbb337e.jpg" target="_blank" rel="noopener"><b>Fig. 9</b></a>).</p> <p>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.</p> <p>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"><b>Fig. 10</b></a> and <a href="/files/original/6a4612dbdc98238350b49fd1d433b615.jpg" target="_blank" rel="noopener"><b>Fig. 11</b></a>).</p> <p>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.</p> <p><i>Force Plate Evaluation</i></p> <p>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. <b>Fig. 12</b> 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.</p> <strong><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.</strong><br /> <p><b>Fig. 13</b> illustrates the forces generated in the same individual during stance on his prosthetic side while using a Seattle foot. <b>Fig. 14</b> shows stance forces generated in the same individual on his prosthetic side using a S.A.C.H. foot.</p> <strong><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.</strong><br /><br /><strong><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.</strong><br /> <p>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.</p> <h3>Conclusion</h3> <p>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.</p> <h3>Acknowledgments</h3> <p>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.</p> <p><b>References:</b></p> <ol> <li>Orthopaedic Appliances Atlas. Vol. 2, <i>Artificial Limbs</i>, Editor J.W. Edwards, Ann Arbor, Michigan, 1960, pp. 149-151.</li> <li>Reswick, J.B., "Evaluation of the Seattle Foot," <i>J. Rehab Research and Development</i>, Vol. 23, No. 3, pp. 77-94.</li> <li>Burgess, E.M. et al., "Development and Preliminary Evaluation of the V. A. Seattle Foot," <i>Journal of Rehabilitation Research and Development</i>, 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," <i>J. Biomechanics</i>, Vol. 13, 1980, pp. 989-1006.</li> </ol> <em><b>*N. Russell, C.P.(C) </b> Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital.</em><br /><br /><em><b>*E. Hommonay, C.P.O.(C) </b> Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital.</em><br /><br /><em><b>*H. Anton </b> Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital.</em><br /><br /><em><b>*W.J. Hartvikson </b> Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital.</em><br /><br /><em><b>*D.D. Murray, M.D. </b> Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital.<br /><br /><br /></em> 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. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-14.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 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. Russell, C.P.(C) * https://staging.drfop.org/files/original/b3a2c7a0584c7b41faa78f8463cf4268.pdf f252ffd28bf2d19a88c0995299dca5af Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_004.pdf Text Any textual data included in the document <h2>An Advanced Approach Toward Improved Prosthetic Fittings</h2> <h5>David F.M. Cooney, R.P.T., C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Keith E. Vinnecour, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The importance of amputation surgery and dedicated follow-up cannot be underestimated by those clinicians who deal with the amputee population. A prosthetist who receives a patient with a residual limb that is of the optimum configuration to receive a prosthesis and permits the lowest energy cost with maximum unilateral weight bearing comfort, is too often the exception. A concerted effort by all professionals involved—physicians, nurses, physical and occupational therapists, psychologists, social workers, and prosthetists—is required for truly successful rehabilitation.</p> <h3>Delineation Of Level</h3> <p>Successful primary healing in patients who have experienced a trauma related amputation is not as great a concern since the average age of this group is much younger than the dysvascular amputee. For the majority of patients who require prosthetic care due to vascular insufficiency, predictions for successful healing, and therefore level of amputation, is a critical consideration and of primary address here. The following discussion and techniques employed, however, can apply to all prosthetic fittings.</p> <p>In the dysvascular patient, the correct assessment of tissue viability and level of limb amputation is paramount to successful rehabilitation. Correct assessment also serves to reduce the length of the hospital stay and, therefore, costs. Patient morbidity and mortality are also reduced.<a></a></p> <p>A number of methods are employed to determine amputation level. Absolute determinants include ischemia and necrosis. Skin temperatures, absence of hair, sensory deficits, and peripheral pulses are also clinical tools of relative, though unreliable, demarcation. A less direct way of determining level of amputation is the condition of the underlying tissues and skin bleeding during surgery.<a></a></p> <p>Objectively defined methods are being used to more accurately determine surgical level. Doppler pressure measurements use systolic pressure differentials between the level of concern and brachial pressure. The literature cited offers relative values for prediction of successful healing,<a></a> but also points out the Doppler method's fallibility.<a></a> Two other non-invasive tests, segmental systolic pressure readings and pulse-volume recordings, can provide a reasonably valid prediction of primary wound healing, but should not be used as the sole indicators for amputation site.<a></a></p> <p>Thermography has been used to estimate the optimal site of amputation. Infrared emissions from the involved extremity are displayed on a screen to show temperature differentials. One study claimed a 96 percent success rate with amputation levels recommended via thermography<a></a>.</p> <p>Skin blood flow by the Xenon-133 clearance techniques to predict primary healing levels in amputation surgery have shown positive results. A 100 percent primary amputation healing is claimed by these authors for surgeries where recommendations according to their standards were followed.<a></a></p> <p>The choice of any of the above methods rests with the abilities of the institution. Though most non-invasive means are available throughout the medical community, invasive techniques using radioactive isotopes, like Xenon-133, require the availability of a nuclear medicine department. Clearly, not all facilities have this capability.</p> <p>Once the level of tissue viability and surgical healing have been determined, operative procedures commence. A residual limb offering optimal function should be a "well muscled, durable stump of effective length with a pliable skin cover that has adequate sensation." The means to this end requires careful attention to the handling of the bone, nerves, and soft tissues.<a></a></p> <h3>Surgery</h3> <p>Subsequent to determining the amputation level is the actual surgical technique, which is an important adjunct to successful rehabilitation of the amputee. Handling of the bone requires close attention to the residual cortical shaping, and in standard practice it should be beveled to prevent sharp margins and potential socket problems.<a></a></p> <p>The reaction of the bone to surgical handling of the periosteum is not fully understood, but when dealing with tissues that are compromised initially, one cannot fault a "kid-glove" approach to dissection and ligation. Delicate handling may avoid subsequent spurring along the bony margins.<a></a> It has generally been considered that fibular length should be less (approximately 2.0 cm.) than the length of the tibia.<a></a> The authors feel that fibular length should be equal to or no more than 5 mm. shorter than the cut tibia. It is felt that this improves prosthetic medio-lateral stability, provides greater distal bulk, and serves to prevent mature conical shaping and increase total tissue contact and weight-bearing.</p> <p>In the procedure described by Ertl,<a></a> the lengths of the two bones are equal. A bony bridge, or periosteal flap, is then created to afford an end bearing residual limb. This synostosis also prevents any relative motion of the two bones. The tibiofibular osteoplasty closes the open medullary canals and can recreate the normal conditions of direct weight bearing pressures and circulation in the long axis of the bone. This can help prevent degeneration in the joints proximal to the amputation.<a></a> It would seem that this procedure should warrant greater attention in appropriately selected patients (especially in light of the much improved fitting techniques now available).</p> <p>Establishing stabilization in the distal musculature at the selected site of amputation is important to provide a more physiologically effective residual limb. Where surgically feasible, the muscles should be sutured to each other as well as to the periosteum and/or bone without excessive tension or laxity. This allows for a well contoured and generally less prosthetically troublesome limb.<a></a></p> <p>Nerve tissue should be handled meticulously to avoid residual problems once prosthetic wear is initiated. Each nerve should be individually dissected and have adequate traction applied. Severing of the nerve with traction maintained will cause it to retract far enough up into the soft tissue so as to be well protected and less threatened by weight bearing pressures.<a></a> Prosthetically crucial are the smaller sural and saphenous nerves, as they are sometimes neglected in lieu of the more major posterior tibial, deep and superficial peroneal nerves.<a></a> Redundancy of soft tissues should be avoided, but adequate coverage of the remaining structures is a must in order to provide a good limb for weight bearing. Closure of the wound should include careful suturing and handling of the already compromised tissues and care should be taken to avoid traction at the suture line so as to prevent contractures of the joint.<a></a></p> <p>It has been shown again and again that immediate post-surgical fitting procedures can improve residual limb viability, reduce pain and edema, and prevent contractures.<a></a> Rigid dressings are common practice in immediate post-surgical fittings, but variations on this theme include the use of pneumatic devices that can also afford the advantages of their more rigid counterparts.<a></a> More tenuous situations that may not allow for early weight bearing and ambulation, secondary to healing problems, can be approached through the use of Una boot dressings<a></a> and an innovative removable rigid dressing technique.<a></a></p> <p>Invariably, the independent and/or conjunctive use of any one of these methods can enhance the post-operative management of even the most difficult rehabilitation patient. By improving a patient's physical and mental status and by providing mobility through this approach, the clinical team can increase a patient's rehabilitation potential.<a></a></p> <h3>Prosthetic Evaluation</h3> <p>Little has changed in the physical aspects of evaluation. Standard anthropometric measures are still used to provide an objective record for modifications and fabrication, and for comparative purposes related to future changes. Accurately determining the anatomical joint range of motion (both in the involved and uninvolved limb) and strength/stability can provide criteria for prescription and serve to mediate problems during fitting.</p> <p>One new tool in the evaluative process is Xeroradiography®. Xeroradiography® is a process that yields an x-ray image on an opaque background. The picture records are easier to store than their x-ray counterparts and provide a clear definition of both the bony anatomy and soft tissue. Evidence of bone spurring, vessel calcification, and presence of vascular surgery staples is readily observed. Measurements are also easy to glean. The use of this information in the treatment of the amputee is obvious and can significantly improve and objectify the prosthetist's skills and, ultimately, improve patient management.<a></a></p> <h3>Casting</h3> <p>Adopting a "hands-on" technique in the quest of obtaining an anatomical replica of the residual limb should be the goal of the prosthetist. A careful volume study of the involved limb can serve to optimize the definitive results.</p> <p>The growing use of static and dynamic test sockets, and the information provided by them, has yielded a twist on the time tested practices utilized by many prosthetists. The technique of automatic build-ups over sensitive areas has been found to be less than necessary. Reversing this thought process to promote negative model modifications over areas of weight bearing can provide better total-contact, total-weight bearing sockets. Doing this in the molding process can reduce the amount of relatively educated guesswork necessary in cast modification by producing better initial cast molds. Methods which have been developed to aid in this pursuit include vacuum casting<a></a> or a three to four stage alginate casting technique.<a></a></p> <p>Another method to improve fit from the initial casting is to work toward a more dynamic casting method. As the casting is predominantly done under non-weight bearing conditions, working toward more "dynamic" casting methods which equalize the weight bearing pressures is warranted consideration. Where an Ertl procedure has been performed, distal weight bearing casting is preferred to achieve maximum results. The same intent should be attempted with the non-Ertl distal end as well. Ultimately, the better the quality of the cast and the less initial modification guesswork, the better the test socket fitting.</p> <h3>Test Socket</h3> <p>Use of clear test sockets for improving fit is well documented in the literature cited. Though the technology for transparent test sockets has been available since the 1950's, the current practice of direct weight bearing modifications to the socket are relatively new.<a></a></p> <p>During the initial static weight bearing period, areas of the residual limb are demarcated according to weight distribution and, therefore, load. This is evidenced by varying degrees of blanching or redness. The goal of a total tissue bearing socket is then pursued to decrease areas of excessive pressure (blanching) and to increase areas of inadequate loading (redness). This goal can be met through either static or dynamic test socket volume changes, or cast model modifications.</p> <p>Under weight bearing conditions, loose areas are marked by redness, and tension analysis is accomplished via "poking" the tissue through holes made in the socket. Various injectable materials (glycerine, alginate, pour-a-pad) are then added to equalize weight bearing pressures. Areas of excessive weight bearing, if not relieved by the weight borne by the newly injected materials, are either relieved in the socket or modified on the master mold.</p> <p>By achieving a careful stump-socket interface tension analysis as described, greater confidence in he ultimate result and an optimum fit is possible. Difficulty of fit dictates the number of check socket fittings. Unfortunately, fittings are also affected by the reimbursement source. The fact is undeniable, however, that a transition to the use of transparent test socket fittings can increase the level of prosthetic expertise and elevate the profession to a higher plateau of fitting success.</p> <h3>Dynamics</h3> <p>Advancements in prosthetic componentry and gait analysis techniques, when used in conjunction with improved evaluation tools and fitting methods, provides a greater arsenal for the prosthetist seeking to optimize his patient's abilities. An exciting variety of new techniques are surfacing throughout the country which not only render prosthetics more professionally demanding to the practitioner, but also challenging to the patient. Different socket styles and theoretical bends are adding to current thought and practice.</p> <p>The above-knee amputee now has a variety of alternatives in not only socket material and construction, but in functional design as well. The Swedish flexible socket offers a lighter weight, more "natural" feeling socket to the AK amputee. It also allows for greater transmission of heat via the polyethylene or Surlyn® material, and therefore a cooler feeling. The flexibility of the socket also encourages physiological muscle activity and provides sensory feedback through the thin material.<a></a></p> <p>Contoured Adducted Trochanteric Controlled Alignment Method (CATCAM) is an exciting new above-knee socket design. Proponents claim it increases comfort secondary to total soft tissue weight bearing, because the ischial tuberosity is no longer on the "seat" of the conventional quadrilateral design, but contained within the socket. The CATCAM also allows for more natural muscle activity by virtue of both the flexible design (a la Swedish flexible socket) and inherent socket mechanics. By improving the socket's purchase on the femur, whereby the ischium, trochanter, and adductor longus tendon are in essence "locked-in," stabilization increases, which then decreases the Trendelenberg tendencies experienced by many above-knee amputees. By obtaining a definite position of adduction of the femur, one can take advantage of the muscle stretch of the gluteus medius and therefore increase pelvic control with unilateral weight bearing.<a></a></p> <p>Ultralight weight components continue to be preferred in the above-knee prosthesis. The availability of titanium, carbon graphite, and higher density plastics in the manufacturing of the pylons, joints, and attachment plates allow for lighter weight limbs and, ultimately, decreased energy costs for the amputee.</p> <p>The below-knee amputee has a varied repertoire of options. A greater array of suspension methods—latex rubber, neoprene sleeves, total suction prostheses—are now available. The Flex-foot prosthesis<a></a> utilizes a sleeve suspension and is comprised of a carbon graphite and fiberglass pylon and a heel that is very strong, light weight, waterproof, and energy cost effective. The Flex-foot design provides "stored energy" upon weight bearing that "propels" the amputee forward, mimicking "normal" muscle activity in gait. This can also be used for the above-knee amputee. The Flex-foot is proving to be a great advance toward increasing the abilities of the athletic amputee and shows great promise for the elderly and less physically challenged.</p> <p>New liner materials have also provided alternatives for the below-knee amputee, with greater comfort as a result. Silicone gel and leather liners,<a></a> Ipocon gel,<a></a> and injection molded silicone gel liners<a></a> offer the amputee who has minimal tissue coverage and/or scarring the benefit of shock absorption and a "new skin" type feel. The active, athletic below-knee amputee also captures the benefit of the gel system and suffers less trauma as a result.</p> <p>Prosthetic feet, such as the Seattle<a></a> foot and S.A.F.E.<a></a> foot, appear to offer better gait characteristics and function, and also allow for increased activity by virtue of their functional, flexible designs.</p> <p>Ancillary methods of evaluating and improving gait performance are making their way into the more aggressive practices. John Sabolich, C.P.O.<a style="text-decoration: none;">*</a> in Oklahoma City has been utilizing a bio-feedback device with his above-knee patients in an attempt to re-educate the gluteus medius muscle during gait training. Utilizing the system in a dynamic fashion, i.e. patient ambulating with the electrodes over the targeted muscle, provides the patient audible feedback of muscle activity.</p> <p>Use of a video tape camera also provides patients with optimum benefits during the alignment and gait training period.<a></a> Careful analysis of the saggital and frontal views provides the practitioner with a better opportunity to critically analyze and improve his patient's gait. Improved problem-solving subsequent to delivery is also a benefit of this technique. The film serves as a learning tool for the new amputee and the practitioner, and also serves as a record of a patient's progress and delivery status for ironing out future fitting problems relative to gait induced complaints.</p> <p>The Computer Aided Design, Computer Aided Manufacturing (CADCAM) technique<a></a> is presently available for use in designing below-knee prosthetic sockets and will soon be available for design of above-knee prosthetic sockets as well. Measurements are taken from the residual limb and entered into the program. A screen display then allows for modifications to be made relative to the entered data and design scheme. Once the design is created, the information is transmitted to a computerized milling device that then carves out a model of the residual limb. From this model a socket is fabricated from polypropylene.</p> <p>In the future, "shape-sensing" will allow for modifications from the sensed data rather than the standard methodology. The ability to draw from the digitalized information of Computerized Axial Tomography (CATSCAN) or x-rays is also in the offing. This system is also an excellent, accurate record keeping tool. The potential to "sense" size and shape, store the information, recall, modify, or duplicate as desired is an enticing prospect. Further research is both warranted and forthcoming.</p> <h3>Conclusion</h3> <p>With the advent of better technology and methods, a concomitant increase in prosthetic professionalism occurs. Improved education must also follow. Industry-wide attention to continuing the trend will help prevent our field from lapsing into the mundane.</p> <p>The practice of this increased professionalism and improved techniques also commands a higher cost. Jan Stakosa, C.P.'s<a style="text-decoration: none;">*</a> method of using a wide variety of componentry per patient during the fitting and alignment phases in order to optimize function not only serves to improve the patient's quality of life, but carries with it an increased time commitment and cost. Due to this increased input and component variability, thorough education of the public and professionals per the costs involved is required. Ultimately, third party payers and the government will also have to be addressed. Until such time as these practices and advancements become standard, there will not be reimbursement for them.<a></a></p> <p>How do you value human needs in a marketplace in which the trend is toward price reduction? The reality is that all these advances will increase the cost of prosthetic care. Prosthetists, the public, third party payers, and the government will need to be willing to improve the quality of life for this sector of the population, who deserve to be rehabilitated to the maximum and be allowed to perform as well as any able-bodied individual.</p> <p>It is our hope that the prosthetic industry will take up the challenge to advance the profession and invest the time in testing preferred methods and improvements. Equally important is the quest to participate in their creation. Through improved knowledge of the mechanics of amputation surgery and the variables of follow-up care, combined with mutual professional dialogue, we can better serve the amputee population.</p> <p><b>References:</b></p> <ol> <li>Barnes, R.W.; Shanik, G.D.; and Slaymaker E.E., "An index of healing in below-knee amputation: Leg blood pressure by Doppler ultrasound," <i>Surgery</i> 79(1):13-20, 1976.</li> <li>Bonner, F.J. and Green, R.F., "Pneumatic airleg prosthesis: Report of 200 cases," <i>Archives of Physical Medicine and Rehabilitation</i>, 63:383-385, 1982.</li> <li>Burgess, E.M., "General principles of amputation surgery," <i>Atlas of Limb Prosthetics: Surgical and Prosthetic Principles</i>, St. Louis, MO, Mosby, Ch. 2, p.p. 14-18, 1981.</li> <li>Burgess, E.M., "Postoperative management," <i>Atlas of Limb Prosthetics: Surgical and Prosthetic Principles</i>, St. Louis, MO, Mosby, Ch. 3, p.p. 19-23, 1981.</li> <li>Burgess, E.; Hittenberger, D.; Forsgren, S.; and Lindh, D., "The Seattle foot," <i>Orthotics and Prosthetics</i>, 37(1):25-31, 1983.</li> <li>Campbell, J. and Childs, C, "The S.A.F.E. Foot," <i>Orthotics and Prosthetics</i>, 34(3):3-16, 1980.</li> <li>Cary, J.M. and Thompson, R.G., "Planning for optimum function in amputation surgery," <i>Atlas of Limb Prosthetics: Surgical and Prosthetic Principles</i>, St. Louis, MO, Mosby, p. 28, 1981.</li> <li>Ertl, J., "Uber amputationstumpfe," <i>Chirurg.</i>, 20:218, 1949.</li> <li>Gibbons, G.W.; Wheelock Jr, F.C.; Hoar Jr, CS., et al, "Predicting success of forefoot amputations in diabetics by noninvasive testing," <i>Archives of Surgery</i>, 144:1034, September, 1979.</li> <li>Graves, J., "Selectively placed silicone gel socket liners," <i>Orthotics and Prosthetics</i>, 34(2):21-24, 1980.</li> <li>Hanak, R., "Fabrication procedures for the ISNY above-knee flexible socket (instruction manual)." Course at New York University, Post-Graduate Medical School, Prosthetics and Orthotics, January, 1984.</li> <li>Henderson, H.P. and Hackett, M.E.J., "The value of thermography in peripheral vascular disease," <i>Angiology</i>, 29:65-71, 1978.</li> <li>Hittenberger, D.A. and Carpenter, K.L., "A below knee vacuum casting technique," <i>Orthotics and Prosthetics</i>, 37(3): 15-23, 1983.</li> <li><i>Ipocon Silicon Liner Technical Manual</i>. IPOS, Lune-berg, West Germany.</li> <li>Kerstein, M.D., "Utilization of an air splint after below-knee amputation," <i>American Journal of Physical Medicine and Rehabilitation</i>, 53(3): 119-126, 1974.</li> <li>Koniuk, W., Personal communication. San Francisco Prosthetic-Orthotic Service, Inc., San Francisco, 1985.</li> <li>La Noue, A.M., "More on Ertl tibiofibular synostosis," <i>Newsletter . . . Amputee Clinics</i>, (V)4:3-4, July, 1973.</li> <li>Leal, J., "The Flex-foot prosthesis" (instruction manual). Presented at UCLA Prosthetics Education Program, Advanced Below Knee Prosthetics Saturation Seminar, October, 1984.</li> <li>Loon, H.E., "Below-knee amputation surgery," <i>Selected Articles from Artificial Limbs</i>, January 1954 - Spring 1966. Huntington, NY, Krieger, p.p. 305-318, 1970.</li> <li>Malone, J.M.; Leal, J.M.; Moore, W.S.; et al., "The Gold Standard for amputation level selection: Xenon-133 clearance," <i>Journal of Surgical Research,</i> 30:449-455, 1981.</li> <li>Malone, J.M.; Moore, W.S.; Leal, J.M. and Childers, S.J., "Rehabilitation for lower-extremity amputation," <i>Archives of Surgery</i>, 116:93-98, January, 1981.</li> <li>Mehta, K.; Hobson II, R.W.; Jamil, Z; et al., "Fallibility of Doppler ankle pressure in predicting healing of transmetatarsal amputation," <i>Journal of Surgical Research</i>, 28:466, 1980.</li> <li>Mooney, V. and Snelson, R., "Fabrication and application of transparent polycarbonate sockets," <i>Orthotics and Prosthetics</i>, 26(1):1-13, 1972.</li> <li>Moore, W.S.; Henry, R.E.; Malone, J.M.; et al., "Prospective use of Xenon Xe 133 clearance for amputation level selection," <i>Archives of Surgery</i>, 116:86-88, January, 1981.</li> <li>Pike, A.C. and Black, L.K., "The orthoglas transparent test socket-an old idea, a new technology," <i>Orthotics and Prosthetics</i>, 36(4):40-43, 1982-83.</li> <li>Pollack Jr, S.B. and Ernst, C.B., "Use of Doppler pressure measurements in predicting success in amputation of the leg," <i>American Journal of Surgery</i>, 139:303, 1980.</li> <li>Reger, S.I.; Letner, I.E.; Pritham, CH.; et al., "Applications of transparent sockets," <i>Orthotics and Prosthetics</i>, 30(4):35-39, 1976.</li> <li>Sabolich, J. and Guth, T., "The C.A.T.C.A.M. above knee prosthesis pilot course" (instruction manual). Course at UCLA Prosthetic Education Program, March, 1985.</li> <li>Saunders, C.G., "Computer-aided socket design: A computer-aided design and manufacturing package for fitting below-knee amputees with sockets," <i>Medical Engineering Resource Unit</i>, Shaughnessy Hospital, Vancouver, BC, Canada, March, 1984.</li> <li>Saunders, C.G. and Fernie, G.R., "Automated prosthetic fitting." Proceedings of the 2nd International Conference on Rehabilitation Engineering, Ottawa, 1984.</li> <li>Schmitter, E.D., "Surgical principles and practice: Lower Extremity amputations." Lecture-Prosthetics and Orthotics Course for Physicians and Therapists. Provided by Prosthetic-Orthotic Education Program, School of Medicine, Department of Surgery (Orthopaedics). University of California, Los Angeles, April 5-9, 1982.</li> <li>Staats, T.B., "Advanced prosthetic techniques for below knee amputations," <i>Orthopedics</i>, 8(2):249-258, 1985.</li> <li>Stakosa, J.J., "Prosthetics for lower limb amputees," <i>Vascular Surgery: Principles and Techniques</i>, Norwalk, CT, Appleton-Century-Crofts, p.p. 1143-1162, 1984.</li> <li>Sterescu, L.E., "Semirigid (Una) dressing of amputations," <i>Archives of Physical Medicine and Rehabilitation</i>, 55:433-434, September, 1974.</li> <li>Varnau, D.; Vinnecour, K.E.; Luth, M.; and Cooney, D.F., "The enhancement of prosthetics through Xerora-diography," <i>Orthotics and Prosthetics</i>, 39( 1): 14-18, 1985.</li> <li>Whipple, L. and Stakosa, J., "The not so simple ABC's of high technology," <i>Disabled USA</i>, Washington, D.C., July, 1983.</li> <li>Wu, Y.; Keagy, R.D.; Krick, H.J.; et al., "An innovative removable rigid dressing technique for below-the-knee amputation," <i>Journal of Bone and Joint Surgery</i>, 61-A(5):724-729, 1979.</li> </ol> <div style="width: 400px;"><b>Footnote</b> Jan Stakosa, C.P. is Director of the Institute for the Advancement of Prosthetics, Lansing, Michigan. <br /><br />John Sabolich, C.P.O., is Vice-President of Sabolich Orthotics-Prosthetics Center, Oklahoma City, Oklahoma.<br /><br /></div> <div style="width: 400px;"><em><b>*Keith E. Vinnecour, C.P.O. </b> Keith E. Vinnecour, C.P.O., is owner and president of Beverly Hills Prosthetics Orthotics, Inc., Beverly Hills, California.</em><br /><br /><em><b>*David F.M. Cooney, R.P.T., C.P.O. </b> David F.M. Conney, R.P.T., C.P.O., is a senior vice-president at Beverly Hills Prosthetics and Orthotics, Inc.</em><br /><br /><br /></div> Page Number(s) 4 - 9 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Advanced Approach Toward Improved Prosthetic Fittings Creator An entity primarily responsible for making the resource David F.M. Cooney, R.P.T., C.P.O. * Keith E. Vinnecour, C.P.O. * https://staging.drfop.org/files/original/f27b5d0368f4e859eccd1d6f3bbc38f3.pdf 2f3ebf3eaaf369545618afd8223fa39a https://staging.drfop.org/files/original/f035dc301e4fd1b9f7d498b18103cf33.jpg bc8736187d5b1cf372db15bae5fecbd1 https://staging.drfop.org/files/original/2f7fa7cb9146f525c58ba9d5bcdceee4.jpg d214434a7961b9d5b14e264027271d7a https://staging.drfop.org/files/original/3a3c0bf2056231987373ba4f3814cbdf.jpg 23890f5cc143cafe9297a430b85fd568 https://staging.drfop.org/files/original/1a23101ee14ed4cb9aada341d3d3c26e.jpg 93936696164a3d915c3460beb861e616 https://staging.drfop.org/files/original/448a0c6b9b0421ba2d64bccc76c9c0ea.jpg d170fb3ae9f4307cbf7564df55fca257 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_114.pdf Text Any textual data included in the document <h2>The UCLA Anatomical Hip Disarticulation Prosthesis</h2> <h5>David H. Littig, B.A., CP.&nbsp;<a style="text-decoration: none;">*</a><br />Judd E. Lundt, B.S., A.E.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This article discusses a new approach to hip disarticulation and hemipelvectomy fittings developed at the UCLA Prosthetics Education Program. It employs fundamental principles and methods in a new and different combination to produce a more complex and more natural biomechanical system. The results include:</p> <ul> <li> <p>a smoother, and apparently less energy consuming gait</p> </li> <li> <p>improved stability</p> </li> <li> <p>improved suspension</p> </li> <li> <p>improved wearer comfort</p> </li> </ul> <h3>Introduction</h3> <p>For several years now, the UCLA Prosthetics Education Program has been involved in an effort to understand, develop, and refine a teaching method for the CAT-CAM Socket,<a></a> the anatomically shaped above-knee socket. The very essence of this effort is a broader and more detailed understanding of the pelvic anatomy and its optimal containment within the socket. With the dramatic above-knee results that have been achieved through this understanding has come a compelling and obvious need to examine the application of the same principles to hip disarticulation fittings.</p> <p>It was felt that a hip disarticulation socket design, which would encapsulate the ischium and ischial ramus in a more anatomical contour than previous socket designs, might produce an improved prosthetic fitting.<a></a> Since much of the CAT-CAM experience alluded to employed a frame supported flexible polyethylene socket, the flexibility of such a design applied to a hip socket seemed a reasonable way to provide more comfort. These factors formed the basis for this work.</p> <p>To date, three hip disarticulation patients and one complete hemipelvectomy patient have been successfully fit with the design described. The hemipelvectomy application followed the hip patient fittings by a number of months and was tried only as a whimsical experiment. Based upon the initial understanding of the biomechanics, this fitting was not expected to succeed. However, the results were quite surprising and motivated another look at the biomechanical analysis. Two of the hip cases and the hemipelvectomy case will be described in this article along with the biomechanics.</p> <h3>Patient Experience</h3> <p>The first hip disarticulation patient is a 23 year old male who had an amputation on the right side at age five for tumor, and who has rejected a prosthesis since age ten because it was too limiting and cumbersome. Owing to immature muscular and skeletal development at the time of amputation, he is significantly atrophied on the amputated side. This individual is extremely active, participates and excels in athletics as an equal with the able-bodied, and is impressively agile on crutches. Consequently, his remaining limb is hyperdeveloped to the extent that the thigh musculature extends well past the midline of the body.</p> <p>The second hip case, a right amputee as well, could be described as a more typical patient. He is a 40 year old professional, amputated at age 28, also due to a tumor. He has worn a prosthesis continuously since his amputation, the most recent being an Otto Bock en-doskeletal design. When this project was begun, he had recently taken delivery of a new one-piece flexible socket prosthesis which combined a Flex-Foot™ with Otto Bock endo-skeletal knee and hip components.</p> <p>The hemipelvectomy case was a 26 year old male who had undergone complete amputation on the left side for a massive tumor in the hip joint. At the time of the work described here, which was six months post-surgery, he had not yet been fit for a definitive prosthesis, but was wearing a socket only for sitting comfort. This patient was first seen as a demonstration subject for prosthetic certificate students at UCLA. For that program, he was fit with a fairly conventional design. However, since his level of amputation is somewhat uncommon, and because the patient was willing to experiment, the design was altered to include the suspension system that had been found to be so successful with the hip disarticulation patients.</p> <h3>Fabrication</h3> <p>The hip patients were cast using a similar technique with splints, circular wrap, iliac crest definition, anterior and posterior compression, and ischial weight-bearing while the plaster hardened. Since this was an attempt at a more anatomical socket, contours detailing the ischial ramus angle and the medial inclination of the ischium were included in the cast. Unlike the above-knee socket which flexes and extends with the femur through each stride, the hip socket is expected to remain relatively fixed, relative to the pelvic anatomy. Thus, the medial brim need not extend as high or contain as much of the ischial ramus. If properly executed, a cast which includes the bony contours of the pelvis will take much of the guesswork out of cast modification and fitting and should reduce the number of check sockets needed to attain an optimum result.</p> <p>The initial concept for a hip disarticulation socket was a one-piece polyethylene design with a laminated frame to which the hip joint would be attached. Accordingly, such a system was fabricated for the first fitting. The results were reasonably successful. However, sound side comfort and piston action of the resulting prosthesis were not wholly satisfying. Since this was an experiment, it was decided to push further. Through several reiterations of socket size, volume and shape, and through several experiments with suspension, the design described in this article was arrived at: a two-piece system composed of a laminated anatomically shaped socket, encompassing only the amputated side and connected to a polyethylene suspension segment for the sound side waist with Dacron® webbing (<b>Fig. 1</b>).</p> <strong><a href="/files/original/f035dc301e4fd1b9f7d498b18103cf33.jpg">Figure 1</a>. Posterior view of suspension system showing "X" pattern strapping.</strong><br /> <p>Fabrication of the socket for the hip patients was relatively simple because of the two-piece design. The original model was split and only the amputated side laminated. For the contralateral side, a shell of Aliplast®-lined polyethylene was vacuum formed over that half to serve as the suspension system.</p> <p>Since the initial fitting of the hemipelvectomy patient was meant to instruct the certificate students in basic prosthetics for this level of amputation, the approach was very straightforward. He was cast in a suspended attitude with a simple circular wrap. Modification involved little more than smoothing of the model. A total flexible polyethylene socket was vacuum formed over the entire model. Following this, a frame for mounting the hip joint was laminated over the amputated side only of the polyethylene socket. As this was a demonstration fitting with no intent to finish, the hip joint was only temporarily attached.</p> <p>Prostheses for all patients were assembled with Otto Bock endoskeletal 7E7 hip joints and 3R20/3R36 knee units. Several feet were experimented with on the first patient until an Otto Bock single axis foot proved optimum. The Flex-Foot™ that had been included with the second patient's recently delivered prosthesis was incorporated into his set-up. The hemipelvectomy patient was also fit with an Otto Bock single axis foot.</p> <p>The socket and sound side suspension segment for the hip disarticulations were joined posteriorally with Dacron® webbing. Using temporarily attached four-bar buckles and the webbing, the proximal and distal aspects of the socket and the polyethylene segment were connected with the webbing to form an "X" pattern across the posterior gap (<b>Fig. 1</b>). At their cross point, the straps are not connected but are allowed to freely move with respect to each other. The buckles were found to be necessary for "fine tuning" adjustments of the suspension during fitting and alignment. Anteriorly, a single strap attached at the distal aspect of the laminated socket was passed through a loop on the polyethylene portion and back to a roller buckle on the anterior proximal socket (<b>Fig. 2</b>).</p> <strong><a href="/files/original/2f7fa7cb9146f525c58ba9d5bcdceee4.jpg">Figure 2</a>. Anterior view of suspension system.<br /></strong><br /> <h3>Functional Results</h3> <p>Results achieved with this combination of socket and suspension were dramatic. After some adjustments, the hip patients felt no discomfort from the socket, despite the obvious upward curve of the medial brim in the perineum. This edge, along with the distal portion of the socket, particularly under the ischium, were lightly padded with 1/8" Pe-Lite™, as is customary in most hip sockets. Neither patient perceived any piston action or discomfort from the proximal brim of the socket or the polyethylene waist segment. The most obvious benefit was a significant reduction in lateral trunk bending that is so common with hip disarticulation amputees. In fact, this gait anomaly was reduced beyond that usually seen with many above-knee amputees. Both patients were impressed with the comfort and secure feeling that the design afforded.</p> <p>With the adjustable diagonal posterior straps, which in the finished prosthesis are replaced with buckleless double Dacron® webbing, the socket can be optimally positioned under the pelvis to more effectively encapsulate the bony pelvic anatomy. This is somewhat akin to adducting an above-knee socket of similar medial brim design (CAT-CAM). By a careful balance in the strap length adjustments, comfort and suspension in the entire system can be achieved.</p> <p>Because of the success that had been achieved with the hip disarticulation patients with this suspension technique, it was decided to try it on the hemipelvectomy patient. His reasonably comfortable and functional single piece socket was modified by removing the center portion of polyethylene in the posterior and rejoining the two separate segments with Dacron® webbing in the same cross strap pattern. An anterior closure as previously described was also employed (<b>Fig. 3</b>). The result was about 1/8" of piston action and improved comfort over the one-piece design, probably because the prosthetic socket could more accurately follow the body contours.</p> <strong><a href="/files/original/3a3c0bf2056231987373ba4f3814cbdf.jpg">Figure 3.</a> Posterior view of hemipelvectomy setup showing adjustable cross strapping.<br /></strong><br /> <h3>Biomechanics</h3> <p>In all cases, it appears that during the gait cycle the polyethylene segment that encompasses the contralateral hip will tilt from the vertical as it follows the changing sound side body contour. The forces thus imposed on each of the posterior straps will vary alternately, and their crosspoint will shift slightly with each stride. For example, as the amputee reaches heel strike on the prosthesis, tension in the strap originating at the posterior proximal socket (the lateral support strap) will build as the body moves forward, and the center of gravity begins to shift laterally. As the patient progresses, this force reaches its maximum at mid-stance (<b>Fig. 4</b>) and then begins to fall off. Tension in the other (suspension strap) is at its lowest at mid-stance on the prosthetic side and then begins to build toward its peak when the amputee reaches mid swing-through (<b>Fig. 5</b>). The cycle then repeats itself with each successive stride. This alternating action in the straps, coupled with an accurately contoured socket, provides a continuously snug and secure suspension without the need for excessive tightness.</p> <strong><a href="/files/original/1a23101ee14ed4cb9aada341d3d3c26e.jpg">Figure 4</a>. Suspension system forces at mid-stance.</strong><br /><br /><strong><a href="/files/original/448a0c6b9b0421ba2d64bccc76c9c0ea.jpg">Figure 5</a>. Suspension system forces during swing.</strong><br /> <p>At the outset of these efforts, it was believed that much of the success of the suspension system depended upon a well-contoured medial brim, which accurately encapsulated the ischium and ischial ramus. The hemipelvectomy fitting quickly dispelled this consideration as a major factor. However, all hip disarticulation patients fit to date have perceived far greater comfort and control when in a socket so described. The idea behind ischial containment is to provide greater mediolateral stability in the prosthesis. It appears that the cross strap suspension is contributing the better part of this stability.</p> <p>Results to date suggest that the two-part socket and posterior cross strapping provide a mechanism which more closely conforms to changing soft tissue and muscle contours through the gait cycle. With a one-piece socket, regardless of flexibility, slight and subtle motions about all three body axes are not fully accommodated by "give" in the socket, as well as they seem to be in the one described here. Thus, the body must either move inside the socket or limit its movements due to the restrictions imposed by the rigidity of the socket. In either case, the result is a less natural gait and a greater apparent expenditure of energy. With this new approach, these shortcomings of the hip and hemipelvectomy fittings seem to be significantly reduced.</p> <p><b>References:</b></p> <ol> <li>Sabolich, John, "Contoured Adducted Trocanteric Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles," Clinical Prosthetics and Orthotics, Vol. 9, No. 4, Fall, 1985, pp. 15-26.</li> <li>Sabolich, John and Tom Guth, "CAT-CAM Innovations," Ability, Vol. 6, No. 3, Winter, 1986, p. 48.</li> </ol> <p><em><b>*Judd E. Lundt, B.S., A.E. </b> UCLA Prosthetics Education Program, Rehabilitation Center, 1000 Veteran Avenue, Room 22-41, Los Angeles, California 90024.</em></p> <p><em><b>*David H. Littig, B.A., CP. </b> UCLA Prosthetics Education Program, Rehabilitation Center, 1000 Veteran Avenue, Room 22-41, Los Angeles, California 90024.</em></p> Page Number(s) 114 - 118 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-5.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 The UCLA Anatomical Hip Disarticulation Prosthesis Creator An entity primarily responsible for making the resource David H. Littig, B.A., CP. * Judd E. Lundt, B.S., A.E. * https://staging.drfop.org/files/original/9fce2f56ec56ccbbaff5166e0706b01f.pdf 5548abda79aee7e1363a542a22e37550 https://staging.drfop.org/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg 0222f4152435fc260955f32524bbb711 https://staging.drfop.org/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg d1dbb049869929f1473972725498c986 https://staging.drfop.org/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg 3bafaaab01346b31406d8d2d21b0be9c https://staging.drfop.org/files/original/de4e477cd3382de1d4516750b81da61d.jpg abf27e1e5360c4d5dfa6da2f7932a611 https://staging.drfop.org/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg 7bc8b46ef73d497018dceb1b1133d3c5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_027.pdf Text Any textual data included in the document <h2>Flexible Socket Systems</h2> <h5>David J. Jendrzejczyk, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Over the past two years there has been impetus towards the use of the flexible socket interface in above knee prosthetics. For our purposes here, it is widely accepted that the flexible socket is of multiple benefit to the patient. We will concentrate on discussing the different systems available.</p> <p>The history of flexible sockets dates back a number of years. The article by Charles Pritham, C.P.O., et. al. "Experience with the Scandinavian Flexible Socket"<a></a> provides a concise summary of this train of development.</p> <p>At the present time, there are numerous flexible socket systems being used in the United States and throughout the world. These sockets differ in design in two major areas: flexible socket interface and the outer hard socket. The flexible socket is currently being used with three types of support mechanisms:</p> <ol> <li> <p>Total hard socket as the support</p> </li> <li> <p>Hard socket with strategic fenestrations</p> </li> <li> <p>True frame design</p> </li> </ol> <p>The prosthesis discussed by R. Volkert in the article, "Frame type Socket for Lower Limb Prosthesis"<a></a> is constructed with a frame outer socket and an elastic stocking interface. This system can accommodate stump volume changes, therefore, it appears to be most useful with early amputees.</p> <p>The TC Couple Socket<a></a> above-knee prosthesis used a polyethylene flexible interface and an external polypropylene socket. There are no fenestrations in the outer socket, so it doesn't have some of the benefits of sensory feedback as a fenestrated outer socket would. The advantage of this system is its light weight polypropylene outer socket.</p> <p>Work done at the Institute of Rehabilitation Medicine, New York University Medical Center, is detailed in "Flexible Prosthetic Socket Technique."<a></a> Two systems are described in the article, both have a hard outer socket with windows cut out in strategic locations (<a href="/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg"><b>Fig. 1</b></a>). The interface is either of thermo-formed polyethylene or of silicone elastomer lamination.</p> <strong><a href="/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg">Figure 1</a>. Prosthesis incorporating a flexible Polyethylene socket in a support with fenestrations in selected areas as fitted at the Rusk Institute of Rehabilitation Medicine (Photo courtesy RIRM).</strong><br /> <p>Currently, in the United States, the external frame with the thermoplastic interface seems to be the most commonly used. There are three major fabrication techniques for the frame system described. They are the IPOS System (<a href="/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg"><b>Fig. 2</b></a>),<a></a> the ISNY (<a href="/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg"><b>Fig. 3</b></a>),<a></a> and the SFS System (<a href="/files/original/de4e477cd3382de1d4516750b81da61d.jpg"><b>Fig. 4</b></a>)<a></a> (Fillauer Technique).<a></a><a style="text-decoration: none;">*</a></p> <strong><a href="/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg">Figure 2</a>. Flexible AK socket as fabricated by IPOS (Photo courtesy IPOS).</strong><br /><br /><strong><a href="/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg">Figure 3</a>. Icelandic Swedish New York (ISNY) flexible socket (Photo courtesy NYU).</strong><br /><br /><strong><a href="/files/original/de4e477cd3382de1d4516750b81da61d.jpg">Figure 4</a>. Scandinavian Flexible Socket (SFS) (Photo courtesy Durr-Fillauer Medical, Inc.).</strong><br /> <p>The intention of this article is to describe the differences and similarities of the above three systems.</p> <h3>Socket Interface</h3> <p>All three systems use a thermoplastic material for their inner socket.</p> <p>IPOS uses ipolen,<a></a> which is a specially formulated polyethylene and which reportedly provides a uniform socket thickness and has little shrinkage. The resulting socket is translucent.</p> <p>The ISNY system prefers polyethylene which has a tendency to shrink. NYU reports that the shrinkage is not a problem. This socket is also translucent.</p> <p>The SFS system recommends Surlyn®, but polyethylene can be used. Surlyn® is a thermo-formable plastic which shrinks little and provides a transparent socket.</p> <p>The thermo-forming method for the interface is basically the same for all three systems. The only difference is that IPOS recommends that you preheat the vacuum forming frame, and they prefer a dry cast. If a wet cast is used, they recommend that an IPOS sheath be pulled over the cast before the thermo-forming. The SFS system recommends a warm, wet mold for Surlyn®. ISNY states no preference.</p> <h3>Frame (Structural Element)</h3> <p>The most variation occurs in the fabrication of the frame. Materials and lay-up have a wide range of variation (<a href="/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg"><b>Table I</b></a>).<br /><img src="/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg" /><br />IPOS laminates on the positive model with the flexible socket in place. Carbonacryl, which has been specially formulated to use with carbon fibers (13-1), is laminated over the appropriate layers of nylon stockinette, carbon-glass stockinette, fiberglass matting, and fiberglass stockinette. Total lay-up is seven layers for the average size patient of 120 to 180 pounds.</p> <p>The ISNY system laminates on the positive model with the flexible socket in place. Their recommendation is for 100 percent rigid polyester, acrylics if desired. A polyester lamination is done over the appropriate layers of nylon stockinette, fiberglass stockinette, and 1" and 2" unidirectional carbon tape. The total layup is 26 layers in both directions. In addition, they recommend adding dacron felt "to insure sufficient thickness in strategic areas."<a></a></p> <p>SFS laminates their frame over the positive model, which has been built up with varying layers of stockinette used as a filler in place of the flexible socket. An acrylic lamination is done over the appropriate layers of nylon stockinette, fiberglass stockinette, and 1" unidirectional carbon tape. Total lay-up at the proximal brim is 25 layers, and 26 layers at the medial brim.</p> <p>In the ISNY and SFS systems care must be taken in the lay-up of the medial/proximal brim where the materials overlay to avoid excessive thickness.</p> <h3>Frame Dimensions</h3> <p>There are some variations in the final trim-lines of the frame. The medial strut on the SFS and ISNY are approximately 2 1/2" and 2 3/4" wide. The medial strut on the IPOS frame extends around the anterior and posterior medial edge by one centimeter.</p> <p>The proximal trimlines on the SFS, anteriorly and posteriorly, are 2/3 the medial/lateral width. The proximal trimlines of the ISNY extend to the anterior and posterior lateral socket corners. The proximal trimlines of the IPOS extend around the anterior and posterior lateral corner by 2 centimeters.</p> <p>In the SFS and IPOS systems, the distal trim-line cups around the lateral distal femur. The ISNY does not. All systems tell you to take care to have an adequate radius on connecting edges between the medial strut and the proximal and distal trimlines.</p> <h3>Comments and Conclusions</h3> <p>The afore-mentioned indicated that there are many questions still unanswered. The varying lay-up design makes for varying flexibility and weight difference in the frames. At Newington, we question why the severe differences in build-up exist and as a result are undertaking a research project with some students at the Engineering Department at the University of Hartford. As a senior research project, they are planning an evaluation of the mechanics and structure of the three strut designs as well as the flexible socket material.</p> <p>It should be noted that if there are severe undercuts on the positive model, removal of the finished strut from the model can cause stress cracks in the frame.</p> <p>Problems have been noted by Newington and</p> <p>others of the flexible socket breaking after delivery to the patient. Care must be taken in fabrication of the socket that all flares are built into the positive mold. This will help reduce the stress in the molding process. Another recommendation to remove the stress from the finished flexible socket is an annealing process. We have yet to evaluate its effectiveness.</p> <p>In conclusion, there has been some confusion as to the different systems. Our purpose here has been to clarify the systems and their differences. As with any new system, questions and confusion are to be expected.</p> <p>It is still a subjective evaluation. As long as the patient benefits, use the system (or combination of systems) with which you are the most comfortable.<br /><br /><b>Footnote</b> Further reference to the SFS system will be as it is fabricated by Durr Fillauer Medical, Inc.<br /><br /><em><b>*David J. Jendrzejczyk, CP. </b> David J. Jendrzejczyk, CP. is with Newington Children's Hospital, 181 East Cedar Street, Newington, Connecticut 06111.<br /></em></p> <p><b>References:</b></p> <ol> <li>Berry, Dale, CP., "Flexible above knee socket made from low-density polyethylene suspended by a weight transmitting frame," IPOS-Composite Materials for Prosthetic Orthotic Application, April 10, 1985.</li> <li>Berry, Dale, CP., IPOS-Flexible Socket, Case Study and Overview, April 10, 1985.</li> <li>Davis, Roy B., Ill, Ph.D., "Comparison of Inter-face Pressure Distributions, Soft Socket (ISNY/SFS) vs. Hard Socket," presented at an American Academy Orthotics and Prosthetics-New England Chapter Meeting, March, 1985.</li> <li>Giannini, Margaret, M.D., "Transfer of Rehabilitation Research and Development Results into Clinical Practice," <i>Clinical Prosthetics and Orthotics</i>, Volume 8, Number 1.</li> <li>Kay, Hector W. and Newman, June D., "Report of workshop on below-knee and above-knee Prostheses," <i>Orthotics and Prosthetics</i>, Volume 27, Number 4, pp. 9-12, 21, December, 1973.</li> <li><a href="poi/1981_03_129.asp">Koike, K.; Ishikura, Y.; Kakurai, S.; Imamura, T., "The TC double socket above-knee prosthesis," <i>Prosthetics and Orthotics International</i>, 1981, pp. 129-134.</a></li> <li>Kristinsson, Ossur, "Flexible Above Knee Socket made from Low Density Polyethylene, Supported by a Weight Transmitting Frame," <i>Orthotics and Prosthetics</i>, Volume 37, Number 2, pp. 22-27.</li> <li>Lehneis, H.R., Ph.D., CPO; Chu, Don Sung, M.D.; Adelglass, Howard, M.D., "Flexible Prosthetic Socket Techniques," <i>Clinical Prosthetics and Orthotics</i>, Volume 8, Number 1, pp. 6-11.</li> <li><a href="al/1968_02_028.asp">McCollough, Newton, C, III, M.D.; Sarmiento, Augusta, M.D.; Williams, Edward M., M.D.; Sinclair, William F., CP., "Some considerations in Management of the Above-Knee Geriatric Amputee," <i>Artificial Limbs</i>, Volume 12, Number 2, pp. 28-35, Autumn, 1968.</a></li> <li>Pritham, Charles H., C.P.O.; Fillauer, Carlton, C.P.O.; Fillauer, Karl, C.P.O., "Experience with the Scandinavian Flexible Socket," <i>Orthotics and Prosthetics</i>, Volume 39, Number 2, July, 1985.</li> <li>Technical Notes, <i>Artificial Limbs</i>, Volume 13, Number 1, pp. 69-71.</li> <li><a href="poi/1982_02_088.asp">Volkert, R., "Frame type socket for lower limb prostheses," <i>Prosthetics and Orthotics International</i>, pp. 6, 88-92, 1982.</a></li> <li>"A Revolutionary Technique in Fitting AK Amputees," <i>IPOS Flexible Socket Fabrication Manual</i>.</li> <li>"Prosthetic and Sensory Aids Service," Department of Medicine and Surgery, Veterans Administration, Washington, D.C., <i>Bulletin of Prosthetics Research</i>, pp. 227-229, Fall, 1972.</li> <li>"Fabrication Procedures for the ISN Y Above Knee Flexible Socket," January, 1984.</li> </ol> Page Number(s) 27 - 31 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 5 TABLE I http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Flexible Socket Systems Creator An entity primarily responsible for making the resource David J. Jendrzejczyk, CP. * https://staging.drfop.org/files/original/2af5e4a68353a2eed24a09786fdea090.pdf 90e8b0a379e8b9a8e9201fa5eefad784 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_02_001.pdf Year 1956 Volume 3 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Artificial Limbs - Their Human Owners</h2> <h5>David Shakow, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>In all areas of medicine and engineering where psychological factors are important, consideration of matters of the mind comes late. Physical problems are so obvious, urgent, and definable-mental problems so frequently cryptic, postponable, and unclear. But it usually develops that, soon after some control has been achieved over the immediate physical problems, the psychological problems obtrude themselves and call persistently for solution. Thus, in the field of amputations and artificial limbs, the primary effort has to date been directed quite naturally toward the achievement of physical restoration of function. Proportionately little thought has been directed toward the understanding and handling of the psychological problems which, in the amputee, the markedly altered adjustment situation creates. Although mechanics and the biomechanics of the amputee have many important identical principles, there is a whole area of needed activity of a quite different order.</p> <p>The psychological problems of the amputee are, of course, not merely problems of the physically disabled person himself. The new situations that are created with loss of limb are clearly social-psychological in character-situations where not only the manifold attitudes of the patient, both implicit and explicit, toward the loss and the replacement are important but also where the attitudes of family and associates toward him and his difficulty are equally significant. Hence, any full psychological study of the problem of physical handicap must involve three aspects: the attitudes of the disabled person toward the changes created in him by his new situation, as it affects his previous concepts of himself and the image he has of his body; the attitudes of others, especially significant others, toward his differentness; and, finally, the interaction of these two in the social context in which it occurs.</p> <p>In a recent evaluation of studies in this general area, Roger Barker and associates deplore the inadequacy and rarity of satisfactory investigations. Whatever the importance of adjustment problems, not only in the amputee but in all persons suffering a misfortune, it is only when problems become prominent and when social obligations are keenly felt that there appears a readiness to pay attention to what appear on the surface to be secondary aspects of problems. Just such a situation arose during World War II, when disabled veterans were returning from the battlefields in great numbers but when, although much thought was being given to physical rehabilitation, little had been done to face the problems associated with psychological readjustment.</p> <p>In response to this need, there was established at Stanford University on February 1, 1945, a study group to inquire into the social-emotional relationships between injured and noninjured people. Conducted partially under contract between Stanford and the wartime Office of Scientific Research and Development (recommended by the Committee on Medical Research), partially under a contract between the University and the Army Medical Research and Development Board of the Office of the Surgeon General, War Department, the work continued until April 1, 1948. By far the majority of the handicapped subjects studied were amputees.</p> <p>Despite the technical significance of the final report of the project, only a few mimeographed copies were distributed. It is only now-more than eight years later-that the results are seeing the light of print. Because it recognizes the basic nature of the contribution and its significance in the presentation of important problems in the psychology of handicap, the Prosthetics Research Board of the National Academy of Sciences-National Research Council has seen fit to devote an entire issue of ARTIFICIAL LIMBS to the reproduction of a single, exceptional monograph otherwise long since obscure and inaccessible. From one point of view, the departure reflects a considerable advance in the field of limb prosthetics-an acceptance of the importance of psychics as well as of the long-recognized importance of mechanics. For this major step forward, the Prosthetics Research Board merits the thanks of all.</p> <p>With regard to the unusual content of the monograph itself, a few remarks are in order. Barker and associates point out, for example, that physically deviant persons appear not to be a homogeneous group psychologically and that "so far as the somatopsychological relation is concerned there is no direct univocal link between physique and behavior." They state further that "lawful somatopsychological relations between physique and behavior are mediated by the psychological situation " These affirmations are especially pertinent to the report we are here studying. Indeed, the present material should properly be viewed in the context of these generalizations about the field as a whole. Although many questions are raised, and although many "I-wish-they-had's" remain unfulfilled, it is important to recognize the pioneering character of the study, the complexity of the field, and the reasons for the absence of more objective data and for the limited statistical treatment of the material. We should be grateful for the broad attack on the area, the commonsenseness and humanness of the molar approach used, its consistent emphasis on the total person, and the attempt to tackle the problems broadly in the context of a general theory of loss and maladjustment.</p> <p>We should perhaps not pass by the opportunity of calling attention to a few additional topics of especial interest that are dealt with in the monograph. For one thing, there is the emphasis on the emotional aspects of physical handicap rather than on the intellectual and the attempt to deal systematically with such difficult, though apparently commonplace, topics as misfortune and sympathy, seen from both the standpoint of the stricken person and of the outsider.</p> <p>There is, too, an important discussion on some of the methodological problems, particularly the place of measurement and the interview as a tool, in the present status of psychological study in the field. The presentation is made more effective by the liberal quotations from interviews and the inclusion of records of actual interviews in the appendices.</p> <p>The authors would, to be sure, be the last persons to claim any definitiveness for their study. Its major contribution lies in opening up questions and delineating areas clamoring for further psychological investigation both by more precise methods and with greater intensity. The authors' own attitudes in this respect may be gathered from the fact that they conclude the body of the monograph with a chapter headed Direction of Further Research.</p> <p>It is to be hoped that the recognition given at this time by the Prosthetics Research Board to this area of study will be the stimulus that the field needs for the multiplication of studies on this important aspect of the adjustment of the disabled person and of the noninjured people with whom he comes in contact.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>David Shakow, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Laboratory of Psychology, National Institute of Mental Health, National Institutes of Health, Bethesda, Md.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs - Their Human Owners Creator An entity primarily responsible for making the resource David Shakow, Ph.D. * https://staging.drfop.org/files/original/760e13aa1dc8e1275a4a9976de2db4cb.pdf 71a8cfac282278de7ae518edde8b0333 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_01_004.pdf Text Any textual data included in the document <h2>Editorial: Metal vs. Plastic AFO - A Therapist's View</h2> <h5>Donald G. Shurr, LPT, MA&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Ankle foot orthoses are generally prescribed for patients who are able to ambulate without an orthosis, but for whom an orthosis allows a safer, and often more cosmetic, gait. Traditional "bracing" in these cases calls for a combination of metal and leather, often a spring-assisted ankle joint, and a so-called posterior stop, which simulates the motion of ankle dorsiflexion and prevents toe drag during swing phase.</p> <p>More recently, molded plastic ankle foot orthoses have become available. These lighter weight orthoses provide a nearly invisible option to the conventional metal, riveted to the shoe devices. Presently, little agreement exists as to the indications, the timing of the application, or the overall outcome anticipated with the use of plastic AFOs.</p> <p>The physical therapist plays an important function in the team approach to the care of patients with orthotic needs. Because the physical therapist spends considerable time working with these patients, he or she has an opportunity to continuously evaluate the patient's progress. This constancy is critical to the orthotic decision-making process as changes in patient symptoms may well alter orthotic needs. For this reason, it is often the responsibility of the physical therapist to recommend an appropriate orthotic device. In order to do this, the therapist must not only use the current physical findings, but must accurately predict future changes in these data. He/she must choose a device which will not only facilitate early ambulation, but will also meet the patient's future needs. Thus arise the dilemmas of when to fit which device, and whether to use temporary or longer-lasting orthotic devices.</p> <p>In the past, metal AFOs were considered more adjustable and more temporary. These devices were to act as the precursor to the more definitive, more cosmetic, lighter, and therefore "better" plastic AFOs. However, experience with plastic AFOs revealed problems with lack of adjustability, thus necessitating multiple fittings in order to accomodate the patient's changing clinical picture.</p> <p>The therapist must decide how to most effectively provide devices which not only meet the adjustability requirements demanded for early ambulation, but also provide a more cosmetically appealing, definitive device. Questions that need answering are: can an adjustable orthosis be fitted to allow for early ambulation? When should we recommend the more definitive (presumably plastic) devices? How can this be done with a minimum of dollars spent?</p> <p>In 1971, Lehneis and Sarno made the following statement: "It is clear in the function of our clinic that there is no longer any indication for prescription of the conventional double bar BKO." It would be interesting to know if the authors still feel this way despite evidence to indicate that the double bar device is still routinely being fit.</p> <p>The reason for the continued popularity of the bichannel, double upright AFO in our clinic is its adjustability. This allows for medial-lateral control in both swing and stance phase, as well as knee control during stance. The extension moment generated by an anterior pin stop and long foot plate allows good control of knee flexion. Similarly, knee hyperextension can be controlled by adjusting the posterior pin.</p> <p>The timing for the fitting of such a device should allow a sufficient training period so that the patient can be discharged with skills in the proper and safe use of the orthosis. Frequent return visits or home care sessions are necessary to continue to evaluate progress and provide necessary orthotic changes.</p> <p>In many situations, the cost of the orthotic care for the patient is the smallest total dollar amount spent during the rehabilitation phase, yet it seems to receive a disproportionate amount of discussion. In those cases where early ambulation is indicated and expected changes in condition dictate an adjustable orthosis, the device of choice would seem to be the conventional, double adjustable, double upright, metal AFO. Later, as the condition stabilizes and the need for adjustability subsides, a plastic, more cosmetically acceptable AFO may be fitted. Even with the fitting of two devices, the total dollars spent for orthotic care will remain a small part of the overall cost of rehabilitation.</p> <p>This discussion would be incomplete without specific mention of the polypropylene AFO. Since the arrival of the custom-made poly AFO, manufacturers have saturated the market with standard sized, stamped poly AFOs. Many therapists use such devices and compare them with other types of custom-fitted metal and plastic AFOs. If one inspects these devices, it is apparent that they fit very few patients. They do not provide the necessary dorsiflexion assist without a considerable amount of modification, and often never produce the desired effect. Additionally, they provide little knee extension assistance, which is often necessary for many early ambulators.</p> <p>The choice of plastic vs. metal AFOs should be considered with all aspects of the patient's present and expected future condition in mind. The type of orthotic device prescribed should meet all the needs of the patient, with cosmetics being only one element. Multiple plastic or a combination of metal and plastic orthotic fittings can be justified in order to attain early, safe, and independent ambulation.<br /><br /><em><b>*Donald G. Shurr, LPT, MA </b> Director of Physical Therapy University of Iowa Hospitals and Clinics Iowa City, IA<br /><br /><br /></em></p> Page Number(s) 4 - 4 Year 1983 Volume 7 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Metal vs. Plastic AFO - A Therapist's View Creator An entity primarily responsible for making the resource Donald G. Shurr, LPT, MA * https://staging.drfop.org/files/original/ab7543cd7a89fbb0411d1f34a0263db8.pdf c5354e4247d698b974287ba4eb8c3224 https://staging.drfop.org/files/original/9425bc5ffbf07ebf9c14b731a150ced2.jpg 35a7c0b562014d4fb50dec04e1a2648b https://staging.drfop.org/files/original/9f1ee7129f74d4da85370f348fdb1836.jpg ff2b1aea5b56e7f14acf06a7b8d20da9 https://staging.drfop.org/files/original/4d370fefd91e735d6fb3ee03340951f3.jpg 9f95d03a610ddbb83b1ad23e3450dfd0 https://staging.drfop.org/files/original/963256fd362491bd682b123274398c06.jpg 6418500d7da7c502d4faec1731934241 https://staging.drfop.org/files/original/011d4c628e420168bd0745099f67527b.jpg f292217f59299efecabdeccec457d0ab https://staging.drfop.org/files/original/0d2ed862497f922a0790d0b16cef7986.jpg 2ab9a719c52fc5660d4b56961d2e5209 https://staging.drfop.org/files/original/354d1f58233229ce31c57886ff84b30f.jpg b44e5eff696f208e7c962ed258e16579 https://staging.drfop.org/files/original/cb80d5a12a017e33e08e597ffb4c58af.jpg e1c1fb775ede1e64579fb7405aa8a5d9 https://staging.drfop.org/files/original/06bfecf29692e230dbfd93c908ce83fa.jpg b482408d3255d9e24ad276d2e4ba913a https://staging.drfop.org/files/original/0265d09264022def5d0709d4d7100463.jpg 769232d27df084123462e0300b6af339 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_026.pdf Text Any textual data included in the document <h2>Conventional Fitting of an Unconventional Orthosis</h2> <h5>Donald L. Fornuff, C.P.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>Amyoplasia Congenita</i> (Arthrogryposis Multiplex Congenita) is a congenital abnormality of muscle development which is characterized by marked stiffness and severe deformity in many joints of the limbs—hence, the term arthrogryposis, which means "bent joints." (<a href="/files/original/9425bc5ffbf07ebf9c14b731a150ced2.jpg"><b>Fig. 1</b></a> and <a href="/files/original/9f1ee7129f74d4da85370f348fdb1836.jpg"><b>Fig. 2</b></a>).</p> <p><a href="/files/original/4d370fefd91e735d6fb3ee03340951f3.jpg"><b>Fig. 3</b></a> shows one of our recent patients, a young woman from South America with arthrogryposis, who was seeking greater range of motion with her present left exoskeletal arm orthosis, combined with easier operation and better cosmesis. Her previous orthosis consisted of a left modified laminated shoulder cap with a large cut out for both the left arm and left breast. The shoulder cap extended from the left clavicle over the shoulder to the soft tissue area between the rib cage and the crest of the ilium on the left side. Set on the superior border of the shoulder cap was a nudge control unit which was used to lock and unlock the elbow and was operated by her chin (<a href="/files/original/963256fd362491bd682b123274398c06.jpg"><b>Fig. 4</b></a>). A flexion-abduction joint was used at the shoulder. The elbow joint was an outside locking type. A custom made wrist unit served to receive a terminal device. Quarter inch (1/4")—7 cm diameter adjustable rods were the connecting members from the acromion to the elbow and from the elbow to the wrist unit. Operation of the terminal device was accomplished by means of a perineal strap on the left side. A chest strap was used as a means of suspension. Some major considerations for change were: type of socket, improved harness and a more efficient cable system.</p> <h3>Socket</h3> <p>We felt a more comfortable, cosmetically acceptable, and efficient working, above-elbow type socket would be a large improvement over the heavy, bulky, and ill-fitting shoulder socket she was now wearing. Consequently, the patient was casted as if for an above-elbow type prosthesis, with anterior and posterior wings at the proximal end of the socket and an open end distally (<a href="/files/original/011d4c628e420168bd0745099f67527b.jpg"><b>Fig. 5</b></a>).</p> <h3>Harness</h3> <p>Without a doubt, the two most uncomfortable and least cosmetic harnesses a woman could wear would be a perineal strap and a chest strap. This patient was unfortunately burdened with both. Our solution was to use a conventional A/E harness in conjunction with the A/E type socket with modification of the control attachment strap, which ran from the harness ring through a 1 inch hanger of the control cable, across the back and attaching to the axilla (<a href="/files/original/0d2ed862497f922a0790d0b16cef7986.jpg"><b>Fig. 6</b></a>). This modification serves two purposes: (1) it prevents the harness from rising on the back, which would be uncomfortable, and (2) it promotes cable operation efficiency by maintaining the cable flow through the lower third of the scapula, where maximum excursion occurs as a result of scapular abduction (which is the motion being used for the function of this orthosis).</p> <h3>Cable Control System</h3> <p>A conventional A/E dual control system was used (<a href="/files/original/354d1f58233229ce31c57886ff84b30f.jpg"><b>Fig. 7</b></a> and <a href="/files/original/cb80d5a12a017e33e08e597ffb4c58af.jpg"><b>Fig. 8</b></a>).</p> <h3>Elbow Lock Control</h3> <p>Operation of the elbow lock (E-500 outside locking joints) was facilitated by slight modification of the locking mechanism. Instead of using an elbow lock strap, the cable from the elbow lock was attached proximally to a nudge control unit similar to what was used on her previous orthosis (<a href="/files/original/06bfecf29692e230dbfd93c908ce83fa.jpg"><b>Fig. 9</b></a>).</p> <h3>Forearm</h3> <p>The forearm consisted of a threaded aluminum rod held onto the lower locking strap of an outside locking joint by means of an adjustable bracket which allows for shortening or lengthening of the forearm as necessary. At the distal end of the forearm, an adapter was placed to receive a wrist flexion unit, into which a hook was placed (<a href="/files/original/0265d09264022def5d0709d4d7100463.jpg"><b>Fig. 10</b></a>). The forearm set-up was not an original idea, but was modified slightly to provide more range of motion.</p> <h3>Summary</h3> <p>Again, the overall idea was not an original one, but we feel the modifications which were improved upon and a good idea are worth sharing. With this device, combining both the working knowledge and components of prosthetics and orthotics, we made the life of this patient easier and more functional. We felt we met our original goals, which were to improve her range of motion, give her easier operation, improve cosmesis, and provide a more comfortable fitting orthosis.</p> <h3>Acknowledgment</h3> <p>Thanks to Mr. G. Robinson of Robins Aid, who had the original ideas for this orthosis.</p> <em><b>*Donald L. Fornuff, C.P. </b> Donald L. Fornuff, CP. is with the Prosthetics and Orthotics Department at the Institute of Rehabilitation Medicine of the New York University Medical Center, 400 East 34th Street, New York, New York 10016.<br /><br /><br /></em> Page Number(s) 26 - 29 Year 1985 Volume 9 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-10.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 Conventional Fitting of an Unconventional Orthosis Creator An entity primarily responsible for making the resource Donald L. Fornuff, C.P. * https://staging.drfop.org/files/original/901b570f7984e7d4389bd77bc8b49ab7.pdf 4dc89f03888f81781cc820b1c4281db2 https://staging.drfop.org/files/original/70079561438f68ead76f52fc65dd8527.jpg 9f295a4e4335c10beed8e204bd3902b4 https://staging.drfop.org/files/original/178ecd5991ed2ffe397316d0a4dd0546.jpg 843b4338dc78f6e9769246fa79846425 https://staging.drfop.org/files/original/2b7b51bf9cad86f7ce11a1660d52b387.jpg b0271f700b8d4901edf91d2082d01352 https://staging.drfop.org/files/original/ffaa35ca7b5ac23a6a947d2d3ad255f2.jpg 2fe8351da1a1e6155fb684e2e76de872 https://staging.drfop.org/files/original/f7c3b167230622c735630542cfdca207.jpg 3c649879a171c5ff0e0d93e99308eb76 https://staging.drfop.org/files/original/c4a610256e9b758a37d3623694e2271b.jpg 50f7124cde5cc7ce984f2315ba51fa73 https://staging.drfop.org/files/original/804efb442220a760c2ad6db87361ab61.jpg 373e078a4bb07aaf2eae6726bd391ff6 https://staging.drfop.org/files/original/1e7fab041130f301f034215e0e5b357d.jpg ecae0c1212323fe32a9a5b842bcf28b2 https://staging.drfop.org/files/original/ef3813f645bf9a4a4dd8188a6de82361.jpg 3a0b706d106a04ea3b6e27dcc9b84af6 https://staging.drfop.org/files/original/bb68eabedc0b65835c332efcf81f8201.jpg d34e1f0f082d9b6183dc2c8cee20fa2c https://staging.drfop.org/files/original/ccf65b3120d8051f16e304b8d2ef8f53.jpg 3ef8653b23290da3062586d399ca498b https://staging.drfop.org/files/original/1e94e8303e2979d8bbc043ee1a0e6ee8.jpg abc1ec3d3045264621578c7b7baf7e6e https://staging.drfop.org/files/original/b6daf9f8f83efde86777545189ff48f7.jpg dd96d853a981be0539a39293ad96b1d4 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_031.pdf Text Any textual data included in the document <h2>Flex-Frame Sockets in Upper Extremity Prosthetics</h2> <h5>Donald L. Fornuff, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The development of various new plastic materials has brought about a rapid change in the design and fabrication of lower extremity prosthetic sockets. We can now expect most of these revolutionary developments to overflow into other areas of prosthetics and orthotics. The most natural area next to be influenced is upper limb prosthetics.</p> <p>We at Rusk Institute of Rehabilitation Medicine have been trying various socket frame configurations with all levels of upper limb amputees, from wrist disarticulations to above elbows, including the humeral neck amputation.</p> <p>The following is a brief "technical note" describing the technique we use for fabricating the flex-frame socket for the upper limb prosthesis and a sampling of various socket designs.</p> <h3>Below Elbow Socket</h3> <p>When the below elbow socket model has been modified and smoothed, a flexible socket is made by vacuum molding, using Surlyn or Ethalux polypropylene (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-01.jpg"><b>Fig. 1</b></a>). A thin socket is then laminated in the conventional fashion, over the flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-02.jpg"><b>Fig. 2</b></a>). This socket will act as a frame for the flexible socket and will allow for the secure attachment of the forearm extension and wrist unit. Upon completion of the thin laminated socket, the P. V. A. sleeve is removed. The socket is then covered, using strips of 1" masking tape (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-03.jpg"><b>Fig. 3</b></a>).</p> <p>The forearm extension form, or mold, holding the wrist unit is mounted to the below elbow socket in the correct alignment, position, and length (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-04.jpg"><b>Fig. 4</b></a>). The wrist unit is taped over to prevent foam from clogging various screw holes. A hole is cut in the forearm extension piece just proximal to the wrist unit. Foam is poured into this hole to form the forearm extension piece. Additional foam may be required to ensure proper shaping of the forearm section. When shaping is completed, the wrist unit is heated slightly and removed. Vaseline® is applied to the remaining foam and socket, and a P.V.A. sleeve is pulled on and tied at both ends (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-05.jpg"><b>Fig. 5</b></a>). The wrist unit is replaced over the P.V.A. sleeve, held in place by the layers of material to be used in the second lamination. The material is tied off in the usual manner.</p> <p>When the forearm has been laminated, it should be completely removed from the below elbow socket and foam extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-06.jpg"><b>Fig. 6</b></a>). This removal is relatively easy because of the P.V.A. sleeve applied over the shaped foam forearm section. After the laminated forearm is removed, the foamed forearm section and tape are completely removed from the laminated socket.</p> <p>The laminated and vacuum molded flexible sockets are removed from the model (the model must be broken many times) and the laminated socket frame is cut to its desired shape to allow maximum flexibility of the flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-07.jpg"><b>Fig. 7</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-08.jpg"><b>Fig. 8</b></a>).</p> <p>The frame socket is placed into the forearm section and trim lines are established. Both sections are then sealed together. The flexible socket is placed in the frame socket and the trim line is established: 1/8" to 1/4" above the edge of the laminated frame socket to minimize the stiffness gradient and to allow a gradual transition from the flexible socket to the rigid frame (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-09.jpg"><b>Fig. 9</b></a>). Socket designs are many and quite variable (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-10.jpg"><b>Fig. 10</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-11.jpg"><b>Fig. 11</b></a>).</p> <h3>Above Elbow Socket</h3> <p>All previous steps used in the below elbow prosthesis apply to the above elbow prosthesis until removal of the laminated humeral section with the attached elbow turntable. When the humeral section is removed from the foamed humeral extension, it is set aside (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-12.jpg"><b>Fig. 12</b></a>), while the laminated above elbow socket is cut out to allow maximum flexibility of the flexible socket. The laminated humeral extension holding the turntable is then re-attached to the flex-frame socket with a rigid plastic resin (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-13.jpg"><b>Fig. 13</b></a>). Easy removal of the flexible socket will allow for easy access to the elbow friction and attachment nut at the elbow turntable.</p> <p>Again, configurations of both below and above elbow flex-frame sockets are many in design, but must provide attachment areas for harnessing and base plates for proper transition of the cable control system.</p> <h3>Acknowledgments</h3> <p>The author wishes to acknowledge Mr. Steve Szabo's technical assistance.</p> <em><b>*Donald L. Fornuff, CP. </b> Donald L. Fornuff, CP., was formerly Assistant Director of Orthotics and Prosthetics at Rusk Institute of Rehabilitation Medicine, New York, New York. He is presently Director of Medishare Orthotics and Prosthetics Laboratories, Fords, New Jersey.<br /><br /><br /></em> Page Number(s) 31 - 34 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Flex-Frame Sockets in Upper Extremity Prosthetics Creator An entity primarily responsible for making the resource Donald L. Fornuff, CP. * https://staging.drfop.org/files/original/2758dcc8f04d4645d2251d024de4b117.pdf 47ba774f7aaadae410bf2c3710d4d082 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_114.pdf Text Any textual data included in the document <h2>Winter Sports for the Amputee Athlete</h2> <h5>Doug Pringle&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Organized participation in winter sports by people with disabilities has a relatively short history. It began in the early 1950s when amputee veterans of World War II began to experiment with skiing despite the loss of limbs. The West Germans are credited with the invention of the outrigger, a crutch with ski tips attached, which are used as balance assisters. This invention helped popularize the sport and several amputee ski clubs were formed in the United States.</p> <p>During the late 50s and early 60s, amputee skiing was the mainstay of the sport. It was during the late sixties and early seventies that others with one "bad" leg, such as polio victims, began to ski using the technique developed for amputees. It was also during this time that amputees began experimenting with skiing with a prosthesis.</p> <p>Simultaneously, visually impaired people began to participate and the sport began to include more than amputees. In the late 70s, the major innovation was development of the "Four-Track" technique, which allowed many types of severely disabled people to ski.</p> <p>The 1980s have contributed the technique known as 'sit skiing.' This technique allows people who are wheelchair bound to participate in the sport.</p> <p>The benefits of participation in skiing are numerous. Physically the participant develops stamina, strength, balance, and coordination. These are all valuable physical traits for a person trying to compensate for a physical problem.</p> <p>Psychologically, participants begin to develop a positive self-image and a "can do" attitude. This positive thought cycle carries over into other aspects of life such as education and employment.</p> <p>Skiing offers a unique opportunity as a sport that can be done with family and friends in a facility open to the public. In that sense it is a mainstreamed activity done with everyone else rather than in a special facility.</p> <p>Finally, there is something wonderful and invigorating about the freedom of movement, speed, risk, and the natural environment of skiing. All these add to the experience.</p> <p>Skiing is the only winter sport offered to people with disabilities through formal programs. These programs offer adaptive equipment, qualified instruction and a competition system. Participation in other winter sports is not extensive.</p> <h3>Downhill Skiing</h3> <p><i>Alpine Skiing</i></p> <p>Alpine (or downhill) skiing is the most popular winter sport of people with disabilities in the United States. There are approximately 10,000 disabled skiers. The sport offers unique benefits to participants who are mobility impaired, not the least of which is that gravity supplies the means for movement.</p> <p>The development of adaptive equipment and techniques has made it possible for even the severely disabled to participate. Adaptive skiing is divided into five major categories or techniques:</p> <ol> <li> <p>Three track skiing</p> </li> <li> <p>Four track skiing</p> </li> <li> <p>Blind skiing</p> </li> <li> <p>Sit skiing</p> </li> <li> <p>Other adaptive techniques</p> </li> </ol> <p><i>Three Track Skiing</i></p> <p>Above-knee and below-knee amputees, persons with polio or birth defects, and those with a variety of other problems, ski three track in which the common element is having one good leg and two good arms. Above-knee amputees ski without their prosthesis because it is difficult to control. Below-knee amputees can ski with their prosthesis. The advantage is that they can stand on it when stopped. The disadvantage is increased risk of injury.</p> <p>Adaptive equipment for three trackers are outriggers. Outriggers are forearm crutches with ski tips attached. They act as balance as-sistors and are used to "walk" on the flats. Three track skiing derives its name from the three tracks made in the snow by two outriggers and the single ski.</p> <p>Some three trackers, especially racers, learn to ski with ski poles instead of outriggers. In fact, that is how people with one leg skied before the invention of outriggers. While more difficult, "one tracking" is also a possibility for many and skiing with poles is an advanced instructional method.</p> <p><i>Four Track Skiing</i></p> <p>Four track skiing is used by people with a wide variety of disabilities including: double leg amputees, spina bifida, cerebral palsy, muscular dystrophy, multiple sclerosis, stroke, head trauma, paraplegia, and polio. An individual with two legs and arms, natural or prosthetic, who is capable of standing independently (static balance), or with the aid of outriggers, could use this method. Many severely disabled people ski using this technique.</p> <p>In addition to outriggers, a lateral stability device is often used. This device is commonly referred to as a "ski bra." It helps keep the skiis parallel and also allows the student's strong side to help control the weaker side.</p> <p><i>Blind Skiing</i></p> <p>Visually impaired students are taught the same as any other skier with the exception that the instructor must learn to communicate more clearly. A number of holds or assists have been developed as well. Once the student can ski, the task becomes one of guiding or talking them down the hill.</p> <p>No adaptive equipment is required for the visually impaired. Often the student and instructor (or guide) wear bright bibs which signal to other skiers to be alert.</p> <p><i>Sit Skiing</i></p> <p>Sit skiing is the technique used by anyone who cannot ski standing. Sit skiers include people with muscular dystrophy, multiple sclerosis, cerebral palsy, spina bifida, paraplegia, and quadriplegia. This technique has been used since 1980 and it has opened skiing to people who are wheelchair bound.</p> <p>The sit ski has a fiberglass shell and metal edges. It is steered by leaning the body and by dragging a "pole" on the side to which the skier wants to turn. An instructor skies behind the device holding a length of nylon mesh cord in order to stop the skier and to assist with turns when necessary. Sit skiers often become proficient enough to ski "untethered" or without the instructor and safety line.</p> <p>The most recent development in sit skiing is the mono-ski. Here the fiberglass shell is mounted on a single ski and the skier uses outriggers. Use of a mono-ski requires good upper body strength. Therefore, it is a technique that is not suitable to quadriplegics and high-level paraplegics.</p> <p><i>Other Adaptive Techniques</i></p> <p>This catch-all category is used for a variety of people with disabilities who don't fit into any of the other four. Among them are upper extremity impairment: people who have lost the use of one or both arms. Those with one good arm use one ski pole and a pole can also be used with an arm prosthesis.</p> <p>Below-knee amputees may choose to ski using their artificial leg or legs. A heel line is usually necesary to achieve a bent knee position. Waist straps and thigh lacers help provide lateral stability, a snug fit, and reduced pis-toning and rotation. A special ski leg can be made if the student decides to seriously pursue skiing.</p> <p>The combination of disabilities and adaptive equipment are numerous. In competitions, some 19 different classes are recognized. But, generally, most people ski using one of the four major techniques.</p> <p><i>Instruction</i></p> <p>There are a number of programs of ski instruction available. Most are voluntary, weekend programs. There are five full-time professional ski schools which specialize in adaptive skiing and about 25 voluntary ones. All but a few of these programs are chapters or affiliates of the National Handicapped Sports and Recreation Association (NHSRA).</p> <p>The NHSRA has also developed a clinic team which trains instructors in adaptive ski teaching. The team also advises on program delivery. There is an instructor testing and certification program conducted by NHSRA which is approved and recognized by the Professional Ski Instructors of America.</p> <p><i>Competition</i></p> <p>A natural outgrowth of participation in sports is the development of competition. A very well developed system is in place. Learn to Race clinics and training camps are conducted by a few of the instructional programs locally and by the NHSRA nationally.</p> <p>Those interested in competition can race in any number of programs open to the public such as NASTAR and United States Ski Association races. Further, there are ten sanctioned regional championships at which racers can qualify for the nationals.</p> <p>Both the NHSRA and U.S. Association of Blind Athletes conduct annual national championships. Both organizations also select athletes for the U.S. Disabled Ski Team which competes in the World Winter Games for the Disabled and the Winter Olympics for the Disabled. In 1986, the U.S. Disabled Ski Team was number one in the world at the games in Sweden.</p> <p><i>Resources</i></p> <p>National Handicapped Sports and Recreation Association<br />4405 East West Highway, Suite 603<br />Bethesda, MD 20814</p> <p>U.S. Association of Blind Athletes</p> <p>Professional Ski Instructors of America<br />5541 Central Ave.<br />Boulder, CO 80301</p> <p>Alpine Skiing, contact:<br />Vineland National Center<br />P.O. Box 308<br />Loretto, MN 55357</p> <h3>Nordic Skiing</h3> <p>Nordic (or cross country) skiing is also popular among people with disabilities. Since the sport does require more muscular effort for motion than Alpine skiing, it is not an option for some severely disabled individuals.</p> <p>Among the participants are amputees skiing with their prosthesis and some who ski on one leg. Those on one leg must rely upon upper body strength and use their poles to push themselves along.</p> <p>Nordic skiing is well suited for the visually impaired. They may ski with a guide or follow pre-set tracks in the snow.</p> <p>Some more severely disabled people who would be four-trackers in Alpine skiing, such as those with cerebral palsy, muscular dystrophy, multiple sclerosis, stroke, head injury, etc., can also participate in Nordic skiing if they are able to ambulate well. Some will require assistance, pushing or pulling with a rope, and frequent rest breaks are always a safe practice.</p> <p>There is a sit ski for Nordic skiing. The sit skier will need excellent upper body strength to push themselves over any appreciable distance. Again, assistance and rest stops will help.</p> <p><i>Instruction</i></p> <p>There are very few Nordic skiing instructional programs in the U.S. The sport is just beginning to develop. Those interested in learning the sport should check with a local cross country ski resort to see if they have an instructor willing and qualified. Most will have difficulty finding a program nearby.</p> <p><i>Competition</i></p> <p>The competition program described under Alpine skiing exists for Nordic skiing. Nordic events are held separately from Alpine events, but the U.S. Disabled Ski Team includes both Alpine and Nordic competitors.</p> <h3>Other Winter Sports</h3> <p>Snowmobiling has been a sport in which people with disabilities have participated for at least 15 years. It was one option open to more severely mobility impaired individuals before development of four track and sit skiing.</p> <p>Ice boating and bike sailing are adaptable to a wide variety of mobility impairments. Ice fishing can also be enjoyed by many people.</p> <em><b>*Doug Pringle </b> Doug Pringle is the past president of the National Handicapped Sports and Recreation Association, 5946 Illinois Avenue, Organeville, California 95662.</em> <div style="width: 400px;"><br /><br /></div> Page Number(s) 114 - 117 Year 1987 Volume 11 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Winter Sports for the Amputee Athlete Creator An entity primarily responsible for making the resource Doug Pringle * https://staging.drfop.org/files/original/1d0b1902a4d7fb7cc437f75ca2c997b1.pdf f5ec7dfc784092ec4c05b42b0a9ca722 https://staging.drfop.org/files/original/07c03e80401b5c87d8d82c363e054d8c.jpg 53dd0b9a9b94ba4619665e0dc21d6fd3 https://staging.drfop.org/files/original/ace09578c7da7ee48bdd67c240b778fe.jpg f52289221839e24d1976512808b88d40 https://staging.drfop.org/files/original/ad5dc9979c8c97cb0bd8047ec31bc02f.jpg 5bf470bdcf3132b882ae78d66b4fd38d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_122.pdf Text Any textual data included in the document <h2>Research and Development Considerations and Engineering Perspective</h2> <h5>Douglas A. Hobson, P. Eng.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Background And Introduction</h3> <p>Contrary to the impression given by a segment of current literature, the rapidly emerging field of specialized seating remains largely an art rather than a science. Established clinical principles, supported by a documented knowledge base are sparse, and clinical decision making remains largely subjective. That is, seating practice is not promulgated by an organized educational process.</p> <p>Specialized seating is still in the 1950's era. At that time, significant advances in prosthetics and orthotics were being made. Prosthetics advancements included below knee and above knee socket fitting, fabrication, and alignment principles. In the 1970's, orthotics introduced vacuum formable plastics to the field. Only in the last five years has specialized seating offered more than one or two commercial options for individuals requiring custom contoured body support.</p> <p>Specialized seating is still a comparatively young, but now a rapidly developing sub-specialty of rehabilitation technology.</p> <p>It is probably of value to attempt to define what is meant by the field of specialized seating. First, it is a clinical process which attempts to maximize function through the provision of appropriate "body support" for a nonambulatory person, usually in the seated posture, and usually in combination with a wheeled device, such as a wheelchair. The nature of the body support is dependent largely on the needs arising from the individual's disability. It can be thought of as providing seated body support in a manner that is usually less intimate and technically demanding than is required by conventional spinal orthotics (i.e., a body jacket).</p> <p>Specialized seating has been an exciting area for involvement and research and development, especially during the last ten years or so. Engineers first became clinically involved in specialized seating in the late 1960's in Canada. During the intervening years, other professionals such as prosthetists, orthotists, therapists, and technicians throughout North America and Europe have been actively involved in specialized seating developments. This article attempts to focus on the research and development process that has led to the emerging principles and products that are now becoming common place throughout the delivery system, especially for individuals with cerebral palsy.</p> <p>Perhaps of importance are the experiences that have shaped the views (and biases) of the author regarding the research and development process in the rehabilitation field. Firstly, early design experience in lower extremity modular prosthetics (Winnipeg, 1963-69), strongly reinforced the opinion that research and development should ideally take place in close proximity to an ongoing clinical commitment. Secondly, design and development must take place with a sense of reality towards the strengths and limitations of the manufacturing, marketing, and delivery system associated with the particular technology. This later view is the result of many frustrations, failures, and sometimes successes, in attempting to guide approximately a dozen "ideas" from conceptualization through clinical application over the past 15 years.</p> <p>The R&amp;D process for the field of rehabilitation engineering technology may be viewed as consisting of three interrelated phases of activity, a) research, b) design and development, and c) clinical utilization. The approach taken in this article will be to examine each of these activities as they relate to the development of principles and devices currently employed in the field of specialized seating. Emphasis will be given to applied clinical research versus basic research. The final section will address the current status of the field and suggest future needs for its continued growth. Along the way, developments familiar to the author will be used to illustrate key points. The flowchart (<a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg"><b>Fig. 1</b></a>) illustrates the process and suggests the primary outcomes from each step of the process.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg"><strong>Figure 1. The three steps in the seating product development process, suggesting the major outcome for each step.</strong></a><br /> <h3>Research Contributions</h3> <p>The engineer, especially when entering new clinical areas, can be overwhelmed by the apparent opportunities to employ engineering principles towards what appear to be readily resolvable problems. With the passing of time, the realization emerges that most problems are much more complex than they first appeared and the best solutions involve creativity, simplicity of design, patience and a good deal of perserverance. Applied research, as it applies to technology and rehabilitation, could be defined as "a logical process which attempts to reduce chaos in favor of logical problems solving, during which time a few significant principles and related devices can be developed." This definition may appear rather non-scientific; however, most developments of significance to date have resulted from attempts to solve a morass of seating problems. From these attempts we see repeated positive results become positioning principles and related successful devices become commercial products.</p> <p>At this point the question could be asked, What, of significance, has been learned about meeting the needs of individuals requiring specialized seating over the past 15 years? First, every person has a unique set of needs, therefore one generalized solution does not work for all. Second, it has been possible to group needs, or residual abilities, which can greatly assist in clinical decision making regarding the choice and provision of technical options. Third, there are three disability related (intrinsic) factors that dictate both research and clinical activities in specialized seating. These are a) lack of postural control (i.e., resulting from spasticity); b) existing or potential deformity; and c) the degree of loss of tissue sensation. The schematic diagram (<a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg"><b>Fig. 2</b></a>) combines these intrinsic factors in a three dimensional array. As can be seen, postural control can be graded as good, fair, or poor; deformity as mild, moderate, and severe; and sensation as normal, impaired, or asensitive. The groupings that result (Groups 1, 2, 3) give an indication of the degree of body support that the seating system must provide to compensate for the patient's intrinsic deficiencies. For example, a child with cerebral palsy, with a mild deformity, good postural control, and essentially normal sensation falls into Group 1. Individuals with Group 1 needs usually do not require custom contoured body support and often only need a simple seat insert (standardized modular insert) that can provide midline orientation and improve the fit of the wheelchair. Whereas a teenager with Duchenne Muscular Dystrophy, who has poor postural control, severe deformity, but normal sensation, would be in Group 3. This individual would require extensive custom contoured support, including pressure relief throughout the seating surface to accommodate for the discomfort associated with prolonged stationary sitting. A person with a low level spinal cord lesion (paraplegic) with only moderate deformity and fair postural control would fall into Group 2. In this case, some contoured support may be necessary to compensate for deformity and loss of postural control. Also, a primary concern may be the loss of tissue sensation, so pressure redistribution over the seat surface would be necessary.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg"><strong>Figure 2. A three-dimensional representation of the key intrinsic factors (control, deformity, and sensation) that guide decision-making in specialized seating.</strong></a><br /> <p>Let us now go a step further and briefly look at a few disabilities in more depth. For example, individuals with cerebral palsy typically demonstrate a wide range of symptomatic intrinsic factors. It's usually obvious what group (i.e., Group 1, 2, or 3) they fall into for their general seating needs. However, what will be the short and long term postural needs for the child, how these needs can best be met through the seating system, and how the whole seating system must relate to the child's primary environments are all extrinsic factors that are best addressed by our therapy colleagues. That is, not only does one type of seating device not work for all, the manner in which it is configured for an individual, as well as how well it compliments the broader needs of the individual and the families are equally important. Experience has shown that specialized seating is best accomplished through a multidisci-plinary approach in which the technical and therapy contributions are orchestrated within a medical environment, with a physician assuming primary medical responsibility.</p> <p>In recent years, clinical research has begun to scientifically investigate the therapeutic principles related to positioning children with cerebral palsy. For example, Nwaobi<a></a> has shown that under certain conditions approximately 90° of hip flexion tends to minimize spasticity and optimize upper extremity function. More recent work by the same group<a></a> has also shown the importance of posturing in order to improve respiratory function in children with cerebral palsy. Present studies are looking at the potential contributions of posturing and seating support to reduce asymmetrical spinal muscle activity, which is thought to be a caustive factor in spinal deformity in the child with cerebral palsy.</p> <p>Earlier work in Rehabilitation Engineering at Rancho Los Amigos Hospital with the spinal cord injured<a></a> established safe pressure level thresholds for the tissue over the bony prominences, such as the ischial, coccyx, and the greater trochanters. These thresholds provide guidelines for clinicians when fitting cushions for individuals who require pressure relief in order to prevent development of pressure sores. This early work has paved the way to more recent work that is now modifying and refining these principles.<a></a> Clinical programs employing these techniques have significantly reduced the onset and development of pressure sores. For example, Ferguson-Pell<a></a> has developed a computer program which assists therapists and others in decision-making regarding the selection and fitting of wheelchair cushions. This system combines and integrates much of the existing knowledge in terms of pressure sore prevention and guides the clinician towards a logical solution in which the chances for error are minimized.</p> <p>Research in recent years has also developed other useful clinical tools. Again, for the spinal cord injured, there are now at least three commercially available devices (Scimedics TIPE, Oxford Pressure Monitor) that will measure and record the pressure that exists between the seated person and his support surface.<a></a> Other seating approaches use what is termed a "simulator approach" to assist in evaluation and fabrication of seating devices. For example, the MPI system<a></a> for cerebral palsy in children uses a multiadjustable frame and quickly detachable seat and back modules to allow the therapist to rapidly simulate the definitive seating arrangement. Tools of this type help in terms of therapy decision making and the subsequent communication with the technical staff responsible for the fabrication and fit of the device. Another research effort<a></a> is concerned with the collection of anthropometric data derived from taking measurements of a patient positioned in a subjectively good posture. This information will eventually be useful in the design of standardized componentry that will better match the dimensions and shapes of the individual.</p> <p>Another outcome of research activities has been the classification of seating devices into five generic groups based on their methods of fabrication. Space does not permit detailed discussion of this classification scheme, especially since it has been published elsewhere.<a></a> The following table is a synopsis of the classification scheme as it applies primarily to individuals with cerebral palsy. The table also incorporates the needs groupings discussed previously. This overall scheme has proven useful in helping inexperienced clinicians to better understand the key issues involved to match a client's needs with available commercial options.</p> <p>In addition, the above classification scheme provides a framework through which a student in the field of specialized seating can begin to appreciate the differences that exist between the various technical options; and more importantly, what general needs each system is designed to meet. Further study involves learning the fabrication steps involved in the various systems, the positive and negative features associated each approach, and how features from various types can be combined to produce hybrid devices for meeting very specialized user needs.</p> <p>Probably the most significant advancement is that both research and clinical experiences are now being brought together in the form of educational manuals<a></a> and instructional courses. This development is a major step towards establishing the body of knowledge that is so crucial if specialized seating is to progress from an "art" to a recognized field of professional endeavor.</p> <h3>Design And Development</h3> <p>One of the obvious benefits of a research team working in close proximity to clinical activities is the potential for identification of "real" needs requiring technological intervention. Once these needs are identified, they then form the basis of design specifications which become the goals for the initial phase of the design and development process. Of all the endeavors involving rehabilitation engineering technology over the past twenty years, this step of defining what needs to be done has probably been the most poorly managed. There is probably no greater waste of technological resources than to solve problems for which there is either already an existing solution, or for which a solution cannot be sufficiently generalized to meet the needs of a commercially viable segment of the population.</p> <p>Assuming a "green light" is still on after the "real" needs are identified, the next step is to develop a prototype solution, which in this context could be a technique, a clinical tool, or a seating device. The development is usually very "fragile" at this time, and the sooner it can be subjected to clinical trials and critique in a positive environment the better. Invariably, modifications and design refinements are required until a solution is developed that is acceptable to both the clinicians and their test subjects. Ideally, the development should then be exposed to wider critique within environments different from those in which the development took place. Also, manufacturing, marketing, and costing analysis should take place in preparation for the preproduction phase. Assuming all these steps yield positive outcomes, an initial preproduction run is made so controlled evaluations can be done in selected external environments. The results of the external evaluations should be carefully monitored, documented and made available to the production design team. Over the past six years, four such developments from the University of Tennessee Rehabilitation Engineering Program have gone through this process, some more rigorously than others. These developments, the Modular Plastic Insert, the Spherical Thoracic Support, the Foam-In-Place, and the Bead Seat System, are now all commercial products being marketed by three different commercial firms.</p> <p>The final stages of the design and development process can vary depending on development and the resources of the commercial firm involved. In general, the market volume for seating devices is still relatively low. Therefore, it is important that the "front end" cost to the commercial firm be minimized. This can be accomplished in several ways by the development team. First, it is crucial that the design be "elegantly simple" so that it can be reproduced in relatively low volumes inexpensively. Secondly, design refinements and problems solving support should be provided well into the commercialization phase. Royalty arrangements and other "front end" type payments to the developer should be minimized and based on product sales. And finally, support in terms of providing educational materials, publications, and instructional seminars all assist in creating a receptive market place.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-3.jpg"><b>Table</b></a></p> <h3>Clinical Utilization</h3> <p>This final phase of the R&amp;D process is most often neglected, since it is usually not very exciting to the development team. From the R&amp;D perspective, this design activity addresses those features of the development that will make it an attractive alternative to existing methods or devices being used. Again, development of instructional materials, provision of evaluation prototypes to "trend setters" and conducting instructional courses have already been mentioned. However, these supporting activities in themselves are usually not the key influencing factor. The development team must address the question, Why would a service provider working within a particular service delivery system choose the new development over another technical option? The answer usually is that the service provider can provide a higher quality service at equal or lower cost. Therefore, the new development must provide improved function to the user, and possibly increased status for the clinic/provider, at costs that can be paid for by the payment structure in which the service is provided. Failure by the design and development team to recognize the realities of the delivery system in which the development must be marketed is probably a primary reason why so many developments fail to make the transition from laboratory to widespread clinical application.</p> <h3>Current Trends In Specialized Seating</h3> <p>A 1985 survey of 26 facilities in 17 states<a></a> provides considerable insight into the state of maturity of the field of specialized seating. Of the 26 respondents, 12 were hospital based, six were state funded programs or institutions, and 8 were from private industry. The majority reported the use of plywood and foam technology (61 percent) or custom produced molded plastic parts (17 percent). The payment was received primarily from Medicaid, State Crippled Chil-drens Services, or private insurance carriers. The average number of clients fitted with new devices per year/facility was 185, with a total number fitted of 3,293.</p> <p>The importance of this survey, in the context of design and development, is that the majority of the facilities reported the use of basic "bench" fabricated technology (78 percent). This is not surprising since the majority of the new developments have only been available commercially for less than three years, and related educational programs are just beginning to have a significant clinical impact. Continuing education programs supported by the American Academy of Orthotists and Prosthetists, the Rehabilitation Engineering Society of North America, and institutions like the University of Tennessee Rehabilitation Engineering Program, Newington Children's Hospital, and Elizabethtown Children's Hospital, and private firms, such as Pin Dot Products, and Mobility Plus have been the primary sources for training in the new concepts and seating systems. As these efforts are expanded to involve larger numbers of clinicians, the newer technology in seating will permeate into the service delivery system.</p> <p>Of importance to the prosthetic and orthotic professions is that many of the professional skills and shop resources required to deliver improved specialized seating services are already in place. Also, specialized seating is now becoming recognized by many of the major third party payment sources as a recognized clinical service. The new commercial systems have been designed to be less labor intensive and to permit the provision of a quality product at a reduced cost. The overall result is that it is now feasible to invest in the education and inventory required to enter the field and expect to realize a return on that investment over a 2 to 3 year period. That is, specialized seating now presents a viable growth area for the prosthetic and orthotic field.</p> <p>Projecting into the future, one may speculate as to what developments are likely to take place in the field. As far as design and development, it is likely that refinements to the newer commercial products will preoccupy the efforts and available development resources over the next two to three years. New and ongoing basic research will continue to develop or validate positioning principles for the cerebral palsy population. We should see refinement and expansion in the use of computerized expert systems, primarily by institutional settings that are doing larger volumes of evaluation and prescription of seating devices. Educational courses should become more available on a regional basis through several of the participating professional associations. Hopefully, the American Academy of Orthotists and Prosthetists will continue its continuing education efforts in this area.</p> <p>Probably the most urgent and difficult issue to be resolved is the further education of third party payment sources, so that seating services can be provided and reimbursed throughout the country. In this regard, initial efforts by the Rehabilitation Engineering Society of North America appear promising. Similar, and probably coordinated, efforts by other organizations such as the American Occupational Therapy Association, the American Orthotic and Prosthetic Association, and the American Academy of Orthotists and Prosthetists would be most timely.</p> <p>In summary, research and development has made significant contributions to the field of specialized seating. This statement is based in the fact that there are not less than six new seating developments that have become available to the practitioner over the past five years. Basic studies, published articles, and manuals are establishing the foundation for educational activities that are becoming more widely disseminated. Third party payment sources have been slow to respond, but diverse efforts throughout the country have been successful at receiving reimbursement for seating services. In conclusion, more remains to be accomplished, and research and development can be expected to continue its contribution. Specialized seating is being transformed from an "art" to a recognized field of professional endeavor.</p> <p><b>References:</b></p> <ol> <li>Nwaobi, O.M., Hobson, D.A., Trefler, E., "Hip Angle and Upper Extremity Movement Time in Children with Cerebral Palsy," <i>Proceedings of the Eight Annual Conference of the Rehabilitation Engineering Society of North America</i>, Memphis, Tennessee, June, 1985, pp. 39.</li> <li>Nwaobi, O.M., Smith, P.D., "Effect of Adaptive Seating on Pulmonary Function of Children with Cerebral Palsy," <i>Develop. Med. Child Neurol.</i>, 28, 1986, pp. 351-354.</li> <li>Rodgers, J.E., Rewsick, J., "Program for Prevention of Tissue Breakdown," <i>Annual Report</i>, Rancho Los Amigos Hospital-REC, 1974/75, pp. 24-31.</li> <li>Paterson, R., "Is Pressure the Most Important Parameter," <i>Proceedings, National Symposium on Care Treatment and Prevention of Decubitus Ulcers</i>, Paralyzed Veterans of America, Washington, D.C., November, 1984, pp. 73-74.</li> <li>Ferguson-Pell, M., "Research Relating to Pressure Sore Prevention," <i>Proceedings, National Symposium on Care Treatment and Prevention of Decubitus Ulcers</i>, Paralyzed Veterans of America, Washington, D.C., November, 1984, pp. 53-54.</li> <li>—Scimedics, 170 Vander St., Units A &amp; B, Corona, California 91720.&nbsp;<br />—TIPE-Tee Kay Applied Technology, 11915 Meadow Trail Lane, Stafford, Texas 77477.&nbsp;<br />—Oxford Pressure Monitor-International Medical Equipment Corporation, 11000 E. Rush Street, Suite 4, South El Monte, California 91733; (213) 350-1410.</li> <li>Modular Plastic Insert System marketed by Pin Dot Products, Inc., 2215 Belmont Street, Chicago, Illinois 60618.</li> <li>Reger, S., Hobson, D.A., "Seat Design Factors for Wheelchairs," <i>Annual Report</i>, University of Virginia- REC, 1985, pp. 25028. Charlottesville, Virginia.</li> <li>Hobson, D.A., Trefler, E., "Towards Matching Needs with Technical Approaches in Specialized Seating," <i>Proceedings of the Seventh Annual Conference of the Rehabilitation Engineering Society of North America</i>, June, 1984, Ottawa, Canada, pp. 486-488.</li> <li>Bergen, A., Colangelo, C, <i>Positioning the Client with CNS Deficits: The Wheelchair and Other Adapted Equipment</i>, Valhalla Rehabilitation Publications, Ltd., New York, 1982.</li> <li>Trefler, E. (Ed.), <i>Seating for Children with Cerebral Palsy: A Resource Manual</i>, University of Tennessee Center for the Health Sciences-Rehabilitation Engineering Program, Memphis, Tennessee, 1984.</li> <li>Ward, D., "Positioning the Handicapped Child for Function," <i>Pin Dot Products</i>, Chicago, Illinois, 1983.</li> <li>Holte, R., Shapcott, N., "A Survey of Wheelchair Seating Service Delivery Programs in the USA," <i>Proceedings of the Eighth Annual Conference of Rehabilitation Engineering Society of North America</i>, Memphis, Tennessee, June, 1985, pp. 157-159.</li> </ol> <b>*Douglas A. Hobson, P. Eng. </b> Douglas A. Hobson, P. Eng., is Technical Director at the Rehabilitation Engineering Center, for the University of Tennessee Health Science Center, 682 Court Avenue, Memphis, Tennessee 38163.<br /><br /> <div style="width: 400px;"></div> Page Number(s) 122 - 129 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-2.jpg Figure 3 TABLE http://www.oandplibrary.org/cpo/images/1986_04_122/1986_04_122-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research and Development Considerations and Engineering Perspective Creator An entity primarily responsible for making the resource Douglas A. Hobson, P. Eng. *