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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_04_137.pdf Text Any textual data included in the document <h2>Seating for Children and Young Adults with Cerebral Palsy</h2> <h5>J. Martin Carlson, M.S., C.P.O. <a style="text-decoration: none;">*</a> John Lonstein, M.D. <a style="text-decoration: none;">*</a> Karen O. Beck, R.P.T. <a style="text-decoration: none;">*</a> David C. Wilkie, B.F.A. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> This paper will reflect the experience, perspective, and design rationale of one institution rather than attempt to give a comprehensive survey of the full spectrum of experience and designs. Several examples are given and references made to Duchenne muscular dystrophy (D.M.D). The D.M.D. examples are used when they are particularly good illustrations of a general principle which helps complete our understanding of seating for children with cerebral palsy. For more information on our experience and rationale relative to seating boys with Duchenne Muscular Dystrophy, refer to the reference section.<a></a> The study of seating has many facets (cosmetic, functional, economic, etc.) and many professional perspectives (engineer, therapist, orthotist, physician, manufacturer, etc.). Engineers tend to relate to biomechanics and the economics of standard design. Therapists are concerned with function, development, inhibition of spasticity, etc. Each medical specialist has a different predominant focus. In different settings, it is inevitable that availability of professionals, availability of funds, age and severity of client population culture, etc., vary, and these factors will direct the seating program. Another important factor is that ortho-tists have not traditionally been trained in the provision of special seating, most are not active in special seating, and in most communities, there is a shortage of orthotists. These realities are a major reason why pre-manufactured, easy to assemble, and adjustable designs have predominated in many regions. The potential for commercial success and profit for the manufacturer, the ability to provide a system without the involvement of orthotic professionals (who are scarce and often inexperienced in seating), and the need to minimize costs, all seem to be best served by the wide distribution of pre-manufactured designs. In many communities, that is the best option available at this time. However, there are communities and settings wherein the circumstances make it possible to have a higher average of custom fabricated designs. To help you put this paper into perspective, we need to provide some information on the history of our seating program. The Orthotic/ Prosthetic Laboratory at Gillette Children's Hospital became involved with seating in 1974. Our seating program developed out of almost ideal circumstances. Orthotic services were strong and there was a close working relationship between our orthotists, therapists, and medical specialists. Weekly clinics brought a steady stream of clients through our outpatient clinic where the team members worked together to solve both general and individual problems. Also extremely important was our strong tradition and mechanisms for follow-up, which provided us with excellent feedback. Our early entry into seating, and the growth of the program, quickly gave us a significant volume so that specialists could be assigned and efficient procedures developed. Another factor bearing positively on our program is Gillette's extensive experience in spinal orthopedics. The volume of patients and specialization of our staff enabled us to offer quality care at economical costs. Although we have some experience with people of middle and advanced age, our experience at Gillette Children's Hospital is primarily with people from birth into young adulthood. This younger age group will be the focus of this paper. Our client population with cerebral palsy includes the full spectrum of severity, but the severe cases far out number the less severe. It is important that we all endeavor to recognize and respect the various aspects, perspectives, and variable circumstances mentioned earlier. Two very different seating programs may offer equally excellent care, but both can be even better if they "compare notes." This paper is a compilation of our "notes." <h3>Fundamental Goals</h3> The seating systems we provide must benefit the impaired person, those who care for that person, and society. Balanced against that, every piece of equipment inherently carries costs and disadvantages. Our systems cannot be all things to all people, but we will most nearly approach the ideal by keeping our sights aimed directly at the fundamental benefits and goals, while we endeaver to minimize the negatives. What are the fundamental goals? The main categories are outlined below. <ol> <li> Function </li> <li> Orthopedic/Neurologic </li> <li> Cosmesis </li> <li> Safety </li> <li> Economy </li> </ol> Function is primary. It affects a range of activities and benefits which can be best explained by examples: recreation for the child and family, making it easier for a care worker to feed a youngster, improving the child's field of vision, increasing his comfort, increasing the level of independence, etc. A functional seating system improves the childs development, decreases the amount of work required to take care of the child, and promotes a more enjoyable existence for the entire family. Federal laws passed in the U.S. in the early and mid 1970's mandated that children be transported from their living environments to educational settings. Safe transportation necessitates secure seating. Ultimately, society benefits, both tangibly and intangibly. From an orthopedic/neurologic standpoint, the ideal would be to prevent the progression of hip and spine deformities, and maintain body positions which reduce spastic reflex patterns. The benefits are better voluntary control, less severe deformity, less surgery, and a corresponding decrease in the work and cost of daily care. The advantages are perhaps most apparent to those of us who have visited state hospitals and have seen severely involved adult patients who were maintained only in recumbent positions during their earlier years. Positioning options for these adults are so severely limited that constant and expensive care is required to prevent ulcers and maceration. Also, hospitalization for those problems and pneumonia tend to be more frequent. Cosmetically the ideal is a well camouflaged, hidden, or attractive seating system which helps the youngster sit upright with the head in a position to see and be seen. The aesthetic and emotional benefits of a cosmetically appealing seating system accrue to the child and everyone in his environment. Comparing the costs of various seating approaches is difficult, because of the many costs which should be taken into account and the complexity of the various alternatives. We must take into account the cost of the seat, the cost of wheeled bases, repairs, frequency of replacement, and the cost of therapist involvement. The most important economic factor is the impact of a particular seating decision or system on the long range cost of daily care and health care. Long range costs must be considered, but they are very hard to estimate. <h3>Biomechanics Of Seating</h3> A normal head-trunk complex gets its stability from the spinal column, which acts as a controlled stack of compression elements, and partly from a multitude of muscles, which support it in different ways. The paraspinal muscles have a direct action on the configuration of the spine extention through lateral flexion and rotation. The abdominal (and to some extent, costal) muscles, in addition to being direct skeletal motors, affect the spine's stability and configuration indirectly, but importantly, through their action on the viscera. Muscle action to constrict and control the circumference of the abdomen and thorax allow compressive body weight loads to be taken partly down through the fluid filled abdominothoracic cylinder rather than all acting down through the spinal column. This adds significantly to the stability of the torso. We must note that recent research by Nachemson, et al.<a></a> (indicating that the Valsalva maneuver fails to lower pressure in the intervertebral disks) challenges this classical explanation of Morris,<a></a> but does not propose a new analysis of abdominal muscle function in trunk stabilization. Swedish data suggests that we don't fully understand what the Valsalva maneuver consists of and how it functions biomechanically. (The Valsalva maneuver is a general tensing of abdominal muscles.) The normal activity of sitting consists of a series of frequently changed postures. Each of those postures would be non-functional, uncomfortable, and even injurious if it were the only posture available to us and maintained for hours. It is the frequent voluntary change which makes those postures collectively safe, acceptable and tolerably comfortable for more than ten minutes. It is quite an undertaking to design a seating system in which our client can safely and comfortably sit, with little or no change, for a matter of hours. In the case of a person with cerebral palsy, the abnormally high muscle tone about the pelvis and thighs is the major reason this can be accomplished. It is important to note that when a child has some limited postural alignment capability, that capability is greatest at the head and neck. There is less ability to control the pelvis (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg">Fig. 1</a>). (This capability reflects the early developmental stages of an infant, but when we see it in the older child, it represents delayed or arrested development.) Arm-propping is typically used to stabilize the upper thorax for effective neck and head control. This illustrates two seating principles. The first is that the postural control and use of the superior body elements is dependent on the stability of body elements inferior to them. Second, the seat should bring the stability from the pelvis upward to meet the descending/decreasing voluntary stability of the client. Terminating stability too low will fail to maximize the child's function. Carrying stability too high will deprive the client of his full voluntary movement capability. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg">Figure 1. Alignment capability is greatest at the head and neck, less at the pelvis.</a> Since "normal" sitting postures are so variable and changeable, we cannot relate supported sitting postures to a specific normal posture. We must reason and choose a sitting posture which has the most advantages, and propose it as a "standard." We choose the "sitting at attention" sagittal configuration (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg">Fig. 2</a>), because it represents a mid-range spine configuration, it allows significant weight bearing on the proximal thighs as well as the bottom of the pelvis, it is a cosmetic posture (chest and head upright, facing outward), and it is a functional posture (head in a position to observe and thorax and shoulders forming a secure base for the neck and arms to move). In the sagittal plane, the sacrum is tilted anteriorly a moderate amount. There is moderate lumbar lordosis, thoracic kyphosis, and cervical lordosis. We would further propose that the "standard" posture consists of a pelvis level and the spine straight in the frontal plane. When the left side of the pelvis is elevated, the pelvis is said to be "tilted rightward," and when the right side is elevated, it is "tilted leftward" (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-03.jpg">Fig. 3</a>). Likewise, in the sagittal view, the pelvis is "tilted posteriorly" or "tilted anteriorly" depending on which direction the upper parts of the pelvis are oriented relative to "standard" (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-04.jpg">Fig. 4</a>). In the transverse plane, if the right side of the pelvis is rotated forward relative to the shoulders, we would say the pelvis is "torqued leftward." We do not present this nomenclature as the most correct, but offer it for use in the absence of standard nomenclature. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg">Figure 2. Sitting at attention represents a mid-range spine configuration.</a> Cerebral palsy is a disease that expresses itself in a wide variety of static and dynamic patterns, and we cannot go into the mechanics of all those variations. We will limit ourselves to a discussion of what, in our experience, is the most common combination. Fortunately, even some of the children with severe cerebral palsy do not have a significant deformity or collapse in the frontal plane. This is not to say, however, that scoliosis is rare in this group. Scoliosis is quite common, and we see very severe cases. When we examine a child with scoliosis, we should evaluate whether or not the scoliotic collapse is aggravated by asymetric trunk muscle spasticity. We can expect to be much more effective at controlling a scoliosis deformity when asymetric trunk muscle spasticity appears not to be a significant factor. One of the usual characteristics of scoliosis in neuro-muscularly impaired sitters is lateral tilting of the pelvis in the direction of the convexity of the major scoliosis curve (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg">Fig. 5</a>). This is not surprising when we consider that pelvic orientation is usually not under voluntary control. This characteristic will become more interesting later as we discuss the various methods for generating spine stability. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg">Figure 5. Lateral tilting of the pelvis in the direction of the convexity of the major scoliotic curve.</a> There are several distinct biomechanical schemes for providing spine stability to resist scoliosis. These schemes do not, of course, operate exclusively in the frontal plane. Also, the employment of one scheme does not preclude the simultaneous employment of one or more other schemes. The first and most familiar of these is "three-point-force". We need not explain the principles of this scheme since they are so well known. However, it is appropriate to note that three-point-force schemes are much less effective at stabilizing a multi-joint, multi-axis system such as the spinal column, than stabilizing a single-joint system such as the elbow or knee. The application of the three-point scheme in a spinal support system, which includes a seat, has some advantage over a traditional spinal orthosis in that the most inferior force can be located at greater distance from the more superior forces to give a longer moment arm. However, the more the client functionally moves in his seated position, the less the seat is able to apply three-point support, because it doesn't move with the client. Furthermore, a spinal orthosis can be worn 23 hours per day, if necessary. These latter considerations make the spinal orthosis a stronger orthotic treatment of progressive spine deformity. The second scheme we will discuss has to do with the Valsalva maneuver, given earlier, in which the abdominal and costal muscles function to relieve the spinal column of compression and bending loads. No matter what exactly happens during the Valsalva maneuver, the Morris explanation is a valid biomechanical analysis of how a snug corset contributes to trunk/spine stability in the presence of flaccid paralysis of abdominal and costal muscles. Engineering analysis and empirical evidence indicate that when we passively apply circumferential abdominal constraint (ie. a snug corset), a hydraulic load bearing column is created and we reduce the magnitude of flexible collapse (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg">Fig. 6</a>). In our experience, the corset is seldom used for children with cerebral palsy, but is virtually always useful for children with muscular dystrophy. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg">Figure 6. Reducing the magnitude of flexible collapse.</a> The third scheme for enhancing spine stability derives from the fact that the sacro-pelvic complex forms the foundation on which the flexible spinal column rests. Voluntary pelvic control is an important component of spine stability in the unimpaired trunk. If, by a conforming design about the pelvis and a proper donning procedure, we can increase the foundation (bottom end) constraint conditions, much is added to spinal stability. The pair of diagrams on the left side of <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg">Fig. 7</a> illustrates the similarity between the spinal column in the case of an uncontrolled pelvis and the slender column pin jointed (free to tilt) at its lower end. The two diagrams on the right in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg">Fig. 7</a> illustrate the similarity between the controlled pelvic case and the built-in base end condition. Elastic column buckling equations for the two beams indicate that the built-in beam will withstand almost twice as much load as the other before buckling.<a></a> To achieve this end condition stability, we need a well made seat, as well as a procedure to level the pelvis each time the child is seated. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg">Figure 7. The diagrams on the left illustrate the similarity between the spinal column in the case of an uncontrolled pelvis and the slender column pin-jointed (free to tilt) at its lower end. The two diagrams on the right illustrate the similarity between the controlled pelvic case and the built-in base end condition.</a> To fully appreciate the strength of this scheme in practice, compare the two x-rays in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg">Fig. 8a</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg">Fig. 8b.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg">Fig. 8a</a> is the x-ray taken just before the pelvic leveling procedure was performed and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg">Fig. 8b</a> is the x-ray taken a few minutes later, after the pelvic leveling procedure was performed. The Cobb angle is reduced from 36 degrees to 20 degrees by this quick procedure, which is normally performed as a routine part of positioning the child in the sitting support orthosis. These x-rays are of a boy with Duchenne Muscular Dystrophy; he was not wearing a corset. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg">Figure 8a. An x-ray taken just before the pelvic leveling procedure was performed.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg">Figure 8b. The x-ray taken a few minutes later after the procedure.</a> A second example is given in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg">Fig. 9.</a> The left and center x-rays show the progression which occurred in the eight months following fitting. During this period, the parents did not use the pelvic leveling procedure. The x-ray on the right was taken a short time after the center x-ray, with the only difference being the pelvic leveling procedure was performed before the last film. Note: once a spine deformity has become partially structural, the pelvis can be leveled only to the degree that the deformity is still flexible. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg">Figure 9. The left and center x-rays show the progression which occured in eight months following a fitting. During this period, the parents did not use the pelvic leveling procedure. The x-ray on the right was taken a short time after the center x-ray, and after the pelvic leveling procedure was performed.</a> In summary, maintaining a level pelvis makes it easier to control the spine. Pelvic control and orientation in the frontal plane also relates strongly to the uniformity of pressures in weight bearing areas and minimizing the progressive deterioration of sitting comfort. Let us now look at two examples were these stabilizing schemes have been simultaneously applied. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg">Fig. 10a </a>is a photo of a 12 year old boy with muscular dystrophy, sitting as he was presented to us. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg">Fig. 10b</a> shows the sitting support system properly applied. The corset is entirely independent; it is not attached to the seat. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg">Fig. 10c</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg">Fig. 10d </a>compare his A-P spine x-rays without and with the orthotic system. The lateral tilt of his pelvis is reduced from 30 degrees to 14 degrees. The Cobb angle of his scoliosis was reduced from 65 degrees to 35 degrees. Curve control of this magnitude is not unusual as long as the deformity is still flexible. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg">Fig. 11a</a> is the x-ray of J.S., a 14 year old girl with cerebral palsy. She presented a right thoraco-lumbar scoliosis of 38 degrees and a rightward pelvic tilt of 8 degrees. Her shoulders were tilted 13 degrees to the left partly because she used her right arm for propping to avoid falling to the right. We provided her with a soft corset and the Gillette Sitting Support Orthosis. The Sitting Support Orthosis was to provide pelvic control and bilateral "propping" support. It had no head rest or anterior support. The x-ray taken just after fitting shows pelvic tilt reduced to 2 degrees (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg">Fig. 11b</a>), the Cobb angle of the scoliosis reduced to 22 degrees, and shoulders leveled. Both hands were free to function, and she said she could breathe deeper. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg">Figure 10a. A 12 year old boy with muscular dystrophy as presented.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg">Figure 10b. The Sitting Support System properly applied. Corset is independent.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg">Figure 10c. A-P spine x-rays without the orthotic system.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg">Figure 10d. A-P spine x-rays with the orthotic system.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg">Figure 11a. X-ray of J.S., a 14 year old girl with cerebral palsy.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg">Figure 11b. J.S. provided with a soft corset and the Gillette Sitting Support Orthosis</a>. In cerebral palsy, we occasionally see a case of lateral pelvic tilt and scoliotic posture secondary to a unilateral hip extension contracture. A right hip extension contracture, if not accommodated, will cause the right side of the pelvis to be elevated. The pelvis will be tilted leftward and a compensatory convex left scoliosis will be produced. When we see this problem, it is usually an older child or adult. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg">Fig. 12</a> is an example of a rather extreme case of how the deformity was accommodated to minimize pelvic and spinal malalignment and stress. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg">Figure 12. An extreme case of how pelvic and spinal malalignment and stress is minimized in a cerebral palsy patient.</a> In the sagittal view, we commonly see a posture dominated by the powerful, very active hamstring muscle group. The gluteals are often helping to resist adequate hip flexion for an ideal sitting alignment. To a greater or lesser degree, the pelvis is maintained in a posterior tilt position with weight bearing shifted posteriorly toward the sacrum. This pelvic alignment tends to reduce lumbar lordosis and convert it to a kyphosis (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg">Fig. 13</a>). The loss of lumbar lordosis makes it more difficult for the thoracic extensors to maintain a vertical upper thorax. This explains why a flexible spine, maintained with a pelvic belt and lumbar bolster to restore lumbar lordosis, often produces better active alignment of the upper thorax and head. (We would caution you that different solutions are necessary for people with rigid hyperkyphosis.) <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg">Figure 13. A sagital view illustrating the pelvis in a posterior tilt position with weight bearing shifted posteriorly towards the sacrum, converting lumbar lordosis to a kyphosis.</a> The three forces needed to maintain the position of the pelvis and lumbar spine are the thigh support, lap belt constraint, and lumbar support (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg">Fig. 14</a>). Attention must be given to properly provide all three. The seat bottoms must be configured specifically to provide optimum thigh support. A flat horizontal seat bottom will never maintain hip flexion against active extension (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg">Fig. 15</a>). The anatomy itself calls for a depression under the pelvis to bring the femurs to a horizontal position (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg">Fig. 16</a>). More importantly, the hip flexion required to "break through" the extensor spasticity varies from child to child, but we usually find that some degree of seat bottom incline (pelvis to knees) is needed for the more severely involved children (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg">Fig. 17</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg">Figure 14. The three forces needed to maintain the position of the pelvis and lumbar spine are the thigh support, lap belt constraint, and lumbar support.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg">Figure 15. A flat horizontal seat bottom will never maintain hip flexion against active extension.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg">Figure 16. The anatomy calls for a depression under the pelvis to bring the femurs to a horizontal position.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg">Figures 17a and 17b. We usually find that some degree of seat bottom incline (pelvis to knees) is needed for more severely involved children.</a> The pelvic belt force is perhaps the most critical. The pelvic belt must be perfectly anchored: close to the body posterolaterally for good "wrap around" and at the correct level to achieve a good downward force component (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg">Fig. 18</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg">Fig. 19</a>). The most common mistake is to anchor the lap belt too high. We have never seen one anchored too low. (We must remember that none of the hip/lumbar support forces function properly in service unless the caretakers know why and how to put the pelvis in position and snug up the pelvic belt. Without education and training of the users, our designs are worthless. We must train and retrain on every return visit.) <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg">Figure 18. The pelvic belt force is perhaps the most critical.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg">Figure 19. The pelvic belt must be perfectly anchored: close to the body posterolaterals for "good wrap around" and at the correct level to achieve a good downward force component.</a> A fourth support force is sometimes needed in the area of the upper thorax or shoulders to maintain adequate thoracic extension. This is accomplished with a vest or shoulder straps which must be adjustable for grading the amount of support to fit the need, which may vary through the daily routine of activities. Seating misalignment and deformity problems in the transverse plane are not uncommon among the severely involved cerebral palsy population. The problem consists of the pelvis being torqued right or left by deformities of one or both hips. A severe adduction confracture of the right hip will, for instance, cause a seated misalignment which includes leftward direction of the thighs (with respect to the pelvis), a rightwardly torqued pelvis, and an apparently (not actually) short right femur. This misalignment has been well diagrammed in an article by Mercer Rang, et al.<a></a> A severe abduction contracture of the left hip will cause a similar misalignment. These deformities are often referred to as "wind blown hips." We can see that when such a condition exists, forcing the thighs to be aligned straight forward will obligate the client to sit facing to one side, or the spine will be continuously twisted. In most cases, the direction of the thighs may be altered enough to avoid much of the spinal twist. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg">Fig. 20a </a>is a photo of a top view of a Sitting Support Orthosis we provided for such a client. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg">Fig. 20b</a> is the same view of the client in the orthosis. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg">Figure 20a. Top view of a Sitting Support Orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg">Figure 20b. A client seated in the S.S.O. The direction of the thighs is altered to avoid much of the spinal twist.</a> It is of utmost importance, as we treat these clients, that we keep function and quality of life issues uppermost in our mind. Biomechanics and deformity prevention ideals often must be compromised to avoid undue impingement on any aspect of the child's development or function. <h3>Client Evaluation</h3> Seating evaluations at Gillette always include an orthotist, a therapist, and a physician in addition to the client, parents or caretakers, and, if available, a community therapist. The physical evaluation includes an assessment of orthopedic deformities, spastic reflex patterns, voluntary sitting capability, and other functional abilities. To assess sitting ability, two people manually control the child's thighs, pelvis and lower trunk. If, with this amount of stabilizing assistance, the child still cannot manage an upright sitting posture, we would grade voluntary sitting capability at non-existent to poor. If the child can, with that assistance, struggle to an upright sitting posture and maintain it for fifteen seconds, we would grade voluntary sitting capability at poor to fair. Better performance would be graded accordingly as better than fair. A thorough interview of parents and others with the child is immensely valuable. We want to find out about the child's daily routine, mode of family transportation, what they feel are positive and negative features about their present equipment and routine, and the child's usual status compared to what we are observing. We also seek all concerns and ideas they may have for optimum seating. The interview should gradually become more of an educational session and finally a discussion of options. The child and parents or caretakers should, as much as possible, feel they were heard, were educated, and have participated in the decisions made on the seat, mobility base, accessories, etc. <h3>Seating Design</h3> We currently solve the majority of the seating problems we encounter with variations on two basic designs. Both are custom made. Although there have been many very significant design changes along the way, the Gillette style Sitting Support Orthosis (S.S.O.) has continued, from 1974 to the present, as a portable system utilizing a custom molded unpadded plastic shell mounted in a plastic foam base (Fig. 18 and Fig. 24). We have provided approximately 1100 of these Sitting Support Orthoses. Our present rate of S.S.O. production is about 140 per year. Figure 24. Anterior upper thoracic support provided by shoulder straps. In the early years, we also constructed upholstery and plywood seats. In 1983, we converted that rectangular design to one that used upholstered removeable components attached to the inside surfaces of a plastic seat frame as shown in Fig. 21. (We first saw a design similar to Fig. 21 at the Royal Ottawa Rehabilitation Center. In addition to our own changes, the present design incorporates features also learned from the Rehabilitation Engineering Center at Children's Hospital at Stanford.) To distinquish this design from the contoured plastic shell type S.S.O., we call it an Upholstered Sitting Support Orthosis (U.S.S.O.). We currently construct and fit about 200 of these units annually. Figure 21. A plastic seat frame with upholstered removable components. A more specific discussion of the design of the S.S.O. must start with noting that the main structure is an unpadded, thin plastic shell. Because of the thinness of the supporting shell, the seat is less bulky, less visible, and lighter than other seats. It allows us to provide close thoracic support up to the axillary level and wrap around the thorax, between the arms and chest, and well past mid-line, without impinging on the arms (Fig. 18 and Fig. 19). When properly contoured, the shell can be left almost totally unpadded. The unpadded shell is easier to clean and requires less maintenance. The pelvic portion is contoured and sized to fit the hip/pelvic area quite close, but not snug. At fitting time, we leave adequate space to push our fingers between the Glueteus Medius and the seat bilaterally. About 18 months ago, we began providing room in the shell to install bilateral pelvic growth pads (visable in Fig. 22), which are removed later as the pelvis grows wider. Figure 22. An unpadded shell with room to install bilateral pelvic growth pads, which are removable as the pelvis grows wider. Anterior upper thoracic support is provided by either a special vest (Fig. 23) or shoulder straps (Fig. 24). The shoulder straps are more efficient at keeping the thorax in an extended, upright posture. However, when the child has some arm function, we prefer to use the vest because it can be configured to impinge less on the anterior deltoid muscles. Note that the lower attachment points for the vest or shoulder straps should be in the sub-axillary area to provide good wrap-around and a posteriorly directed holding vector. Some commercially available seats anchor the shoulder straps to the lap belt. That design is seriously flawed because the shoulder straps then pull the lap belt up out of proper position and pull down on the shoulders. Figure 23. Anterior upper thoracic support is provided by a special vest or shoulder straps (see Figure 24). When the S.S.O. is used for people with severe scoliosis or hyperkyphosis, the polypropylene shell accomodates to the contours of the deformity. However, sometimes our best efforts fail to create sufficiently precise contouring to spread pressure evenly over the entire rib prominence. Fig. 25 diagrams how we sometimes solve that problem: an adjustable denim cloth panel is installed through vertical slits in the shell. The panel wraps around the prominence, conforming to the contour. Figure 25. An adjustable denim cloth panel is installed through vertical slits in the shell. The panel wraps around the prominence, conforming to the contour. Head support varies from nothing to a simple occipital prop to a variety of designs, depending on the particular challenge presented. A few of the many designs we have contrived over the years are shown in Fig. 26, Fig. 27, and Fig. 28. We do not have a good solution for the child who persists in actively bringing the head forward and down. In seating children with hydrocephalus, the sheer weight of the head presents special safety and weight bearing problems (Fig. 29 and Fig. 30). We haven't the space to show and explain the wide variety of accoutrements which are variously added for shoulder protraction, arm positioning, etc. We work closely with the therapists so that they can help design the final configuration for best functional positioning. As emphasized earlier, a seating program must consider the sitting functional environment. The seating orthoses we produce are re-moveably mounted in wheelchairs, strollers, buggies, and other bases as the circumstances indicate. Being portable, they are also utilized as car seats, or to place the child very near the floor to facilitate peer interaction (Fig. 31). We have found that a seating program, to be effective, must address the full spectrum of life activities. It must also address related equipment in the sitting environment. Footrests, wheelchair upholstery, laptrays, and control boxes are some of the most common things which must be modified, moved, or completely replaced with special designs. It seems to us that the "standard" wheelchair was designed to be "slouched" into (Fig. 32) rather than to be sat erect in. Those chairs are not adequate, as manufactured, for extended use by anyone. In spite of the newer, more enlightened designs coming along, those "standard" wheelchairs are still part of the scene and must be dealt with. When we sit a client erect on a firm seat, and then place that seat in a wheelchair, the client's shoulders are far from the center of the drive wheels (Fig. 33). For clients who self-propel, the seat must be sized or shaped to sit between the upholstery mounting bars. The standard upholstry must be removed and replaced with straps so that the seat can be recessed down and back between the bars (Fig. 34 and Fig. 35). Figure 31. The seating orthoses we produce are removable and made to mount in a variety of bases as the circumstances indicate. Figure 32. Lateral view of typical posture produced by hypotonic spine extensors and tight hamstrings. Figure 33. Lateral view of a patient positioned too high and forward. Figure 34. For clients who self-propel, the seat must be sized or shaped to sit between the upholstery mounting bars. Figure 35. Standard upholstery is removed and replaced with straps so the seat can be recessed down and back between the bars. At semi-annual follow-up visits, we accommodate the child's growth by adjusting the size of the S.S.O. Thigh length is added as necessary. The bilateral pelvic growth pads are thinned or removed when appropriate. The back and sides of the shell can be heated to widen the shell width across the chest. Axillary extensions are welded on as necessary to accommodate increase in thoracic height. Head rests and the anchor points for vests and shoulder straps are also elevated as necessary. Presently, the basic S.S.O. shell is serving for an average of 37 months for children between 3 years and 14 years of age. We expect the use of the pelvic growth pads to push that service life even higher. For adults, the average useful life of S.S.O.'s is much greater. We recommend the S.S.O. for children who have non-existent to poor voluntary sitting capability. Other factors which would indicate a need for the S.S.O., in our program, would be significant orthopedic deformities (of the hips and spine) and moderate to severe spastic reflex patterns. Completed physical growth may also be an indication for the S.S.O., because the polypropylene shell is very durable. It requires less repair maintenance than the upholstered systems. There is complete freedom within the design to reduce the level and amount of support or match the client's need: it may not include a head support, vest, or shoulder straps, and bilateral thoracic support may be terminated at a lower level and leave more room for movement as appropriate. Provision of a good quality S.S.O. requires a relatively high level of specific orthotic skill and practice. This may be considered a disadvantage, but we feel the adaptability and quality which results more than justifies the necessary investment. The structural components of the Upholstered Sitting Support Orthosis are made of ABS plastic. The upholstered firm inserts are removable to facilitate cleaning and adjustments for growth. Thoracic supports are thin (of metal) and can be easily adjusted to change height and spacing. The pelvic belt is used on every U.S.S.O. Lumbar bolsters, vests or shoulder straps, and head rests are used when appropriate. Fig. 31 shows some of these design features. During therapy sessions, and for certain daily time periods, therapists or parents may wish to work specifically on improving upper trunk or head control. For this reason, shoulder straps and vests are designed for partial or complete loosening. Head rests can be easily removed from the unit (true of the S.S.O. as well as the U.S.S.O.). The U.S.S.O. is most appropriate for children with poor-to-fair voluntary sitting capability, minimal orthopedic deformities, and less severe spastic reflex patterns. The easy size-adjustability of this design gives it some advantage over the S.S.O. for younger, rapidly growing children. For children under two years, we often utilize one of the commercial infant seat or car seat frames to which we can add support bolsters, lap belt, etc. (Fig. 36). Figure 36. A commercial infant car seat can be supplemented with bolsters, lap belt, etc. <h3>Fabrication</h3> Much about the fabrication of these orthoses can be inferred from the photos and design information given earlier. Some information on fabrication of the "Gillette" S.S.O. has been discussed in earlier articles on that orthosis.<a></a> However, there are some serious errors in the S.S.O. fabrication process we made in the very beginning. Other orthotic labs might repeat those errors unless we reiterate a couple of the procedural steps and more clearly explain the rationale for those steps. The polypropylene shell is obtained by covering a pattern developed from an impression of the child. To obtain the impression, we position the child, on a supporting fixture (Fig. 37) in a face-down, hips-flexed, knees-flexed configuration (Fig. 38). We use the weight relieving (horizontal) trunk alignment, support under the knees, and a waist belt for the precise purpose of achieving an impression which does not possess the poor alignment characteristics we are trying to avoid. The support under the knees allows us to locate the pelvis as directly as possible in alignment with the spine. For the child with tight hamstring muscles, a waist belt on the fixture helps reduce lumbar kyphosis and perhaps achieve a little lumbar lordosis, if possible. The contrasting diagrams in Fig. 39a and Fig. 39b illustrate the critical role of knee support. The hip flexion angle of the fixture can be varied and is adjusted according to the amount of hip flexion we want in the seat shell. On the positive model, plaster is added to create the bulges and contours needed to avoid pressure on bony prominences (Fig. 40). Plaster is added across the back of the upper thorax to give room for extension. Fig. 41a and Fig. 41b are posterior and lateral views of a positive model fully modified and ready for covering. The resulting polypropylene seat shell is mounted in a polyethylene foam base (Fig. 42). Final trim lines, lap belt and vest attachment points, head-rest placement, etc. wait until the child comes for fitting. Figure 37. A supporting fixture. Figure 38. To obtain an impression for a polypropylene shell, the child is positioned facedown, hips-flexed, and knees flexed on a supporting fixture. Figure 39a. Hip flexion angle of the fixture can be varied. Figure 40. On the positive model, plaster is added to create the bulges and contours needed to avoid pressure on bony prominences. Figure 41a. Posterior view of a positive model fully modified and ready for covering. Figure 41b. Lateral view of a positive model fully modified and ready for covering. Figure 42. The polypropylene seat shell. The molded "Chailey Heritage" supportive seat,<a></a> which also utilizes vacuum dilatancy to obtain an impression, creates a positive model, and vacuum forms the seat materials over that model. With the exception of those general similarities, the procedures, materials, and design of the Chailey Heritage seat is very different from the Sitting Support Othosis developed at Gillette Children's Hospital. Fabrication of the U.S.S.O. does not require a pattern and is therefore free of the potential problems inherent in obtaining and modifying a model. <h3>Conclusions</h3> This paper has dealt most heavily with biomechanics and design, but many other programmatic components have been mentioned. Devices do not solve seating problems. A program is required. A truly successful seating program, one that approaches the fundamental goals discussed at the beginning of this paper, must contain at least the following components: <ol> <li> Involvement of all appropiate and available professional disciplines. </li> <li> Comprehensive discussion with, and education of, the client (when possible), the parents and/or other caretakers, and other available community-based professionals. </li> <li> Attention to finding and solving the family-specific functional (including play, recreation, and transportation) problems and opportunities. </li> <li> Provision of effective equipment with thorough instructions on its use. </li> <li> Tenacious follow-up to uncover and solve the inevitable problems and opportunities brought on by growth and functional changes; to obtain feedback necessary to the efficient evolution of the program; and to reinforce, as necessary, the education of the users. </li> </ol> <h3>Acknowledgments</h3> The important roles of some individuals and institutions have been cited earlier and will not be repeated here. Our experience with Duchenne Muscular Dystrophy has come primarily through Dr. Lowell (Hap) Lutter, chief of the Growth and Development Clinic at Gillette, and orthopedic surgeon for the Muscular Dystrophy Clinic at Fairview Hospital. The seating systems were provided at Gillette by Team Leaders, Mark Payette and David Wilkie, and the people they supervise. Those people include (currently, and in the recent past) Tracy Lillehaug, Joe Bieganek, Dannel Friel, John Spielman, Katie Voss, Lee Hegfors, Bruce Tew, Wendy Schifsky, Rick Weber, Paul Swanlund, Paul Lemke, and Marcia Munson. Gene Berglund is orthotic group manager at Gillette. Former Therapy Superivsors, Diane Twedt and Jan Headley were very involved and important during the early years of the program. Gillette therapists significantly involved with the program currently (or in the recent past) include Rebecca Lucas, Lynn Bowman-Bathke, Cindy Theisen, Patricia Mathie, Gail Graff, Marilyn Kochsiek, and Ellen Kratz. Over the years, we have been privileged to work with many outstanding individuals and institutions in various communities in our referral area. Three institutions which have been especially cooperative and capable are the Cambridge Regional Human Services Center (formerly Cambridge State Hospital), People's Child Care Residence, Homeward Bound, Brainerd State Hospital, and Moose Lake State Hospital. We have significantly learned from (in addition to centers cited earlier) the professionals associated with seating programs at the Rehabilitation Engineering Center of the University of Tennessee, the Hugh MacMillan Center in Toronto, and the Winnipeg Rehabilitation Center for Children. Address inquires to: J. Martin Carlson, Director of Orthotics and Prostetics, Gillette Children's Hospital, 200 E. University Avenue, St. Paul, MN 55101. References: <ol> <li><a href="http://www.acpoc.org/library/1973_10_007.asp">Bowker, John H. and Reed, "A Vacuum Formed Plastic Insert for Neurologically Handicapped Wheelchair Patients," Inter-Clinic Information Bulletin, 12:10, July, 1973, pp. 7-12.</a></li> <li>Carlson, J. Martin and Payette, Mark, "Seating and Spine Support for Boys with Duchenne Muscular Dystrophy," Program and Proceedings of the Rehabilitation Engineering Society of North America, Memphis, Tennessee, June, 1985.</li> <li>Carlson, J. Martin and Winter, Robert, "The Gillette Sitting Support Orthosis," Orthotics and Prosthetics, 32:4, December, 1978, pp. 35-45.</li> <li>Crandall, Stephen H. and Dahl, Norman C, "Stability of Equilibrium," An Introduction to the Mechanics of Solids, McGraw-Hill, 1959, Chapter 9, p. 420.</li> <li>Morris, J.M., Lucas, D.B., and Bresler, B., "Role of the Trunk in Stability of the Spine," The Journal of Bone and Joint Surgery, 43-A:3, April, 1961, pp. 327-351.</li> <li>Nachemson, Alf L., Andersson, Gunnar, B.J., and Schultz, Albert B., "Valsalva Maneuver Biomechanics: Effects on Lumbar Trunk Loads of Elevated Intra-abdominal Pressures," Spine, 11:5, June, 1986, pp. 476-479.</li> <li>Rang, M, Douglas, G., Bennet, G.C., and Koreska, J., "Seating for Children with Cerebral Palsy," Journal of Pediatric Orthopedics, 1:3, 1981.</li> <li><a href="poi/1978_01_030.asp">Ring, N.D., Nelham, R.L., and Pearson, F.A., "Moulded Supportive Seating for the Disabled," Prosthetics and Orthotics International, 2:1, April, 1978, pp. 30-34.</a></li> <li>Winter, Robert B., and Carlson, J. Martin, "Modern Orthotics for Spinal Deformities," Clinical Orthopedics, 126:5, July-August, 1977, pp. 74-86.</li> </ol> *David C. Wilkie, B.F.A. David C. Wilkie, B.F.A., is an Adaptive Equipment Team Leader at Gillette Children's Hospital. *Karen O. Beck, R.P.T. Karen O. Beck, R.P.T., is a Senior Physical Therapist at Gillette Children's Hospital. *John Lonstein, M.D. John Lonstein, M.D., is Chief of the Cerebral Palsy Spine Clinic at Gillette Children's Hospital and a Clinical Associate Professor with the Department of Orthopedic Surgery, School of Medicine at the University of Minnesota. *J. Martin Carlson, M.S., C.P.O. J. Martin Carlson, M.S., C.P.O., is Director of Orthotics and Prosthetics at Gillette Children's Hospital, 200 East University Avenue, St. Paul, MN 55101-2598, and Clinical Instructor for The Department of Orthopedic Surgery, School of Medicine at the University of Minnesota. Page Number(s) 137 - 158 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg Figure 8 Figure 8a http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg Figure 8b http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg Figure 10 Figure 10a http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg Figure 10b http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg Figure 10c http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg Figure 10d http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg Figure 11 Figure 11a http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg Figure 11b http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg Figure 19 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg Figure 20 FIGURE 20A http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg FIGURE 20B http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg Figure 21 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-27.jpg Figure 22 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-28.jpg Figure 23 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-29.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 Seating for Children and Young Adults with Cerebral Palsy Creator An entity primarily responsible for making the resource J. Martin Carlson, M.S., C.P.O. * John Lonstein, M.D. * Karen O. Beck, R.P.T. * David C. Wilkie, B.F.A. * https://staging.drfop.org/files/original/3ec7888cee2f851b5ad939cfc35e9698.pdf fa3c522ca3dfd7e1953c8cf88f054613 https://staging.drfop.org/files/original/2616f512f3d92ac4e805d79a4a8c64e8.jpg 6cd68ef1007dbe4d5d6544411ccf6f4f https://staging.drfop.org/files/original/d371115128acfc7dc1bd1659a5ceb2f1.jpg 8deb734fb9677fc2cf23fb2b9da7508a https://staging.drfop.org/files/original/e917b8732cef50461c1b681f0c7ecf1b.jpg e7deb03a7c60d3420be551312817837d https://staging.drfop.org/files/original/e1cf8112df2a1bb2aaf97e8332e6283c.jpg 00d0af6d0e569c08eb99f6c8a0b9bfb9 https://staging.drfop.org/files/original/c47154226c8b4249202c0177d968f9e4.jpg 788be41c8c242497efb0357b9909d3bd https://staging.drfop.org/files/original/d2df4f38ae19ba6c1560527a9c637a97.jpg 789ef1b71b6b7f3880aa1cc1b897b13b https://staging.drfop.org/files/original/425550a68b616b6cce5a9eeb50c3fc1b.jpg 11e3639315fd4c06d8fd6f7599c446ed https://staging.drfop.org/files/original/c00b05fc2d9be2f9a1cbf792263fab16.jpg 468d623d117056703073eb6525cb72bd https://staging.drfop.org/files/original/f7ef05f73d6d3e5119b1b1a3ea3df648.jpg 0f90542403702a924a2c605a62d317aa https://staging.drfop.org/files/original/62f30434ecf0464e8a03a8e7566f1fee.jpg e87645ad72adee68b98015e48c906e9d 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_159.pdf Text Any textual data included in the document <h2>Commercial Options for Positioning the Client with Muscular Dystrophy</h2> <h5>Michael Silverman, CO. <a style="text-decoration: none;">*</a></h5> Before the advent of modern medicine, progressive weakening of the musculature was thought to be due to disorders of the nervous system. Early researchers thought the problem was with the nerves somehow being unable to activate the muscles, which in turn caused the muscles to atrophy. It wasn't until the late nineteenth century that researchers began to understand that these problems were due to the muscles only, without involvement of the nerves. In 1861, Guillaume-Benjamin-Amant Duchenne, a Bolognese sea captain's son, published the first description of the severe childhood form of muscular dystrophy now known by his name. Specifically, Duchenne noted that the disease ran in certain families, and he clearly defined pseudohypertrophy (false overdevelopment) of the calf muscles as one of the disease's symptoms. It was thirty years later that Wilhelm Erb described the underlying clinical features of the various forms of progressive muscular dystrophy and outlined four subvarieties. "Some of the observed features included symmetrical muscle wasting, progression, abnormal gait, a development of charcter-istic body deformities. Erb was the first to see that these symptoms were disorders of muscle tissue, not of nerves, and he hazarded to guess that they were due to a complex nutritional disturbance."<a></a> Over the last few decades, many categories of muscular dystrophies have been designated. Some, such as Myasthenia Gravis, are controllable with simple medication and do not require special devices other than lightweight orthoses. Others, such as Duchenne muscular dystrophy, are progressive and require increasing amounts of specialized equipment to make the disability as manageable as possible. In this paper, the development of specialized seating for clients with muscular dystrophy, as well as new systems on the market today, which can help to make these clients remain as functional as possible for as long as possible, will be reviewed. Below are listed some of the major types of muscular dystrophy whose treatment will often require specialized seating. <blockquote> Duchenne (Pseudohypertrophic) Rapid, ultimately involving all the voluntary muscles. Death usually occurs within 10-15 years of clinical onset. Werding-Hoffmann (Infantile Spinal muscular atrophy) The earlier the onset, the more rapid the course. Respiratory failure and/or infection usually cause death. Kugelberg-Welander (Juvenile spinal muscular atrophy) Variable, but usually very slow. Most patients live to old age. Amyotrophis Lateral Sclerosis Rapid, leading to death usually within three to five years.<a></a> </blockquote> There are no easy rules for seating the client with muscular dystrophy. The pattern and severity of weakness varies from client to client and is usually changing so that each client has to be looked at for his individual needs. With the early onset of Werdnig-Hoffmann, specialized seating can be used to help with the prevention of deformities. These children tend to be very floppy. The positioning system will make them easier to handle and put them in a position where they can use their arms and hands to explore the world around them. The pre-adolescent onset of Duchenne muscular dystrophy will often times lead to extreme curvatures of the spine unless the client is properly managed in a positioning system or orthosis. The advantage of using a positioning system in place of an orthosis is usually that of comfort. The positioning system should provide greater comfort to its user than the use of a wheelchair with a sling seat and back. The orthosis can be a source of discomfort to the user and, for this reason, is likely to be left in the closet. "This tendency for the brace to be uncomfortable is understandable because of deformity is a collapsing type of scoliosis and the patient lacks the muscle power to pull away from a painful pressure area."<a></a> With degenerative forms of muscular disease, the most important thing a positioning system can do for the client is to aid in increasing his function, allowing him to continue with normal activities of daily life for as long as possible. The client with Amyotrophis Lateral Sclerosis (ALS) presents a whole new set of problems for the clinician. Because of the age of onset and rapid progression of the disease, the clinician does not usually have to worry about the prevention of deformity. But these same problems make it nearly impossible to design a positioning system that will provide these clients with comfort and function for any reasonable length of time. Clients with ALS tend to prefer less contoured systems, and require adjustable reclining mechanisms for comfort. Once the decision has been made that a positioning device may be beneficial, certain questions must be considered and information about the clients' family and home environment must be obtained. Then methods of transportation must be looked into. What is the prognosis of the clients condition? Is the client out with the family occasionally or most of the time? Are the outside conditions rural or urban? What are the client's favorite activities? What are the families needs? Does the family have, or will they be getting, a van which would allow the client to be transported in his or her positioning system? How close is the roofline to the clients head while seated in their standard wheelchair? Is powered mobility needed now or in the future? An overall clinical evaluation should be made and the results of these tests should be available before any positioning decisions are made. A complete physical and functional evaluation of the client is necessary to determine the extent of the weakness and whether there are any contractures present. Orthopedic considerations add another dimension and may require the input of a surgeon to determine if releases are possible to aid in good long-term positioning. (A consideration with Duchenne muscular dystrophy is the question of a possible spinal fusion.) Any deformities which are present must be noted, as their severity will help further narrow the options for positioning the client. Slight flexion contractures of the hips or knees should not pose a problem for a successful positioning system. However, extension contractures of the hips or ankles could be more of a problem. Remember that a positioning system can serve a preventative role in reducing the formation of contractures and deformities, but the positioning system cannot be used to correct these situations. If correction is needed, it is best done on the operating table before the seating system is provided. The seating system should allow the client enhanced abilities when using the system. The extremities also need to be looked at in relation to function. Arms must be free if independent mobility is possible. Strength must be tested to determine if ultralight bases would be of benefit. The wheelchair is as much a part of the seating system as a headrest or foot support. There are many types of wheelchairs on the market today and the initial evaluation is critical in determining what type wheelchair would best serve the client. For the purposes of this paper, we will concentrate on positioning solutions only. When deciding on the best position in which to seat a client with muscular dystrophy, it is necessary to start with the pelvis and achieve a neutral position to provide a stable base of support. Standard sling seats provide an unstable surface for sitting, as the pelvis will not sit level and forces a lateral compensatory curve up the spine (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg">Fig. 1</a>). The pelvis should be in midline and should not be allowed to slide laterally by blocks built into the positioning system. A 90 degree position of hip flexion is desired, and in some cases, a back-to-seat angle of less than 90 degrees may be beneficial, especially when introducing increased lordosis into the spinal section. An anteriorly wedged seat will help to achieve a proper hip angle, while assisting to maintain the client in the seating system. The object is not to immobilize, but to stabilize the pelvis. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg">Figure 1.</a> A person with abnormal tone becomes more a asymmetrical when seated on a hammock type surface. (A. Bergen and C. Colangelo, "Positioning the Client with CNS Deficits," 1985, p. 7). To complete the base of support for the upper body, the clinician must properly position the lower extremities. An abductor (wedge) will help to position the legs slightly apart giving a wider base of support (be careful not to bring the legs any wider apart than the diameter of the hips.) When using an abductor, keep it away from the groin and make sure it is of the flip-down or removable variety if a urinal is being used. Sometimes the clinician may wish to use an abductor as a reminder of the proper placement of the client in the positioning system, especially when there may be multiple care givers. The knees and ankles should be at 90 degrees unless contractures are present. In many cases, the knees may have to be extended slightly in order to clear the front casters of the wheelchair. The feet should always be supported so as to complete the stable positioning of the pelvis. As you can see, a great improvement in seating can be made just by replacing the sling seat upholstery with simple plywood and foam componentry (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg">Figure 2.</a> A firm sitting surface provides a base for symmetrical sitting. (A. Berger and C. Colangelo, "Positioning the Client with CNS Deficits," 1985, p. 7) Now, the clinician is ready to work his way up the spine. The trunk must be held in midline, as close to natural shape as possible to allow better head control. In older clients, the natural shape of the spine includes forward curves at the neck and lumbar region of the spine. For the floppy client, as well as those with a scoliotic deformity, lateral trunk supports are usually required. Usually with scoliosis, the pads are placed under the apex of the curve on the convex side and under the axilla on the other side. The third point of the pressure system is the pelvis held in with good lateral positioners (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg">Fig. 3</a>).<a></a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg">Figure 3.</a> Transverse loading in seating the patient with scoliosis (rear view). With clients who have flexible spines, many different approaches to positioning are used. For the small child with spinal muscular atrophy, allowing the spine to shape into a gentle C-curve may promote the best head position. Increasing the lordosis with these clients may help to push them out of the chair and cause their heads to fall backward. In the case of adolescent clients with Duchenne muscular dystrophy, increasing their lumbar spinal extension may actually help with the prevention of lateral curvature, as well as promote good head positioning. To understand this idea, one must first understand the mechanism of the spinal collapse in the client with Duchenne muscular dystrophy. The first sign of spinal instability as demonstrated by roentgenograms (x-rays) is the appearance of a long thoracolumbar curve of less than 10 degrees sent in patients who are ambulating with the aid of long leg braces. During the early wheelchair bound stage, the curves lose their flexibility. They also involve fewer vertebral segments, primarily in the lumbar spine, without axial rotation in curves of less than 20 degrees of lateral curvature as measured by Cobb's method. Rotation in the upper segment of the curve, which generally extends over the bodies of T10 to L3, is followed with maximal rotation at L2 of an estimated 5 degrees. Vertebral rotation then increases at a faster rate than the lateral displacement. Once rotation reaches 15 degrees and the lateral curve 30 degrees, both parameters increase rapidly. Mr. Jan Koreska and his group at the Hospital for Sick Children in Toronto, Ontario have done many studies of the spine which suggest that if lateral displacement of the lumbar spine is not prevented, axial rotation follows, and by this time conservative bracing is unlikely to succeed since structural failure has already occurred.<a></a> They also found that the posterior facets and ligaments of the lumbar spine appear to be responsible for the linear alignment of the lumbar spine. The influence of the posterior facets on the upper lumbar spine appears to be less significant because their resistance to axial rotation is reduced. "Some 80 percent of the children develop a collapsing type of scoliosis." The observation of 62 spines of boys by the Hospital for Sick Children yielded consistent results. "A few patients' spines gradually became very stiff and somewhat hyperextended over a period of years. When this happens, the patient will be a good sitter for a long time. The more usual pathway involves moving gradually from a straight spine to a rapidly steady progression into a severe kyphoscoliotic."<a></a> The first seating system developed specifically for prophylactic use by clients with Duchenne muscular dystrophy was developed in the mid 1970's. This specially designed seat was effective in limiting the progression of spinal curves to less than one degree per month in 13 out of 16 patients. The thought was, if spinal deformity could be maintained until skeletal maturity was achieved, good spinal alignment could be maintained. Clients whose curves progressed to greater than 35 degrees would usually ultimately require surgery. The Toronto Spinal Support System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg">Fig. 4</a>) is made of a fiberglass shell, lined with custom carved ethafoam, upholstered with a modified urethane foam and a tricot double knit covering. Headrests, arm rests and leg supports are attached to the fiberglass shell. The unit is meant to be inclined backward a minimum of 15 degrees. The pelvis is snugly fitted and the thoracolumbar junction extended, while the back has lateral guides to promote midline sitting. "The snug fit gives the spinal column a stable base (the pelvis), and the extension of the thoracolumbar region reduces the mobility seen when the interarticular facet joints at this level are opened up in flexion. The 15 degree backward tilt reduces the load on the spine every time the patient leans back, while the foam lining makes it comfortable and acceptable to the patient."<a></a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg">Figure 4.</a> The Toronto Spinal Support System. Conclusions from the group in Toronto over the last few years show that, although spinal deformity is not absolutely prevented, development is slowed, prolonging the period of trouble free sitting. This slowing down of the development of the spinal deformity takes place at a time when spinal growth is rapid, making the introduction of the system at a young age before puberty of utmost importance. A 10 year follow-up to the development of the Spinal Support System (SSS) sponsored by the Muscular Dystrophy Association of Canada was completed in late 1983. Following are some of the more significant findings. <ol> <li> The Spinal Support System has made a significant contribution to the management of individuals with Duchenne muscular dystrophy across Canada. Improvement of user comfort is the attribute most consistently stated. The SSS development has been particularly well received by parents. </li> <li> The SSS in its originally conceived design does not arrest the progression of spinal deformity. However, reduction in the rate of progression of deformity (1/3 to 1/2) was reported by the participating clinics. </li> <li> From the clinical data available, it was not evident that any one single feature of the SSS is the key to the improvement of spinal management; but rather suggests that there is a combination of multiple interrelated factors involved. </li> <li> There is no clear evidence supporting the hypothesis that extension of the lumbar spine is the key contributor to the lateral stabilization of the spine. </li> <li> Lack of easy adjustment for growth or change of spinal alignment creates serious delays or the postponement of the necessary revisions. </li> <li> Although biomechanically advantageous, the 15 degree recline of the backrest necessitates that the child lean anteriorly and away from the posterior supporting surfaces when participating in functional activities or seeking head stability. Only rarely were children observed or reported as using the back and head rest as intended by the designers. </li> <li> The use of prefabricated modular components which results in relatively easy assembly is viewed as a very positive feature of the design concept. </li> </ol> The overall experience with the Spinal Support System was pretty well summed up in a follow-up study completed by a review committee in 1983. "Most of the principles obtained from the SSS study in Toronto have included the importance of the incorporation of a lumbar lordotic pad to maintain the lumbar and thoracic spine in a lordotic position. The concept is, if the spine is going to become fused or rigid spontaneously, it will adopt a stiff extended alignment rather than collapsing kyphoscoliosis. However, this is the exception rather than the rule. There is no orthotic or seating system in use today, including the Spinal Support System, that will prevent the majority of these children (approximately 90 percent) from developing a collapsing kyphoscoliosis. Even in the few cases (perhaps 10 percent) in which the result is a stiff extended spine, the contribution of the seating system towards that outcome is probably only minimal. Surgery is serious; it must be offered to the patients and parents with full knowledge of potential complications. The patient's pulmonary reserve must be sufficient to withstand the surgery and the disease. The rationale for surgical intervention may be difficult to accept by the parents when the effects of non-surgical intervention are not yet readily evident. If successful, the surgical intervention will stabilize the spine, making the seating problems easier for the management team. However, even when surgical stabilization is undertaken, appropriate seating systems are required since the patient still requires pelvic support, upper and lower limb alignment and support, head support and mobility. Generally, the Spinal Support System has addressed the problem of development of scoliosis in muscular dystrophy patients. It has decreased the rate of progression, as shown in several studies. However, this may be detrimental to the patients general health because of the progression of the decreased pulmonary reserves. That is, the management team may be lulled into a "wait and see mode," only to find out later that the reduced vital capacities have shifted the balance of risk towards non-surgical management, whereas early surgical intervention would have been the treatment of preference. The use of the modified Spinal Support System in conjunction with early surgical stabilization of the spine may be useful.<a></a> The Spinal Support System was a pioneering development at a time when there were virtually no commercially available seating systems or components. Today, the interest in specialized seating is booming, and commitment by manufacturers has led to a variety of systems and components. In this next section, some of the newer systems on the market and how they are used as tools for positioning different types of clients will be reviewed. Also, current methods of seating and their ability to correct a corresponding level of orthopedic deformity will be considered. In a case where there is no, or very little, orthopedic deformity, that does not present positioning problems; the standard wheelchair should still be modified with a rigid seat insert or off the shelf wheelchair cushion over a rigid base. The normal folding wheelchair with a sling seat and back does not provide a stable base of support for the pelvis. It is alright when used temporarily, but if it is to be used for any length of time, a firm seat insert is mandatory. Sitting on a sling seat causes the hips to internally rotate, which contributes to abduction and usually an oblique pelvis. This causes a compensatory spinal curve. The client with muscular dystrophy will have differential muscle weakening in the spinal musculature and will almost always assume this position in due time. Therefore, for anyone sitting in a wheelchair for more than just quick trips, the addition of a rigid seat is mandatory. Most wheelchairs can be ordered from the factory with a rigid seat of either the drop-hook variety or attached with a special folding mechanism. A firm seat can also be made as a separate piece meant to be placed on an existing wheelchair seat. Those wheelchairs with attached non-removable rigid seats tend to make the folded chair unruly and increase the weight. The separate variety is preferred, but because it is removable, it is often left behind. This problem is usually alievated with the drop-hook seat. After removing the seat upholstery, these cushions have special hooks which clip on to the seat rails with clamps. (The wheelchair then can not be used if the seat is left behind.) The base of the seat cushion is usually plywood, at least 3/8". On top of the wood, different foams can be used. Preferably, a high density urethane which will not bottom out over time. In Chicago, we make three or four-inch cushions of two different types of T-foam or Sun-Mate foam, which have special weight distribution properties. On the first layer, we use one to two inches of firm Sun-Mate for the base and two inches of medium-to-soft foam on top of that. The cushions are then upholstered with a thin flexible vinyl surface. The vinyl takes away some of the properties of the Sun-Mate foam but protects the open cell structure against water damage. Where problems with either boney prominences or an already oblique pelvis are envisioned, the Jay Cushion will provide a stable surface while accommodating these deformities. The Roho cushion provides excellent pressure relief but may not provide enough stability and encourage leaning. The Roho is best used where pressure relief is the main concern and stability is not a problem, as with paraplegics. This is why an overall clinical evaluation is important as well as an understanding of available products. There are many other commercially available seating cushions on the market, and they must be in stock and tried on the client to determine if one will better fit the clients needs than another. A good place to see all of what is commercially available in this field is at the National Home Health Care Expo in Atlanta.<a></a> The show is always in late fall or early winter and is free. For the moderately involved clients with muscular dystrophy, there are also many choices available. More likely, they are the type of clients seen. When not in bed, these clients spend almost all of their time in a wheelchair and are in the early to moderate stages of deformity or contracture. Moderate levels of deformity or contractures are measurable but not enough to create seating or functional problems. The most widely used method of manufacture for seating devices today is using plywood and foam technology. Here, there is a seat and back section, with body supports, pelvic supports, and leg supports bolted on. Many clinicians combine the linear plywood technology with custom carving of blocks of foam (usually ethafoam) to give a custom contoured look. The advantage of the contoured system is that they provide a larger area of contact between the seating system and the client. The Toronto Spinal Support System mentioned earlier is just an advanced version of this method, utilizing component parts such as a preshaped fiberglass shell instead of plywood. It was also one of the first systems to have head rests, arm rests and leg supports specially designed as part of the seating system. Today, it really makes little sense to make an entire seating system from scratch with so many commercially available components on the market. Many companies will actually make the entire seating system based on measurements of the individual client. For componentry and/or complete systems of the non-molded variety, some of the leading systems include those manufactured by Scott Therapeutics, Freedom Designs, Miller's, CRD, Gunnell, and CP seat by Pin Dot Products. Of the contoured modular systems, there is the Winnipeg system, the Otto Bock MOSS System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg">Fig. 5</a>) and the Pin Dot Modular Seating System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg">Figure 5.</a> The M.O.S.S. system from Otto Bock. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg">Figure 6.</a> Pin Dot Modular seating system. These systems are all designed for "moderately involved" clients who have minimal deformities only, with no rotational deformities. Rotational deformities become more and more evident as lateral deformities increase, and the linear systems (or those contoured with preformed cushions) becomes less and less effective. The next group with rotational as well as lateral deformities are designated the high moderates or low severe. Two new systems developed recently by the University of Tennessee Rehabilitation Engineering Program work well for this category. The Foam-in-Place seating system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg">Fig. 7</a>) uses a plastic module with an elastic bladder which fits into the chair, and liquid polyurethane foam is measured, mixed and injected into the empty bladder while the client is properly positioned on a pre-ischial strap. The foam rises and within minutes sets up and forms a customized seat or back cushion. Because the foam takes on the exact contours of the individual, it is possible to accommodate difficult rotational deformities. The difficulties with this system are that the client is forced to sit on a 2 inch wide strap, and be perfectly positioned in a chair while the foam is mixed, injected and set up (about 5 minutes). Even though the foam can shape to the most severely involved, only the high moderates can support themselves or be supported in the proper position under these conditions. Foam-in-Place may be better used for seat cushions only, as they are easier to form and more consistent in their results. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg">Figure 7.</a> Foam-In-Place seating system. It is important to remember that all of the systems described here should not be thought of as complete systems only, but also as various components. The best way to produce an individualized seating system is to use some of the various components of each system in the best way possible to give the desired result for the individual client. Adrienne Bergen, O.T.R., a pioneer in this field, has used the word "eclectic" to describe those devices made from a variety of components from various companies, and it allows her to best fill her clients needs in the most economical manner. The Bead Seat is another new development from Douglas Hobson's group at The University of Tennessee Rehabilitation Engineering Program, which uses essentially the same componentry of the Foam-in-Place seating system. The difference between the two systems is the filling or "stuffing" in the cushions. In the Foam-in-Place system, there is a liquid foam which sets up and forms while the person is suspended over the empty shell. The Bead Seat's "stuffing" is a mixture of a fast setting epoxy and polystyrene pellets (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg">Fig. 8</a>). The epoxy will set up two hours after the introduction of the catalyst, locking the lightweight pellets into the form desired. The form is made while the whole system is under vacuum using the dilation method. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg">Figure 8.</a> Side view of Bead Seat Technology. Dilation is a molding technique used for more than three decades and consists of an airtight bag filled with pellets and attached to a vacuum pump. When the vacuum is introduced into the system, the bag compresses against the pellets and holds whatever shape it has prior to the introduction of the vacuum. To change the shape, air is introduced into the bag, loosening the pellets' structure and allowing a change in shape. The Bead Seat system depends on the vacuum to hold the shape until the epoxy sets up, creating a mechanical bond between the styrene pellets. Once the epoxy has set, the vacuum can be removed and the positioning system completed. The advantage of the Bead Seat over Foam-in-Place is that there is more time available to mold and remold the system, while simulating the finished system, to attain the desired shape. The extra time available for shaping with the Bead Seat allows it to be used with more severely involved clients than Foam-in-Place. This advantage of extra time is also a disadvantage when compared to the Foam-in-Place system, since it takes longer to produce the finished product. Also, when finished, the Bead Seat has a harder surface compared to the flexible surface of the Foam-in-Place cushion. This harder surface may be an advantage with positioning, but a disadvantage when pressure relief is the objective. Bead Seat, as well as Foam-in-Place, will accommodate rotational deformities but may not be durable enough for the long-term needs of the larger clients because of the plastic framework. For lighter clients (under 100 pounds), the Bead Seat will easily accommodate the severely involved. Another limiting factor of both the Foam-in-Place and Bead Seat systems is that only a headrest system and a simple 90 degree legrest are available as options for customizing the systems, as they are designed to be used with the accessories in the existing wheelchair and this may not be enough for the most severely involved clients. When dealing with the severely involved, the traditional orthotic approach is the vacuum-formed plastic or Gillette style seating system. Using this system, a mold is taken of the individual by placing the client prone on a table with the hips flexed to 90 degrees. The mold is taken using either the dilation method or with plaster bandages. This method of taking an impression is a problem. The mold (or measurements) should always be taken while the client is simulating the final seating position. The effect of gravity on the client cannot be felt when the client is molded in a prone position, and the client's shape may be completely different when upright. It is easy to straighten a client's spine when prone on a table; the problem is that the client may not be able to tolerate this corrected position for long periods of time when upright. This applies especially to the client with muscular dystrophy, who may not have the muscle strength to pull away from a sore area. When one is dealing with a client in the severely involved category, the idea is to correct as much flexible deformity as possible, while making the positioning system as comfortable as possible so the client will be able to use the system for long periods of time during the day. Other difficulties with the traditional orthotic approach include the time needed to fabricate the finished system and the inability to adjust the system once it is finished. These problems are the same as those encountered when making a sophisticated seating system out of plywood and foam. With the traditional orthotic approach, the finished mold is filled, smoothed and corrected. Over the finished mold, a layer of foam is vacuum formed, then a layer of polypropylene is added. The plastic shell is then trimmed out, set in a box to form a base so it sits in the wheelchair at the desired angle, and upholstered. Time is valuable, and today most private facilities cannot profitably produce seating systems in this manner. Today, because of the large amount of commercially available componentry, systems do not have to be made this way. Is anybody still hand forging knee joints? Today seating is where orthotics was in the late 50's or early 60's, at the advent of commercially available componentry. Two newly developed systems work especially well for the severely involved clients: the Contour-U seating system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg">Fig. 9</a>) and the Matrix seating system. Contour-U utilizes the same dilation technology as the Bead Seat, but molds are taken on a specially designed molding frame with rubber seat and back bags filled with polyethylene pellets. Once a mold is taken of the individual in the proper position, plaster splints are worked into the mold to give a positive impression of the client. The molds are then turned into flexible upholstered cushions on a central fabrication basis, designed to eliminate the shop time needed for fabrication. The finished seat and back cushions snap into aluminum hardware, which also has the ability to be angularly positioned (both back-to-seat angle and recline orientation) and adjusted for length. This system accepts a wide variety of accessories designed to accommodate even the most severely involved client properly. The system is not labor intensive but can be expensive, especially when used with the many accessories available. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg">Figure 9.</a> Contour-U seating system. As clinicians, knowledge of patient priorities should be uppermost. Don't use Contour-U when a Bead Seat will do. Don't use a Bead Seat where a Jay cushion will do the job. Think eclectically for the patient. Contour-U cushions with plywood and simple componentry can be used to create an inexpensive, custom molded seating system. For another client, a Bead Seat molded back and a Foam-in-Place seat may be the best solution. Another advancement in seating developed in Vancouver and now manufactured in England is the Matrix system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg">Fig. 10</a>). The Matrix takes an altogether different approach by providing a flat sheet of locking ball joints which can be contoured to almost any shape and locked into that position by individually tightening the ball joints. <a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg">Figure 10.</a> Matrix seating system. Essentially, a sheet of material into which tucks can be taken and contours formed, Matrix can be fabricated to position somebody in any position desired. A nice feature of the Matrix is that it can be loosened and reshaped when necessary. Also, where growth is expected, the matrix can be extended by just adding a row or two of modules. The disadvantage of this system is in the time required to produce the finished product. Anywhere from 15 to 25 hours is necessary, which puts it into the same category as traditional orthotic seating systems. Fortunately, Matrix fabrication is also available on a central fabrication basis. Some may consider the Matrix unattractive, but its high tech design also makes it airy, lightweight, and waterproof. The Matrix fits in well with the eclectic approach, as pieces of the material may be used for a custom head rest or arm trough when needed, making a whole system out of material unnecessary, unless preferred for the client. These are brief descriptions of some of the newer systems on the market today. Information is available from the manufacturers to learn the benefits and weaknesses of all these systems (see suppliers list). The idea is to best provide the client with a product which, individually, does what is required for the most economical price. Having a variety of systems at our disposal, as well as the ability to custom fabricate components when necessary, will allow us to provide the best service to our clients and establish our facilities as specialists in this expanding field. In Chicago, we have done just this by establishing the Chicago Seating Institute. At the facility, we specialize in proper positioning of clients, while providing various styles of seating systems, wheelchairs, and environmental controls. In the future, we hope to expand our field of expertise to include communication devices as well. Over the last few years, the development of the specialized seating side of our business has increased our volume from 12-15 clients a year in 1981 to 150-200 clients a year today. In no other area of our business could we have expected to see a ten fold increase in the number of clients seen, even with the same commitment made as we've done for specialized seating. The field of specialized seating is up and coming, not only for the orthotist, but the prosthetist and other allied health professionals as well. Unfortunately, traditional education for specialized seating is not available. However, there are some programs and seminars offered, with increasing frequency in the past few years. Watch the upcoming issues of the American Orthotic and Prosthetic Association Almanac, or contact The Association for the Advancement of Rehabilitation Technology (RESNA) at Suite 700, 1101 Connecticut Avenue, Washington, D.C. 20036; (302)857-1199. Historically, as with orthotics and prosthetics, the best and only real way to learn is to learn by doing. See your clients, and learn from making systems for them. This hands-on method is the best teacher for seating because you can watch the clients expression to know if they are comfortable. The "cookbook" approach with easy rules just doesn't work here since people do not demonstrate this reflex or that reflex, this deformity or that deformity, but a hodgepodge of various reflexes, deformities and contractures. Add to this differing age groups, backgrounds, living conditions, and mental abilities, and the cookbook method becomes impossible. Have a variety of solutions at your disposal. Think of the client as an individual. This education will help you understand your clients discomforts and needs. With the help of a therapist, decide on realistic attainable goals. With this in mind, there are many ways to achieve the desired results of functional (where possible) and comfortable (always possible) seating for clients. <h3>Suppliers</h3> BEAD SEAT Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. (Developed by The University of Tennessee Rehabilitation Engineering Program.) CP SEAT Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. (Second generation of the MPI seating system developed by The University of Tennessee Rehabilitation Engineering Program.) CONTOUR-U SEATING SYSTEM Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. CRE Creative Rehabilitation Equipment, 513 NE Schuyler, Portland Oregon, 97212. FOAM-IN-PLACE SEATING SYSTEM Carapace, Inc., P.O. Box 45040, Tulsa, Oklahoma 74147. FREEDOM DESIGNS Freedom Designs, Inc. 18165 Napa #8, Northridge, California 91324. GILLETTE SEATING SYSTEM Gillette Childrens Hospital, Orthotic Department, Minneapolis, Minnesota. GUNNELL Gunnell Manufacturing, 221 North Water Street, Vassar, Michigan 48768. JAY CUSHION Jay Medical Ltd., 805 Walnut, Boulder, Colorado 80302. MATRIX SEATING SYSTEM Pin Dot Products, 2215, West Belmont, Chicago, Illinois 60618. (Developed by Clinical Engineering Designs, Kingston upon Thames, England.) MILLER'S Miller's Rentals and Sales, 284 East Market Street, Akron, Ohio 44308. MOSS (Modular Orthotic Seating System) Otto Bock Industries, 4130 Highway 55, Minneapolis, Minnesota 35422. PIN DOT MODULAR SEATING SYSTEM Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. ROHO CUSHION Roho, Inc. P.O. Box 658, Belleville, Illinois 62222. SCOTTIE SEATING SYSTEM Scott Therapeutic Designs, 430 Robertson Lane, San Jose, California 95112. TORONTO SPINAL SUPPORT SYSTEM The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario. References: <ol> <li>Ogg, Elizabeth, "Milestones in Muscle Disease Research," Published by the Muscular Dystrophy Associations of America, Inc., 1971.</li> <li>Muscular Dystrophy Associations of America, Inc., "Chart of Differential Diagnostic Characteristics of the Primary Diseases Affecting the Neuromuscular Unit."</li> <li>Gisbon, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," Orthopedic Clinics of North America, Vol. 9, No. 2, April, 1978, pp. 437-450.</li> <li>Letts, M. and Rang, M., "Seating the Disabled," Atlas of Orthotics, American Association of Orthopedic Surgeons, p. 468.</li> <li>Koreska, J. and Robertson, D., "Biomechanics of the Lumbar Spine and its Clinical Significance," Orthopedic Clinics of North America, Vol. 8, No. 1, January, 1977, pp. 121-133.</li> <li>Gibson, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," Orthopedic Clinics of North America, Vol. 9, No. 2, April, 1978, p. 439.</li> <li>Gibson, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," Orthopedic Clinics of North America, Vol. 9, No. 2, April, 1978, p. 440.</li> <li>Hobson, D., Desrosier, F., Beauchamp, R., and Martel, G., "The Spinal Support System and Other Approaches to Specialized Seating for Duchenne Muscular Dystrophy Patients-A Review Report," The Muscular Dystrophy Association of Canada, November, 1983.</li> <li>National Home Health Care Expo, Atlanta, Georgia. Call (305)773-2222 for details.</li> </ol> *Michael Silverman, CO. Michael Silverman, CO., is with Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. <div style="width: 400px;"></div> Page Number(s) 159 - 170 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.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_04_159/1986_04_159-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.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 Commercial Options for Positioning the Client with Muscular Dystrophy Creator An entity primarily responsible for making the resource Michael Silverman, CO. * https://staging.drfop.org/files/original/8c11b3cbe55906e1a1186e314abc12de.pdf 89e25364859efdc360a9591d8eafde92 https://staging.drfop.org/files/original/6cd45f3b1fecdd1934f70f5984f7f04e.jpg 17a303332067cd2cc381bb5fef3e72a9 https://staging.drfop.org/files/original/280c3bdf5f55120e4c0ff0ca8df2cef8.jpg 9a6fcac68852c85bdace0fecdbd25448 https://staging.drfop.org/files/original/e27129c49cee597181f097ae05458f31.jpg 70e3eb3d448acc0502e384554fc7add8 https://staging.drfop.org/files/original/09cab4907fea00930e6fcb6e8e4313e4.jpg 47629a5785f7d3b3038584a0bf02b2e2 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_171.pdf Text Any textual data included in the document <h2>Prostheses to Achieve Independent Ambulation for a Geriatric Quadruple Amputee</h2> <h5>Gustav Rubin, M.D., FACS <a style="text-decoration: none;">*</a> Fred Harris, B.S., CO. <a style="text-decoration: none;">*</a></h5> The elderly quadruple amputee presents a challenge to a prosthetic clinic team. Although this problem is occasionally noted in children with congenital amputations,<a></a> it is much less commonly encountered in adults. During the past fifteen years there has been only one other total quadruple amputee-a young adult who was treated at our center and did not wish to have his case published. Here we have the opportunity to present a report on the prosthetic fitting of a 64 year old veteran who was referred to our Special Clinic Team in 1981, from the VA Medical Center in Cleveland, Ohio, with a history of quadruple amputations secondary to frost bite. H.F. was found on January 8, 1981, on a cold winter day, lying outside his home. He was unresponsive and had a rectal temperature of 77°. After a period of conservative care, amputations on all four limbs were done on February 4, 1981, at the private hospital in Canton, Ohio, to which he had been initially taken. The surgery resulted in a right wrist disarticulation, a left distal forearm amputation just proximal to the carpus, and bilateral below-knee amputations. The residual limbs healed without complications and the patient was transferred, on March 11, 1981, to the V.A. Medical Center in Cleveland, Ohio, where he was started on a course of physical and corrective therapy, including daily strengthening exercises to all four extremities. He was considered highly motivated and an "excellent candidate" for prostheses. He was referred to our center, which was then the V.A. Prosthetics Center, and was examined by the Special Prosthetic Clinic Team on May 21, 1981. H.F. also had a background history of gastrointestinal surgery ten years earlier for a perforated peptic ulcer. The report of the physical examination at the hospital prior to referral for prosthetic prescription revealed a normal cardiovascular examination, a blood pressure of 110/70, but a liver enlarged three cm. below the costal margin. The popliteal pulses were good. The evaluation by the clinic team confirmed that H.F. was well-motivated. He was an intelligent, cooperative, slender individual, whose amputations were all well-healed. The right below-knee residual limb measured 4 inches to the bone end and the left below-knee limb measured 4 1/2 inches to the bone end. There were mild knee flexion contractures which were not considered fitting problems. On the right below-knee limb there was a palpable, slight, irregular, distal anterior tibial bone prominence, unattached to the overlying tissues. On the left side the below-knee limb was poorly padded by soft tissue. As the examiner attempted to mimic piston motion of the soft tissue sleeve by drawing the soft tissue proxi-mally, the distal skin, overlying a slight bone irregularity, blanched. X-rays of the left below-knee residual limb confirmed the clinical impression of bone irregularity and x-rays of the upper extremities confirmed the right true wrist disarticulation and the left amputation just proximal to the carpus at the level of the distal radius and ulna. The amputee had been through a great deal (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg">Fig. 1</a>) prior to referral to the Clinic Team and it was the consensus, at this time, that referral for a lower extremity revision would have adverse impact on his motivation. It was the aim of the staff to make the patient as independent as possible by adapting the prostheses to his donning and doffing capabilities. PTS prostheses were prescribed to be fabricated with loops on the soft socket inserts (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg">Fig. 2</a>) to aid donning. The prostheses for the upper extremities employed a Northwestern ring for the figure of eight harness, double wall sockets, friction wrists, and Dorrance Lyre hooks. <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg">Figure 1. H.F., a 64 year old veteran and quadruple amputee.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg">Figure 2. Below-knee prostheses were adapted with loops on the soft socket inserts to aid in donning.</a> In addition, he was prescribed for platform crutches, which were modified with distal rings for the hooks and forearm loops (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg">Fig. 3</a>). The forearm loops had to be pre-adjusted into a fixed position so that H.F. could slip the prostheses through the loops and avoid the need for repeatedly adjusting the Velcro® straps. <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg">Figure 3. Platform crutches were also modified with distal rings for the hooks and forearm loops.</a> On June 11, 1981, fabrication of the below-knee prostheses was completed and the amputee demonstrated that he could stand and take several steps in parallel bars with assistance on each side. An exercise and training program with the prostheses was outlined at the hospital. The instructions included careful monitoring of the stumps during this time. On June 18, 1981, the amputee was observed to be doing "extremely well," as indicated by the clinic team's notes. By this time he had also been fitted with his upper extremity prostheses and forearm crutches. He rapidly progressed to unassisted ambulation with crutches (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg">Figure 4. H.F. progressed to unassisted ambulation with crutches.</a> When seen by the clinic team on August 10, 1981, H.F. walked with the aid of a platform crutch. Because of irritation over the right ulnar styloid process, which was unresponsive to modification of the socket, a new socket was prescribed incorporating a soft liner and he had no further problems with this. On September 16, 1981, four months after his initial presentation to the team, H.F., who had been under continuous training by the Rehabilitation Service at the VAMC, NY, demonstrated that he was able to don and doff his own prostheses and even walk without crutches. He did, however, have more confidence when using one crutch. He was advised to continue using at least one crutch at all times. He reported the prostheses to be comfortable. Objectively, they appeared to fit satisfactorily and they were accepted. The amputee was returned to the VA Medical Center in Ohio. Subsequent attempted follow-up has been unsuccessful. References: <ol> <li><a href="http://www.acpoc.org/library/1977_11_001.asp">Sullivan, Richard A., and Celikyol, Felice, "Prosthetic Fitting of the Congenital Quadrilateral Amputee: A Rehabilitation-Team Approach to Care," Inter Clinic Information Bulletin, XVI:11-12, November-December, 1977, pp. 1-6.</a></li> <li><a href="http://www.acpoc.org/library/1972_11_013.asp">D'onofrio, F. and Cope, P.C., "Crutches for the Quadrimembral Amputee," Inter Clinic Information Bulletin, XI:11, August, 1972, pp. 13-15.</a></li> </ol> *Fred Harris, B.S., CO. Fred Harris, B.S., CO., is also with STAMP, NY. *Gustav Rubin, M.D., FACS Gustav Rubin, M.D., FACS, is Director of the Special Team for Amputations, Mobility, Prosthetics/Orthotics, New York (STAMP, NY), 252 Seventh Avenue, New York City, NY 10001. Page Number(s) 171 - 173 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.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 Prostheses to Achieve Independent Ambulation for a Geriatric Quadruple Amputee Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., FACS * Fred Harris, B.S., CO. * https://staging.drfop.org/files/original/a35cfabdeded6efeb701fabb13e0203a.pdf 1c6c0d675c28db96ad766418ff443a9b https://staging.drfop.org/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg 14d5744670f9a9f1540367bb959c02c2 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_01_001.pdf Text Any textual data included in the document <h2>Transfer of Rehabilitation Research and Development Results into Clinical Practice</h2> <h5><a href="/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg">Margaret Giannini, M.D. *</a></h5> For more than thirty years, Dr. Margaret Giannini has been a pioneer in creating programs for the diagnosis, treatment, education, rights and affairs of the mentally retarded, developmentally disabled and the handicapped. In 1950, Dr. Giannini founded and directed the Mental Retardation Institute at New York College. In 1980, she accepted a Presidential appointment as the first Director of the National Institute of Handicapped Research, a branch of the U.S. Department of Education. In April, 1981, Dr. Giannini took over the position of Director for the VA Rehabilitation Research and Development Service (Rehab R&D). In addition to these positions, Dr. Giannini is past-president of the American Association on Mental Deficiency and past-president of the American Association of University Affiliate Progams, two of the most influential organizations concerned with the mentally and physically handicapped. Dr. Giannini is the recipient of many awards from varying organizations in recognition of her professional and humanitarian services and achievements. She also has authored and co-authored numerous publications; presented many lectures, papers, keynote addresses; and participated in panel discussions and workshops throughout the world. The Veterans Administration, Rehabilitation Research and Development Service (Rehab R&D) funds approximately 100 projects a year aimed at developing new methods or improving existing techniques for assisting disabled veterans. The program was created by a Congressional mandate, U.S.C. 38, Sec. 4101, (c)(1) and (2), which directs that the VA "carry out a program of medical research including prosthetics research. Prosthetics research should include research and testing in the field of prosthetic, orthotic and/or orthopedic appliances and sensory devices." A review of Rehab R&D scientific and engineering accomplishments provides insight into the VA/Rehab R&D technology-transfer programs. Some of the recent and ongoing research conducted under this sponsorship includes: maxillofacial restorations—to include use of biomaterials and their clinical applications; development and evaluation of robotic aids for the severely disabled; seat cushions for the paralyzed to prevent decubitus ulcers; functional electrical stimulation (FES) systems for upper extremity control; physiological effects of FES on paralyzed muscles; walking restored in a paralyzed man using FES; a motion-guiding load-bearing external frame for the knee; possible myoelectric controlled above-knee prosthesis; oprimum prosthetic foot characteristics for the dysvascular below-knee amputee. Image: Dr. Giannini In addition to sponsoring such research in the past, Rehab R&D has established a program concerned with the transfer of research into clinical practice. This program consists of the following six parts: <ol> <li> Establishing clinically relevant research priorities. </li> <li> Insuring that the significant research encompasses clinically relevant factors. </li> <li> Dissemination of research findings to the scientific community. </li> <li> Evaluation of research results for suitability for transfer to clinical settings. </li> <li> Support to private industry to make new devices and equipment commercially available. </li> <li> Dissemination of new methods to clinical practitioners. </li> </ol> Each of these is examined at length in the remainder of this paper. <h3>Establishing Clinically Relevant Research Priorities</h3> In the past, the VA had only general research priorities for award of Rehab R&D funds. Oftentimes researchers focused proposals on esoteric topics which were of little or no clinical significance while major clinical issues went unaddressed. To remedy this situation, a series of workshops were held with consumers and clinical leaders to develop priorities for research on clinically significant issues. Many of the workshops sponsored by RESNA and the VA have been published. Workshop topics have included sensory aids, functional electrical stimulation, and prosthetics/amputation. Rehab R&D also has participated in meetings of the International Standards Organization (ISO) which established specific priorities within the areas of prosthetics/amputation, spinal cord injury (including wheelchairs), and sensory aids. Rehab R&D now has a policy of soliciting and approving funding for only those proposals which fall within these priorities. <h3>Ensuring that Research Addresses Relevant Clinical Issues</h3> There is a vast distance between research and clinical application of methods and devices. Rehab R&D has the responsibility not only to fund research, but also to initiate and support the development of the clinical methods necessary for effective application. For example, the outstanding work done by Ernest Burgess, M.D., in Seattle, and others on immediate postoperative fitting requires new and complex clinical procedures. A necessary step in promoting clinical application of this method has been the development of a clinical procedures manual and the training of practitioners and patients. <h3>Dissemination of Research Findings</h3> The new VA Journal of Rehabilitation R&D replaces the earlier Bulletin of Prosthetics Research with a number of major changes. Aimed at the entire scientific community, and charged with following the highest standards of scientific quality, the Journal of Rehabilitation R&D is designed to offer an interdisciplinary vehicle for publication of technical materials which can most directly reach rehabilitation professionals. In addition to the Journal, the first edition of a new annual publication Rehabilitation R&D Progress Reports, is now in press. This publication is aimed at providing a comprehensive overview of research and development now in progress both in the United States and internationally. One of the publication's functions will be to serve as a guide to sources of information within the areas of Rehab R&D priorities. Rehab R&D, in the planning stage of developing, will work in coordination with professional organizations in the field to facilitate the translation of scientific results into technical clinical information of direct relevance to practicing clinicians. <h3>Evaluation of Research Results</h3> The Chief Medical Director of the VA has given approval to establish the Development and Evaluation Program (DEP) for the evaluation of research and development findings to determine their suitability for adoption into clinical practice. The program is designed to stimulate, evaluate, and acquire and disseminate information, including the development of educational guidelines and technical manuals. The educational guidelines will be coordinated between the Continuing Education Resources Service and the Prosthetics and Sensory Aids Service (PSAS). Thus, both the people who will prescribe and/or use these new devices, techniques, or concepts, will be trained. Rehab R&D will not actually provide the training, but it will provide the data and/or research scientists as instructors for the training program. This Rehab R&D program is currently limited to devices specifically developed in VA or other federally funded R&D projects. Rigorous evaluation will provide objective and comprehensive information to the key decision makers related to clinical adoption. Information will be provided to funding agencies—including the VA—which must formally approve reimbursement of the devices or use of procedures in clinical practice; to industry so they can decide whether to add the devices to their commercial lines; and to clinicians who must decide on how to apply the new methods or devices. VA responsibility for evaluation will be shared cooperatively between Rehab R&D on new research, and by the VA's Prosthetics and Sensory Aids Service on devices which are already commercially available, but have not been previously evaluated. <h3>Support to Private Industry to Make New Devices Commercially Available</h3> No matter how good research and engineering results are, they are of no value unless they become available to clinicians. Many useful devices which have resulted from research are not commercially available. To overcome this gap, discussions have been held with industrial leaders who have offered advice on the nature of the rehabilitation market, which is just one impediment. Based upon the input of these industrial leaders, commercial availability is being attacked on two fronts. First, an interagency agreement with the Department of Commerce has been developed to assist small minority business firms in tooling-up for offering new products as a part of their commercial lines. Specifically, the interagency agreement provides for the study of marketing and development methods to fully utilize the research and development of new devices for the disabled. The purpose of this interagency agreement is to utilize existing programs in the Minority Business Development Agency (MBDA) and stimulate marketing for devices that result from VA-sponsored R&D. The National Commission of Technology Transfer, of the Department of Commerce, is in the process of offering funding in order to: <ul> <li> plan for an international conference on making prosthetic and orthotic devices and sensory aids readily available to the handicapped population; </li> <li> identify and develop potential markets and financing for such devices; </li> <li> examine the use of microcomputers and other high technology areas; </li> <li> examine the impediments to obtaining funding for high-technology products; and, </li> <li> develop a process that leads to the commercialization of technology researched and developed by the VA, with emphasis on providing access to these markets for minority entrepreneurs. </li> </ul> Arrangements have been made to encourage private industry to adopt the results of individual research products which are judged to have particular merit. As a result of these efforts, the Johns Hopkins Manipulator will soon be commercially available. Other negotiations are continuing. To facilitate this process, VA Rehab R&D has assisted in the creation of a National Commission for Technology Transfer, which is concerned with making research results commercially available to handicapped people. <h3>New Directions</h3> Future plans by VA Rehab R&D to assist in the transfer of technology from research to clinical practice are as follows: <ul> <li> Continued publication of the Journal of Rehabilitation R&D and the R&D Progress Reports; </li> <li> Publication and distribution of papers on subjects potentially relevant to future clinical practice (e.g. training manual for use of robotic systems for the severely disabled); </li> <li> Design and implementation of a formal research program, based at the Office of Technology Transfer, to evaluate and improve the transfer of technology, including: <ol> <li> The collection of clinical practice data from VA facilities to give a chronological picture of the gap between state-of-the-art devices and actual clinical practice; </li> <li> A series of consumer surveys to determine their needs and to uncover problems or frustrations with existing rehabilitation procedures and equipment; and, </li> <li> A series of surveys among clinical practitioners to collect data on clinical needs, problems and priorities. </li> </ol> </li> <li> A periodical and/or a technical communication in existing periodicals for clinicians, designed in cooperation with PSAS, the Academy, AOPA, AAOS, Paralyzed Veterans of America, Disabled American Veterans, National Institute of Handicapped Research, and other organizations to further enrich the transfer of new research findings to clinicians in a format tailored to their practical needs. In the long run, a computerized reference system may be developed; </li> <li> Seminars on selected topics between recognized clinical leaders and senior researchers who have achieved scientific breakthroughs relevant to clinical practice; and, </li> <li> Access to national and international scientific and clinical literature. </li> </ul> These thrusts are ambitious and will take time, but they convey the depth of Rehab R&D commitment to technology transfer. *<a href="/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg">Margaret Giannini, M.D</a>. A native of New York, Dr. Giannini is married to Louis J. Salerno, M.D. and has raised four sons. Dr. Giannini is scheduled to speak at the Academy Annual Meeting in Orlando on January 26, 1984. <div style="width: 400px;"> </div> Page Number(s) 1 - 3 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_001/1984_01_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Transfer of Rehabilitation Research and Development Results into Clinical Practice Creator An entity primarily responsible for making the resource Margaret Giannini, M.D. * https://staging.drfop.org/files/original/12c366995fac640412262b97e21e05bc.pdf 5425bdb7fa0bf0a71fba5604a71cbe09 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_01_003.pdf Text Any textual data included in the document <h2>Prosthetic-Orthotic Research - A New Thrust is Needed: A Clinician's Perspective</h2> <h5>Charles H. Epps, Jr., M.D. <a style="text-decoration: none;">*</a></h5> Since the prime supporter of research, the federal government, has sharply reduced some areas of funding, the efforts of many established investigators and programs have been curtailed. Hardest hit has been the young aspiring investigator without a track record, who has found it virtually impossible to acquire funding for initial research efforts. Basic research as well as clinical research has suffered. Prosthetic and orthotic research programs which have never had abundant or even adequate funding also have been adversely affected. In the area of upper extremity prosthetics, much research remains to be done. For the patient who wears a prosthesis, cosmesis is still a major concern. Cosmetic acceptability must be improved and sensory feedback must be developed; sockets must be made more comfortable and suspension must be improved. Myoelectric control systems and other methods of external power must be made more functional, more compact, and more economical. In the lower extremity, newer materials and techniques must be developed to make prostheses lighter in weight, especially for the geriatric wearer. Although there seems to be less enthusiasm today for skeletal attachment of prostheses, the concept remains a challenge. The mechanical integrity and durability of knee devices can be improved along with fitting and alignment techniques. Because of basic lack of knowledge about the effects of forces on bone, ligaments and tendons, the need for orthotic research is even greater than in prosthetics. More needs to be known about the magnitude and patterns of forces that are necessary and safe to orthotic applications. Workers in kinesiology and gait laboratories around the country are endeavoring to find more answers to diagnostic problems and to collect useful data for orthopaedic assessment and even surgical treatment. New materials offer the orthotist new versatility. The pneumatic orthosis, a new concept, is ready for full development. Electrical applications are at an embryonic stage in the stimulation of paralyzed muscles, inducing therapeutic exercises, and providing afferent or feedback systems. New interest has developed to improve powered mobility devices to replace the conventional electric wheelchair for the high level spinal cord injured patient. Specially adapted vans can be operated safely by paralyzed, limb deficient patients and other severely handicapped. In view of the potential offered by computer applications and rapidly improving robot technology, environment control devices are on the threshold of great advances. So much remains to be done in prosthetic-orthotic research that even the casual observer must be concerned. At the same time that public research dollars have decreased, private research dollars have not increased sufficiently to fill the void. Obviously, research needs offer a challenge to orthopaedic surgeons who must increase the amount of personal time and funds given for research. At least one encouraging sign of private sector philanthropy exists. Bristol-Meyers/Zimmer U.S.A. has donated 1.2 million dollars to the Orthopaedic Research and Education Foundation (OREF) for the 1983-1984 Campaign. To date, more than 150 orthopaedic surgeons have given $1,000 each to OREF for the current campaign. This is in sharp contrast to the previous years' total of $200,000 from all sources. Other members of the industrial community should duplicate and even surpass the example set by the Zimmer group. If this instance of giving by the orthopaedic surgeons and a prime industrial supplier is replicated by prosthetic-orthotic practitioners and members of the corresponding industrial manufacturing community, the funding for prosthetic-orthotic research can be adequately raised to support needed research programs. *Charles H. Epps, Jr., M.D. Division of Orthopaedic Surgery, Howard University Hospital, Washington, D.C. Page Number(s) 3 - 4 Year 1984 Volume 8 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 Prosthetic-Orthotic Research - A New Thrust is Needed: A Clinician's Perspective Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/a32e7ddca38ac3658b7debb50c742a7d.pdf 94386f89329ed90de7d4de19d32ee144 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_01_004.pdf Text Any textual data included in the document <h2>From Research Lab to Consumer: The Manufacturers' Point of View</h2> <h5>Carlton Fillauer, CPO <a style="text-decoration: none;">*</a> Charles H. Pritham, CPO <a style="text-decoration: none;">*</a></h5> The matter of transferring new developments from the researcher to the consumer is one that has bedeviled the American prosthetic-orthotic establishment for years. The researcher, the agency that funds the research, the manufacturer, the clinician, and the patient are all, of course, interested in seeing new products brought to market, and all stand to benefit. Financially, the manufacturer is the one who stands to benefit the most from the successful introduction of a new product. Only by such means does a manufacturer expand his base and increase earnings. If the incentives are greatest for a manufacturer, the risks are also proportionately greater. In making a decision to produce a new product, the manufacturer must weigh the risks against the potential benefits and make a decision about committing his resources. It should be obvious that once resources of time, effort, and money are lost backing an unsuccessful product, they are lost forever. What is not so obvious is the fact that the loss is threefold. Potentially, at least, the resources expended for backing a losing product could have been invested in a successful one, turning a loss into a profit. Also, in making the decision to back a new product the manufacturer commits his prestige and credibility. A positive result resounds to his credit, attracting new attention to products currently being produced and assuring a positive reception for future products. A negative result has the opposite effect, tarnishing the image of other items in the manufacturer's product line and damaging his credibility. That the investment in a new product can be a high one should not be discounted, therefore. A small group of highly skilled and motivated individuals (or an inventor working alone) can, with a relatively low investment in machinery, produce complicated prototypes efficiently and with a low rejection rate. When the time comes to produce the same object in large numbers, the factors are fundamentally different. Production workers are seldom so skilled or motivated. Oftentimes, to overcome bottlenecks in production and to achieve consistent results, a product must be redesigned. The cost of this redesign must be borne by the manufacturer. To achieve productivity and consistent results, the manufacturer will develop tools, dies, and molds with which to produce a device. Resorting to such an alternative can enable relatively unskilled personnel using inexpensive materials to produce products of great appeal and excellent quality. While the material costs of such objects can be measured in the cents, the cost of the molds and dies can frequently run in the thousands of dollars each. If it is necessary to produce the device in a range of sizes and in right and left, the cost can be prohibitive. It should also be borne in mind that the researcher or inventor frequently has only partially tested the prototype and further testing and development must precede redesign for production. The direct expense of manufacturing an object, however, is only a portion of the cost. In order to sell a product it must be promoted and advertised. The total expense of attending a convention (often far from home), renting space to exhibit, and obtaining a suitable display is not cheap. Commissioning the art work and copy of an advertisement, and obtaining space for it in a journal are, similarly, of considerable expense. The organization that makes all this possible (research and development, production, and promotion) can frequently be quite large and demand a sizable indirect labor force to administer the resources and personnel involved. The total expense of all factors involved in developing a new product is a figure to be reckoned with and can be justified only if the product has the potential of selling in sufficient quantities to recoup the original investment and earn a favorable rate of return. It is in connection with this that the greatest stumbling block is encountered. Whatever the merits of a design may be, a manufacturer can not afford to devote the resources to its development if it will not sell in a large enough volume to enable him to sell it at a reasonable cost. Despite the optimistic expectations of a developer, the market for his new object is seldom as large as he hopes. All researchers and developers seeking federal research money are asked to project the number of individuals for whom their work will be applicable. As all involved will admit, it is a fundamental fact of the way that health care is funded in the United States and the way that health care statistics are gathered that the best of projections are crude estimates. What statistics are available point to the fact that the total market for any one product is small. This market is rendered smaller because not all members of that market are in the marketplace at one time, or even interested in the new product. A new product must compete for a share of the market with existing products that do the same thing. It should be kept in mind that few, if any, developments are so radically different as to have no potential competiton for market share. The price at which established products are sold limits the price for which a new product can be sold. For a new product to rapidly gain market share, it must be reasonably priced versus the competition, potentially much better than the competition, and current users must be very dissatisfied with the competing product. On a practical level, the people to whom a product must be marketed are not the ultimate consumer, but the prosthetist-orthotist who will render that product into a form suitable for a particular patient, and who must also frequently convince the physician to prescribe the device. At any one time, there are said to be about 2,000 practicing prosthetists-orthotists; that is hardly a mass market. Prosthetists-orthotists as a group are not the easiest group to introduce to a new product. Most of them have experience with one or more products that, despite the manufacturer's best efforts, were released before all the problems were worked out. Like the car buyer who chooses not to buy a car during its first model year, they prefer to wait and see. Others, while interested in trying a new product are "waiting for just the right patient." On the other hand, a disconcerting number are all too ready to rush in without thought. Battling for preeminence in every prosthetist-orthotist's lexicon of adages to live by are the two: <ol> <li> If all else fails, read the instructions. </li> <li> Don't force it, get a bigger hammer. </li> </ol> Every manufacturer can recount instances of practitioners who provided a device to a patient for whom it was specifically contraindicated, or who neglected one or more crucial precautions in fabricating the completed device. This can result in a wave of negative word of mouth publicity despite a manufacturer's best efforts to promote a new product and educate the profession about its proper use. The end result may be passive indifference, or active rejection whatever the positive merits of a new device are when it is properly prescribed and utilized. A developer of a new object has a vested interest in making it work successfully and will go to considerable pains to make it do so. It is a well recognized fact that a product, when transferred to even the best motivated and prepared practitioners, seldom works as well as it does for the developer. In summary, then, the following points can be made: <ol> <li> The following factors are sizable expenses: <ol> <li> Research and development of the original idea to a workable prototype </li> <li> Production design </li> <li> Tooling </li> <li> Manufacturing </li> <li> Quality control and testing </li> <li> Marketing </li> </ol> </li> <li> Considerable uncertainty surrounds the business of gauging market size and reception for a new product. </li> <li> However well an object sells, the field of prosthetics and orthotics can hardly be said to constitute a mass market of sizable proportions. </li> <li> Experience has repeatedly shown that it takes three years to achieve a profitable volume of sales once a new product is introduced. </li> </ol> The result of these facts is that the manufacturers of items for use in the prosthetic and orthotic market are confronted with the need to make sizable initial investments for a rather small market that is oftentimes slow to adopt new products of even the greatest merit. Considerable uncertainty surrounds the decision to make the investment and it can take many years for a return on the investment to be realized and the decision to be vindicated. Given these facts, it is understandable that manufacturers differ from developers and their backers about the utility and acceptability of many developments, and that they are slower to adopt new products than others might wish. *Charles H. Pritham, CPO Technical Coordinator, Durr-Fillauer Medical, Inc. *Carlton Fillauer, CPO Vice President, Durr-Fillauer Medical, Inc., Orthopedic Division, 2710 Amnicola Highway, Chattanooga, Tennessee 37406. <div style="width: 400px;"></div> Page Number(s) 4 - 6 Year 1984 Volume 8 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 From Research Lab to Consumer: The Manufacturers' Point of View Creator An entity primarily responsible for making the resource Carlton Fillauer, CPO * Charles H. Pritham, CPO * https://staging.drfop.org/files/original/6f9164852f923d934924fa8fcf1f17fc.pdf 1b58d80ae3b0054e7a4e88d749254638 https://staging.drfop.org/files/original/e16607ccd46c9c7e42dd07751d977682.jpg 8eaff6854b224c7b799187bdded6988d https://staging.drfop.org/files/original/2166b64e7aaf0c784c32236c01c93747.jpg 410b2c45e6cf4b741c28fe03999558fd https://staging.drfop.org/files/original/331bf1cb4de93a9584b33553af58c3f7.jpg f1b22d42a14fec42d03dc4b116e3a685 https://staging.drfop.org/files/original/df476f11eb4ab1fd182da42ae9133165.jpg 18ded7ff78503d7a542bdbb93f7fa5fa https://staging.drfop.org/files/original/18d2e38e612b0c2cbc33f88021561703.jpg 3c1da62f89d9fe83a64335c1b8383f6a https://staging.drfop.org/files/original/c9afab133e1b7a0100fb05064a779272.png 2ba2e902e2ced64b216af2c281388060 https://staging.drfop.org/files/original/55b9142f83521a8a0e523c679963214e.png 6960cb5288eaf7123f81be484479e8d3 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_01_006.pdf Text Any textual data included in the document <h2>Flexible Prosthetic Socket Techniques</h2> <h5>H.R. Lehneis, Ph.D., CPO <a style="text-decoration: none;">*</a> Don Sung Chu, M.D. <a style="text-decoration: none;">*</a> Howard Adelglass, M.D. <a style="text-decoration: none;">*</a></h5> The continuous development and availability of new materials of various kinds, e.g., elastomers, copolymer thermoplastics, and composite materials have brought a potentially revolutionary development in the design, configuration, and fitting principles of prosthetic sockets, especially for above-knee prostheses. All of this may result in greater patient comfort, physiological, and psychological advantages. Improvements in socket comfort with concomitant physiological and psychological benefits are not only due to the materials themselves, but rather, the inherent characteristics of the various materials used permit socket configurations heretofore not possible. For example, socket fenestrations over selected or entire stump surface areas are now possible. The desirability and principle of permitting greater flexibility over muscular areas than is possible in a rigid, laminated socket were appreciated more than 25 years<a></a> ago in the fitting and design of the "Flexi-cage" socket<a></a> which consisted of nylon cords strung between the proximal brim and the distal end of the socket. McCollough, et al.,<a></a> as early as 1968, attempted fenestrations over selected socket areas. These attempts, however, were not generally successful because of the potential and real problems with window edema and the properties of the material used. These problems now have been overcome through the availability of materials which can be used as elastic or semi-elastic inserts, preventing window edema, yet permitting removal of the outer rigid socket shell in selected areas.<a></a> Below are described several approaches allowing flexible or semi-flexible stump containment, while maintaining the essential biomechanical characteristics required for interface stability to transfer body weight through the prosthesis to the ground, and for dynamic and safe control of the prosthesis. Two systems are curently used at the Institute of Rehabilitation Medicine at NYU Medical Center (IRM-NYU) to provide the characteristics described above. The first system consists of an inner socket laminated of Perlon fiber and silicone elastomer contained in a rigid plastic laminated socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-1.jpg">Fig. 1</a>). The laminated silicone elastomer has nearly perfect memory and permits fenestrations of the rigid outer socket over the posterior area (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-2.jpg">Fig. 2</a>), rectus femoris (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-3.jpg">Fig. 3</a>) and the adductor group, without causing window edema. This design permits greater muscle expansion than the designs described below because of the elasticity of the silicone material. It also provides enhanced sensory feedback, particularly when sitting, i.e., the patient is able to feel the surface of the chair or seat. The soft liner is also a boon to improved comfort, particularly in geriatric amputees and those with a history of general socket discomfort. The second design utilized at IRM-NYU is a Surlyn® inner socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-4.jpg">Fig. 4</a>) which permits removal of even more of the hard outer laminated socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-5.jpg">Fig. 5</a>). The reason larger areas of the hard socket can be removed is the lesser flexibility of Surlyn®. Thus, more rigid material can be eliminated without compromising the integrity of known biomechanical principles (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-6.jpg">Fig. 6</a>). A more recent design developed in Iceland and further refined in Sweden and at New York University, known as the ISNY socket, consists of a medical rigid frame only, leaving the rest of the polyethylene socket semi-flexible. For below knee amputations, similar systems have been developed at IRM-NYU and in Belgium by Van Rolleghm of CEBELOR.<a></a> In the IRM-NYU system, a Surlyn® inner socket permits removal of material in the outer laminated socket over bony or pressure sensitive areas (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-7.jpg">Fig. 7</a>). This permits easy inspection of these areas and ease of adjustment by heating the inner socket to further relieve painful areas. The CEBELOR consists of a silicone laminated soft socket insert for the SP-SC below-knee prosthesis. Thus, it is self-suspending, provides improved comfort, and permits selected fenestration over pressure sensitive areas, e.g., head of the fibula, distal end of the tibia. To prevent slippage and rotation of the inner silicone socket, distal and posterior plugs are laminated as an integral part of the soft socket to fit into female counterparts in the plastic laminated socket. <h3>Summary</h3> While the various systems described above employ different materials and socket configurations, certain characteristics are common to all systems. These are: improved muscle physiology due to greater socket flexibility; enhanced sensory feedback; quicker heat dissipation due to thinness of the flexible stump containment material; and improved comfort, especially in the IRM-NYU and CEBELOR systems with the soft silicone liner. All these are important improvements which were made possible through the use of flexible or semi-flexible materials. Yet, the biomechanical principles of providing stump containment, weight transfer, and control of the prosthetic limb are not compromised. In the ISNY System, however, it is not clear how lateral and anterior/posterior stability of the femur is achieved, since there are no structural components in areas conventionally considered to provide such stability. This question, however, will be addressed in studies to be conducted in the near future. <h3>Acknowledgments</h3> The participation of Donald Fornuff, CP, and Roger Chin, CPO, in the development of the IRM-NYU systems is gratefully acknowledged. References: <ol> <li>Bach, Johann; Essen, Germany, personal communication, 1958.</li> <li>Fillauer, Carlton; Chattanooga, Tennessee, personal communication, 1983.</li> <li>McCollough, Newton, and Sinclair, William, "Some Considerations in Management of the Above-Knee Geriatric Amputee," Artificial Limbs, 12:2, 28-35, Autumn, 1968.</li> <li>Ockenfels, Peter; Columbus, Ohio, personal communication, 1983.</li> <li>Sabolich, John; Oklahoma City, Oklahoma, personal communication, 1983.</li> <li>Van Rolleghm, Jacques; Brussels, Belgium, personal communication, 1983.</li> </ol> <div style="width: 400px;">*Howard Adelglass, M.D. Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). *Don Sung Chu, M.D. Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). </div> <div style="width: 400px;">*H.R. Lehneis, Ph.D., CPO Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). </div> Page Number(s) 6 - 8 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Flexible Prosthetic Socket Techniques Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., CPO * Don Sung Chu, M.D. * Howard Adelglass, M.D. * https://staging.drfop.org/files/original/55a3a7b173a4ea49841968b5b80df860.pdf 30ec3d14f98a7ba60ecf7428947253e5 https://staging.drfop.org/files/original/3fc21ceaa5b19ada556ba3270df45738.jpg 02bb4d6365ac241f87b6773edcb7e0c1 https://staging.drfop.org/files/original/8f618f54353873ee21984ffd68d8d05a.jpg c3e7d29a8e7b778ed3c74a7defb1e58b https://staging.drfop.org/files/original/44447ecd073a0cc7c351cea452163a32.jpg ee515bdf345c39774428067d5ecef159 https://staging.drfop.org/files/original/5b949cda2964dd9764e61908c066bc6f.jpg 760890658c08795998286568770b9a05 https://staging.drfop.org/files/original/12b48da7443410fc2c39aec2a208a4a8.jpg 517767050abb9972fcd7bb791f3c924c https://staging.drfop.org/files/original/c0bda2f49bcde7fbdb45d9aa932572f0.png da19301ad0fdfca7f5f640abb9c3b40b 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_01_009.pdf Text Any textual data included in the document <h2>A Case History: Clinical Indication for Flexible Above-Knee Prosthetic Socket</h2> <h5>Howard Adelglass, M.D. <a style="text-decoration: none;">*</a> Don Sung Chu, M.D. <a style="text-decoration: none;">*</a> H.R. Lehneis, Ph.D., CPO <a style="text-decoration: none;">*</a></h5> R.W. is a 62 year old male with a 32 year history of insulin dependent diabetes mellitus. He was in a normal state of good health until August, 1982 when he developed gangrene of the first three toes of his left foot. A left femoral popliteal bypass was performed unsuccessfully. He then underwent a left below-knee amputation which also was unsuccessful and, in October, 1982, a left above-knee amputation was done. In December, 1982, he was admitted to the Institute of Rehabilitation Medicine, NYU Medical Center(IRM-NYU) for a prosthetics rehabilitation program. At that time, his stump became infected and dehisced, requiring stump revision. In July, 1983, he was readmitted to IRM-NYU and started on gait training with an AK prosthesis with a semi-suction socket, hip joint and pelvic belt, polycentric knee joint (Lang) and SACH foot (<a href="/files/original/3fc21ceaa5b19ada556ba3270df45738.jpg">Fig. 1</a>). During the course of his rehabilitation training, he began complaining of pain at the distal stump. The socket was adjusted numerous times by alternately relieving painful areas distally and placing padding above these areas, but with little success. Subsequently, x-rays taken of the stump revealed a small amount of soft tissue calcification distally with a small spur at the posterior lateral side of the femur (<a href="/files/original/8f618f54353873ee21984ffd68d8d05a.jpg">Fig. 2</a>). The patient was started on anti-inflammatory agents which provided a moderate amount of pain relief. However, he still had difficulty ambulating secondary to stump pain. A lateral pad above the distal end was inserted into the prosthesis which relieved some of the pain. However, within a few days, the patient developed a skin breakdown in the left peroneal area, and an erythematous area on the distal stump. The patient was not allowed to wear his prosthesis for 2 1/2 weeks. During this time, a repeat stump x-ray showed a large spur in the posterior lateral side of the distal stump and more soft tissue calcifications on the anterior surface of the stump (<a href="/files/original/44447ecd073a0cc7c351cea452163a32.jpg">Fig. 3</a>). Consequently, a new socket was designed to give relief over the distal anterior and posterior stump in order to decrease the pain and improve ambulation. This socket consisted of a vacuum-molded ionomer (Surlyn®) flexible socket contained in plastic laminated socket. There were fenestrations put into the anterior (<a href="/files/original/5b949cda2964dd9764e61908c066bc6f.jpg">Fig. 4</a>) and posterior walls (<a href="/files/original/12b48da7443410fc2c39aec2a208a4a8.jpg">Fig. 5</a>) of the rigid outer socket, which afforded relief to the area of spur formation and soft tissue calcification. The flexible inner socket was chosen for several reasons : <ol> <li> Flexibility of the socket results in a more comfortable fit and reduces pressure concentration. </li> <li> Its transparency allows direct visualization of the stump, if skin breakdown is a problem, and to monitor pressure areas. </li> <li> It permits quicker heat dissipation because of reduction in socket wall thickness. </li> <li> The socket allows improved sensory feedback, especially while sitting, due to flexibility in fenestrated areas. </li> </ol> The patient tolerated the prosthesis well, however, he still had pain over the anterior distal stump. Thus, new x-rays of the patient were taken while he was wearing the prosthesis to determine if the fenestrations were, in fact, over the spur and the soft tissue calcifications. Because of the design of this socket, it was easy to determine that the fenestrations needed correction. The anterior cut out was then enlarged to better accommodate the soft tissue calcification (<a href="/files/original/c0bda2f49bcde7fbdb45d9aa932572f0.png">Fig. 6</a>). This afforded the patient the relief needed. He is presently ambulating independently with a straight cane and the above-knee prosthesis without any pain. In summary, this flexible socket technique allows improved accuracy in fitting not only routine cases, but is especially suited for problem cases as illustrated here. *H.R. Lehneis, Ph.D., CPO Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). *Don Sung Chu, M.D. Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). *Howard Adelglass, M.D. Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). <div style="width: 400px;"></div> Page Number(s) 9 - 11 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-6.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-1.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-2.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-4.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/1984_01_009/1984_01_009-5.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Case History: Clinical Indication for Flexible Above-Knee Prosthetic Socket Creator An entity primarily responsible for making the resource Howard Adelglass, M.D. * Don Sung Chu, M.D. * H.R. Lehneis, Ph.D., CPO * https://staging.drfop.org/files/original/5d0ee93720e3cc29afeb69569f942ec3.pdf ec7d305e66c4b1672edc65546d744f4a https://staging.drfop.org/files/original/7e69b86f4f3e01170fb59ef73e47cd16.jpg 153b782803915d8c141c800756b99b14 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_02_001.pdf Text Any textual data included in the document <h2>Biomechanical Considerations in the Orthotic Management of the Knee</h2> <h5>Victor H. Frankel, M.D., Ph.D. <a style="text-decoration: none;">*</a></h5> The challenges facing the contemporary orthotist are akin to the interminable task of Sisyphus, the Greek mythic figure who was condemned to pushing a huge rock up an endless hill. Unlike Sisyphus, however, the orthotist has made and continues to make significant strides in the rational design and fabrication of prostheses and orthotic devices. Over the past decade major contributions to solving the anatomical and functional problems associated with joint replacement prostheses and orthoses have directly resulted from the growing interaction between orthopaedic surgery and biomechanics. The result of this increased interaction has been improved diagnosis and treatment of musculoskeletal disorders with prostheses and orthotic devices. The knee is certainly one of the joints that has greatly benefited from these biomechanical developments. Biomechanics enables the scientist to accurately describe and quantify surface joint motion of the knee and to analyze the complex forces imposed on the knee. Biomechanics also brings the motion of and the forces acting on the knee into sharp focus by analyzing the mechanical properties of the static and dynamic structures surrounding the knee: muscles, bones, ligaments, cartilage, and tendons. The biomechanical analysis of motion and force in the knee joint can be widely and successfully applied in orthotic management of the knee. The human knee is the largest and perhaps the most complex joint in the body. It is a two-joint structure composed of the tibiofemoral joint and the patellofemoral joint. Both joints sustain high forces and, located between the body's two longest lever arms, are particularly susceptible to injury. The knee transmits loads, participates in motion, aids in conservation of momentum, and provides a force couple for activities involving the leg. Although motion in the knee occurs simultaneously in three planes, the motion in one plane is so great that it accounts for most knee motion. Similarly, muscle forces on the knee are produced by several muscles, but a single muscle group (according to the activity) produces a force so large that it accounts for most of the muscle force acting on the knee. Thus, biomechanical analysis can be basically limited to motion in one plane and to the force produced by a single muscle group, and yet can still give an understanding of knee motion and an estimation of the magnitude of the main forces acting on the knee. To analyze motion in any joint, one must use kinematics, the branch of mechanics that deals with motion of a body without reference to force or mass. To analyze the forces imposed on a joint one must use both kinematic and kinetic data. Kinetics is the branch of mechanics which analyzes the motion of a body under the influence of given forces. <h3>Kinematics</h3> Kinematic data define the range of motion and describe the surface joint motion in three planes: frontal (coronal or longitudinal), sagittal, and transverse (horizontal). The range of motion can be measured in any joint and in any plane. Gross measurements can be made by goniometry, but more specific measurements must be made with more precise methods such as electrogoniometry, roentgenography, or photographic techniques using skeletal pins. <a></a> The range of knee joint motion needed for performing various physical activities can be determined from kinematic analysis. A full range of knee motion is needed for performing the more vigorous activities of daily life in a normal manner. Moreover, any restriction of knee motion will be compensated for by increased motion in other joints. The values obtained in several studies indicate that full extension and at least 117 degrees of flexion are necessary for carrying out the activities of daily life in a normal manner (Table I).<a></a> Table I. Range of Tibiofemoral Joint Motion in the Sagittal Plane During Common Activities <img src="/files/original/7e69b86f4f3e01170fb59ef73e47cd16.jpg" h3="" width="415" height="337" /> <h3>Surface Joint Motion</h3> Surface joint motion, the motion between the articulating surfaces of a joint, can also be described for any joint in the sagittal and frontal planes, but not the transverse plane. The method used is called the instant center technique. This technique allows a description of the relative uniplanar motion of two adjacent segments of a body and the direction of displacement of the contact points between these segments. The instant center for motion of a planar joint can be obtained by the method of Reuleaux (1876).<a></a> Clinically, a pathway of the instant center for a joint can be plotted by taking successive roentgenograms of the joint in different positions (usually ten degrees apart) throughout the range of motion in one plane, and applying the Reuleaux method for locating the instant center for each interval of motion. After the instant center pathway has been determined, the surface joint motion can be described. In a normal knee, the instant center pathway for the tibiofemoral joint is semicircular. Especially pertinent to orthotic management is data concerning knees with internal derangements. If the knee is extended and flexed about a displaced instant center, the tibiofemoral joint surfaces do not slide tangentially throughout the range of motion, but become either distracted or compressed. Such a knee is analogous to trying to close a door with a bent hinge. If the knee is continually forced to move about a displaced instant center, it will gradually adjust to this situation by either stretching the ligaments and supporting structures of the joint or by exerting abnormally high pressure on the articular surfaces. Such internal derangements of the tibiofemoral joint may interfere with the so-called screw-home mechanism, which is a combined motion of knee extension and external rotation of the tibia. The tibiofemoral joint is not a simple hinge joint, but has a spiral, or helicoid, motion. The spiral motion of the tibia about the femur during flexion and extension results from the anatomical configuration of the medial femoral condyle; in a normal knee this condyle is approximately 1.7cm longer than the lateral femoral condyle. As the tibia slides on the femur from the fully flexed to the fully extended position, it descends and then ascends the curves of the medial femoral condyle and simultaneously rotates externally. This motion is reversed as the tibia moves back into the fully flexed position. The screw-home mechanism gives more stability to the knee in any position than would be possible if the tibiofemoral joint were a simple hinge joint. The Helfet test, a simple clinical test, is used to determine if external rotation of the tibia occurs during knee extension, thus showing whether the screw-home mechanism is intact.<a></a> In a deranged knee it may happen that no external rotation of the tibia occurs during extension. Because of the altered surface motion, the tibiofemoral joint will be abnormally compressed if the knee is forced into extension, and the joint surfaces may be damaged. <h3>Kinetics</h3> Kinetic data, based on static and dynamic analysis, are used to analyze the forces acting on a joint. The medical scientist can use kinetic analysis to determine the size of the forces imposed on the knee by muscles, body weight, connective tissues, or external loads in either static or dynamic situations. In particular regard to orthotic management, however, situations and movements which produce excessively high forces can be identified. In static analysis, the three main coplanar forces acting on a body in equilibrium are identified as: (1) the ground reaction force (equal to body weight), (2) the tensile force exerted by the quadriceps muscle through the patellar tendon, and (3) the joint reaction force acting on the tibial plateau. Since most of our activities are dynamic, however, an analysis of the forces acting on the knee during motion-dynamic analysis-must be applied to given situations. In addition to the three coplanar forces of static analysis, the medical scientist must also take into account the acceleration of the body part (the amount of torque needed to accelerate a body, for which anthropometric data-tables are used).<a></a> An orthotist might use dynamic analysis, for example, to calculate the joint reaction, muscle, or ligament forces on the tibiofemoral joint at a particular instant in time during walking, or at a particular instant in time (with a stroboscopic film) while kicking a football. Other biomechanical considerations in the orthotic management of the knee involve the two important functions of the patella: (1) it aids knee extension by lengthening the lever arm on the quadriceps, and (2) it allows a better distribution of stresses on the femur by increasing the area of contact between the patellar tendon and the femur. In a patellectomized knee, for example, the quadriceps muscle, now with a shorter lever arm, must produce even more force than normal to achieve the required torque about the knee during the last 45 degrees of extension. Full, active extension of a patellectomized knee may require as much as 30 percent more quadriceps force than normally required.<a></a> During most dynamic activities, the greater the knee flexion, the higher all the muscle forces acting on the patellofemoral joint. Forces increase proportionately with knee flexion, for example, from walking to stair climbing to knee bends. Patients with patellofemoral joint derangements experience increased pain when performing activities requiring knee flexion, and orthotic management could be greatly aided by knowledge of such predictive biomechanical factors as knee flexion, and the muscle and joint reaction forces for specific situations. Biomechanical analysis can yield invaluable, practical data for the orthotic management of the knee. A continuing, close interaction among orthopaedic surgeons, bio-engineers, and orthotists will insure the applied efficacy of such data. References: <ol> <li><a href="http://www.oandplibrary.org/al/1964_01_044.asp">Drillis, R., Contini, R., and Blustein, M.: "Body segment parameters: A survey of measurement techniques," Artificial Limbs, 8:44, 1964.</a></li> <li>Frankel, V.H., and Nordin, M.: Basic Biomechanics of the Skeletal System. Philadelphia, Lea & Febiger, 1980.</li> <li>Helfet, A.J. : "Anatomy and mechanics of movement of the knee joint," Disorders of the Knee, edited by A. Helfet, Philadelphia, J.B. Lippincott, 1974.</li> <li>Kaufer, H. : "Mechanical function of the patella," Journal of Bone & Joint Surgery, 53A:1551, 1971.</li> <li>Kettelkamp, D.B., Johnson, R.J., Smidt, G.L., Chao, E.Y.S., and Walker, M.: "An electrogoniometric study of knee motion in normal gait, Journal of Bone & Joint Surgery, 52A:775, 1970.</li> <li>Laubenthal, K.N., Smidt, G.L., and Kettelkamp, D.B. : "A quantitative analysis of knee motion during activities of daily living," Physical Therapy, 52:34, 1972.</li> <li>Murray, M.P., Drought, A.B., and Kory, R.C.: "Walking patterns of normal men," Journal of Bone & Joint Surgery, 46A:335, 1964.</li> <li>Perry, J., Norwood, L., and House, K.: "Knee posture and biceps and semimembranosis muscle action in running and cutting (an EMG study), "Transactions of the 23rd Annual Meeting, Orthopaedic Research Society, 2:258, 1977.</li> <li>Reuleaux, F.: The Kinematics of Machinery: Outline of a Theory of Machines. London, Macmillan, 1976.</li> </ol> <div style="width: 400px;">*Victor H. Frankel, M.D., Ph.D. Director of Orthopaedic Surgery, Hospital for Joint Diseases Orthopaedic Institute, 301 East 17 Street, New York, New York 10003, and, Professor of Orthopaedic Surgery, Mt. Sinai School of Medicine, New York, N.Y. </div> <div style="width: 400px;"></div> Page Number(s) 1 - 3 Year 1984 Volume 8 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1984_02_001/1984_02_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Biomechanical Considerations in the Orthotic Management of the Knee Creator An entity primarily responsible for making the resource Victor H. Frankel, M.D., Ph.D. * https://staging.drfop.org/files/original/3736a23e738166381c6803e355cc30aa.pdf cb532dab7ed020184153028bdd91a2d2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_02_003.pdf Text Any textual data included in the document <h2>The Role of Orthoses in the Care of Knee Ligament Injuries</h2> <h5>Kenneth E. DeHaven, M.D. <a style="text-decoration: none;">*</a></h5> The role of braces in the management of knee ligament injuries, particularly in high risk athletics, continues to receive a great deal of attention. There are a multitude of braces currently being manufactured and marketed with various claims relating to the effectiveness, comfort, durability, and cost. Two key questions remain for most clinicians: (1) Should knee braces be used at all?, and (2) If so, what type of brace should be used and under what circumstances? At present there is a paucity of scientific data available to answer either of these questions with certainty, but there are encouraging signs that this essential information will be forthcoming from current and future research. Until an adequate scientific basis has been established it is necessary to develop a philosophy about bracing in athletics that is consistent with the data that is available and our clinical observations. <h3>Should braces be used at all?</h3> There is frequently an ego problem for both the athlete (who views a brace as a sign of weakness) and the physician (concern that a brace reflects less than optimal results) who delight in the statement "Doc, I don't need that brace—I can run and cut without it." Definitive treatment, whether rehabilitation or surgery followed by rehabilitation, must provide the functional stability, and it is rare in my experience that an unstable knee is made stable simply by applying a brace. However, no matter how good it might feel to the athlete, a knee that has previously sustained major ligament injury is not normal, and in fact has suffered ligament disruption at a time when it was normal. The role of bracing, therefore, is not to provide stability but to help prevent reinjury by keeping the knee from going into extreme positions when subjected to sudden stress. When presented in this light, the concept of protective bracing after major ligament injury to the knee is more reasonable and more acceptable to both the athlete and the physician. <h3>What type of brace should be used and under what circumstances?</h3> While not definitively established, it appears that the beneficial effects of knee orthoses are related not only to their mechanical strength but also to providing increased proprioceptive input from the knee area (which can explain how some patients feel more stable in braces that provide little or no mechanical support). Optimal support is provided by braces that protect against varus/valgus and hyperextension stresses and are utilized routinely in our Center following ligament repair or reconstruction of collateral and/or cruciate ligaments. The brace is initially worn for ambulation in the early postoperative period (two or four months) and later for agility, contact, or other types of "high risk" sports. Less sophisticated braces that provide just varus/valgus support usually are sufficient for athletes returning to similar sports in the same season following Grade II collateral ligament sprains. The practicality, efficacy, and cost effectiveness of prophylactic bracing to prevent injury in contact sports such as football is also a topic of great interest but remains unresolved at present. It is important to emphasize that this represents personal philosophy and recommendations based upon the information available at this time. It is recognized that while these concepts appear to be reasonable they are largely unproven, and there continues to be great need for more biomechanical and clinical research to firmly establish a scientific basis for knee bracing in athletics. *Kenneth E. DeHaven, M.D. Professor of Orthopaedics, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, New York 14642. <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1984 Volume 8 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Role of Orthoses in the Care of Knee Ligament Injuries Creator An entity primarily responsible for making the resource Kenneth E. DeHaven, M.D. * https://staging.drfop.org/files/original/366a1b6eaf8bdac3bf9bcd5f96e1e444.pdf c15a1b90ec331cb4018325209aeb65ef https://staging.drfop.org/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg 8e66cf5f8e78aecdf2a5e3408530f798 https://staging.drfop.org/files/original/92afbcf437362864c05cee1d9fa423c2.jpg c0d649cd24f105d7e78a3eab0426d1cf https://staging.drfop.org/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg a90f1c11e95d0e45be2d704ef73f3783 https://staging.drfop.org/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg 5061311d76421aff2b48d025e41524ac https://staging.drfop.org/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg a90f1c11e95d0e45be2d704ef73f3783 https://staging.drfop.org/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg 6a18a10291eac44ee2e3b2f40d37a99c https://staging.drfop.org/files/original/104394cd613cd757fc34ae6b51dfc916.jpg 0cbd76a6321d43132c8d653b6a6537d5 https://staging.drfop.org/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg 5018452d2616ca984b0b8fbc9ddf3f8e https://staging.drfop.org/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg 79e8f6d9e08cb4a44e6e7bbdb9e3957a https://staging.drfop.org/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg 4c431528b25733c9af6035131de80b91 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_02_004.pdf Text Any textual data included in the document <h2>The Technical Aspects of the Orthopaedic Treatment of the Knee after Sports Injuries</h2> <h5>Andre Bähler <a style="text-decoration: none;">*</a></h5> The last decades have shown a marked increase in the number of people, both young and old, participating in sporting activities. As a result of systematic education and schooling, it has become generally recognized that a certain amount of physical exercise is necessary for a healthy body. The mass media—radio, television, the press—as well as schools and private insurance companies, have systematically reported the advantages to be gained by participating in physical activities. Sports are no longer the prerogative of the young; there is no age limit for those engaged in sports in one form or another. Senior citizen keep-fit groups, jogging, and the like, have proven to many older people that age is not a justified reason to neglect physical fitness, and they have become aware that exercise is a means of showing the body the respect it deserves. However, this almost revolutionary attitude towards sports is not limited to amateurs, but has also brought changes into the world of top athletes. Today, the degree of involvement is greater than ever before, but so accordingly are the associated risks. Many forms of sports seem to have lost sight of the original ideal of sportsmanship. Enjoyment and leisure have been replaced by a deadly seriousness in attitude that only total dedication will bring the desired results. Not only in the competition itself, but in the long months and sometimes years of training prior to it, the body is stretched to its utmost. Success at any price is the motto of the day, and such an attitude consciously calculates and accepts casualties and losses as part of the "game." It has been proven that this type of approach to sports results in an increase in injuries, strain, and general wear, particularly in the joints of the lower limbs. Clearly, modern sports put the knee-joint under great pressure. Be it cycling, football, skiing or ice-hockey, the movement of the knee is of central importance, as changing techniques increase the pressure put on it. The large number of knee injuries are a cause of great concern to modern sports medicine. The top athletes in particular, are anxious to start training again as soon as possible after injury. Although the knee is capable of taking great strain, mobility is often restricted, either by external injuries, or because of wear within the joint itself. Immobilization of the joint after injury or surgery can damage the cartilage, hindering the assimilation of nutrients. The ligaments begin to lose their tensility, there is a loss of coordination between muscle groups, and muscles atrophy. Finally, immobilization of a limb also affects the whole organism, particularly circulation, respiration, and the digestive system, and last but not least, the psychological effect of immobilization should not be underestimated. Controlled movement of the knee-joint after ligament surgery has great advantages during rehabilitation: movement between 20-60 degrees does not strain the collateral or cruciate ligaments to any degree. The muscles are also activated within pre-controlled limits. In tests, Hettinger found that 20-30 percent of the maximum pressure was sufficient to retain normal muscle strength. However, in order to increase muscle strength, the pressure must be at least 40-50 percent, and this is not possible after surgery. Therefore, rehabilitation requires electro-stimulation. A pre-condition of functional treatment is the exact restoration of all the anatomical elements, (e.g. cruciate and collateral ligaments). <h3>Rehabilitation Phases</h3> Pre-operative Treatment When reconstructive surgery is required in the case of an old injury to the knee, the time before the operation should be used to improve and retain muscle strength, for coordination exercises, and to instruct and explain the postoperative treatment Post-operative Treatment Day 1: For the rest period, the leg should be held in a preoperative prepared plaster-splint with a flexion angle of 20-30 degrees. Day 5: A knee-orthosis with a 20-50 degree range of movement is fitted and a gentle swinging movement is allowed. The orthosis is also worn in the pool but the injured leg should not actually be used for swimming. Rehabilitation at this stage should also include controlled extension and flexion exercises between 20-60 degrees and isometric quadricep training. Fifth to sixth week: Flexion and extension exercises from 0-90 degrees should be practiced. For walking, the orthosis must be locked in extension with the swiss-lock. After eight weeks: The lock can be removed and the patient may be allowed to walk with free movement of the joint. The orthosis is usually worn for approximately one year. <h3>The Principles of Fixation and Correction with the Orthosis</h3> Both the upper and lower leg must be securely held all round. If necessary, support at the thigh is given on the same principle as a prosthetic support. If the upper and lower leg are kept straight, then it is best to use a physiological (polycentric, Ed.) knee-joint. However, if the securing bands of the orthosis are made of rubber or a similar material, then a simple single-axis knee-joint is sufficient. Besides the above mentioned points, the orthosis for post-operative rehabilitation after ligament reconstruction must also exhibit the following characteristics: <ol> <li> The program of correction or fixation must be exactly determined in advance. </li> <li> The upper and lower leg must be securely held in the orthosis. </li> <li> The construction of the joint must allow for varying ranges of mobility: <ol> <li> 20-50 degrees </li> <li> 0-90 degrees with the option of a locking device </li> <li> 0-120 degrees with free movement. </li> </ol> </li> </ol> <h3>Procedure to Relieve the Medial or Lateral Ligaments</h3> Principle: Triple-point correction (<a href="/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg">Fig. 1</a>) <a href="/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg">Figure 1</a>. Triple-point correction to relieve the medial or lateral ligaments.  The principle underlying the triple-point correction, forms the basis for efficient correction of genu varum or genu valgum. With young patients, it is possible to position the correcting pressure-pads exactly, but with older patients, because of the flaccid tissue, pressure must be applied over as large an area as possible, e.g., with splints which distribute the pressure equally. For technical as well as anatomical reasons, it is often not possible to apply pressure at the centre of the joint itself, therefore pressure must be applied above and below the joint, but as near to it as possible. If the splints do not fit securely, then the orthosis will twist inwards when bent and this results in a reduction of the correcting forces at extension. <h3>Procedure for Controlling the Posterior Drawer</h3> Principle: Posterior pressure on the proximal lower leg and anterior pressure on the distal upper leg (<a href="/files/original/92afbcf437362864c05cee1d9fa423c2.jpg">Fig. 2</a>) <a href="/files/original/92afbcf437362864c05cee1d9fa423c2.jpg">Figure 2</a>. Controlling the posterior drawer. There are two biomechanical procedures to choose from: <ol> <li> Fixation of the upper and lower leg with the orthosis on the basis of the triple-point method. With this method, the splints are fitted individually to the upper and lower leg and the correcting pressures are placed so that a posterior drawer is held firmly. </li> <li> Placing the correcting pressures in such a way that together with the knee-joint of the orthosis, they act as a lever. Here too, it is advantageous to distribute the pressure over as large a surface as possible (<a href="/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg">Fig. 3</a>). <a href="/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg">Figure 3.</a> An alternative approach</li> </ol> <h3>Procedure to Correct the Anterior Drawer</h3> Principle: Anterior pressure on the proximal lower leg and posterior pressure on the distal upper leg This involves, first, the fixation of the upper and lower leg with the orthosis on the basis of the triple-point principle (<a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg">Fig. 4</a>), and second, placing the correcting pressure so that together with the knee-joint of the orthosis, they act as a lever. The greater the distance between the knee and the external counter-pressure, the better the corrective effect (<a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg">Fig. 5</a>). <a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg">Figure 4</a>. Fixation of the upper and lower leg.  <a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg">Figure 5</a>. Increase the distance between the knee and the external counter-pressure <h3> Restricting Rotation</h3> The restriction of rotation depends on how well the orthosis fits the upper and lower leg. The efficiency of the orthosis in restricting rotation is determined less by the type of orthosis, than by the size and type of the surface area of support. In practice, the following points must be checked: <ol> <li> Any fixation of the knee-joint must conform to the principles of biomechanics. </li> <li> The orthosis and all bandages should cover the leg properly to ensure that the orthosis does not slip. </li> <li> The orthosis must fit so as not to hinder or limit muscle activity. </li> </ol> As we found that the orthotic devices available at present did not completely satisfy our needs, we devised a system of our own which we would now like to explain with the help of some photographs. <h3>Type I: Sport Orthosis for Old Injuries to the Knee, or for Instability of the Joint</h3> In order to keep the reduction in fitness to a minimum, the athlete aims to return to training as soon as possible. However, the knee is often not strong enough to cope with the high demands made upon it and needs some form of support, without however, limiting the range of movement. This orthosis guides the joint and eliminates the forward and backward drawer as well as movements to the side (<a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg">Fig. 6</a>, <a href="/files/original/104394cd613cd757fc34ae6b51dfc916.jpg">Fig. 7</a>, <a href="/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg">Fig. 8</a>). If necessary, it can also be fitted so as to restrict all extreme movements. The half-splints of the orthosis are made of the new Plexiglass XTO (natur) by the Röhm Company (Darmstadt 1). This material is much tougher than the well-known Plexidur. It is easy to form, and locks can be fitted to the joints without first having to be strengthened. In order to stop the splints from slipping, they are lined with a thin layer of foam-rubber. The best results are achieved when the orthosis is formed from a plaster model of the leg. <a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg">Figure 6.</a> The sport orthosis eliminates forward and backward drawer.  <a href="/files/original/104394cd613cd757fc34ae6b51dfc916.jpg">Figure 7.</a> The orthosis can be fit to eliminate all extreme movements.  <a href="/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg">Figure 8.</a> The half-splints are made of Plexiglass XTO. <h3>Type II: Orthosis for Operative Ligament Reconstruction, or Other Similar Serious Knee Injuries</h3> Basically the same orthosis is made as in Type I (<a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg">Fig. 4</a>, <a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg">Fig. 5</a>, <a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg">Fig. 6</a>) but with the difference that a lock and positioning-screw are fixed to the outside of the splint (<a href="/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg">Fig. 9</a>, <a href="/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg">Fig. 10</a>). As already mentioned, the positioning screw allows a movement between 20-60 degrees. After a while, this can be removed and the lock used to hold the leg in extension. <a href="/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg">Figure 9</a>. A lock and positioning screw are fixed to the outside of the splint. <a href="/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg">Figure 10</a>. The positioning screw allows movement between 20-60 degrees.  Depending on the injury, the half-splints are placed either at the front or at the back of the upper and lower leg. Securing straps and pressure-pads increase the corrective effect. *Andre Bähler Andre Bähler is an Orthotist/Prosthetist from Zurich, Switzerland. <div style="width: 400px;"></div> Page Number(s) 4 - 7 Year 1984 Volume 8 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-02.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource The Technical Aspects of the Orthopaedic Treatment of the Knee after Sports Injuries Creator An entity primarily responsible for making the resource Andre Bähler * https://staging.drfop.org/files/original/995448e86e0b5f119a7459b183fd0e92.pdf b21593810340917c87578b184eb75be6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_004.pdf Text Any textual data included in the document <h2>Sockets, Linings, and Interfaces</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration: none;">*</a></h5> A prosthesis, whose Greek source means "put to," must of necessity have contact with the residual limb or stump. The functions of this contact region or socket (perhaps supplemented with lining, sock, and further attachments or harness), are to allow the transmission of forces, bending moments, and torques between the amputee and the prosthesis to be as comfortable as feasible in order to sustain body weight and permit locomotion for lower-limb amputees, and to allow purposeful activities by upper-limb cases. Prolonged and vigorous use of a prosthesis should not cause pain, pressure sores, blisters or corns from friction, nor edema from restricted return circulation. Proper ventilation should also prevent such accumulation of moisture as to cause skin maceration. Challenging as these major tasks are, they should not lead to neglect of some of the less obvious functions of a prosthesis. The changing pattern of pressure distribution on the body from the prosthesis should provide important sensory feedback on external forces, on positions of remote portions of the prosthesis, and on events such as knee extension. Professor Ernst Marquartdt,<a></a> realizing the value of the limited sensory information transmitted to the residual limb of an upper-limb amputee by the older soft leather socket, was reluctant to change to rigid plastic laminates despite their other advantages. It should also be possible to control remote joints and locks or external sources of power by small reflex or voluntary motions of remaining muscles in the residual limb and through sensing of mechanical motion or myoelectric activity. Historical Notes Naturally there is a long history of attempts to meet these challenges, that is scattered in patents, papers, catalogs, and atlases.<a></a> There are records of wooden prostheses and peg legs since antiquity, which presumably were padded with fabric or leather. Medieval prostheses, made by armorers, probably had leather or other materials for liners. In the past century, molded leather shells or lacers supported by metal side bars and cuffs, adapted from orthopedic appliances, were used extensively. These allowed slow adaptation to radial displacement and deliberate readjustment of circumference, and provided some tapered flexibility of radial stiffness above and below the proximal and distal reinforcing cuffs. The typical American artificial limb carved out of wood was completely rigid, though it could be carved deliberately to produce enlargements as desired and could be lined, completely or in selected portions of the circumference, with leather. Felt, wax-impregnated materials slowly displaced under pressure at body temperature, and resilient or slowly compacted foam plastics or rubbers have been used by various developers. Diagonally woven straps or cords (sometimes called Chinese Magic Finger Grip in the U.S., or Nuremberg Witch's Finger in Germany) have been suggested repeatedly as resilient sockets and perhaps as suspension. Parallel vertical cords between upper and lower rigid frames have also been used for both flexibility and ventilation. End-Weight-Bearing Some early sockets attempted to provide direct end-weight-bearing on the unrestrained end of the amputated residual limb. Typically, the amputated end of the bone without deliberate plugging developed only a thin and flexible closure to resist transmission of end load to the medullary canal, causing discomfort or pain. In addition, the ring of bony cortex tended to produce painful direct loading on the skin at the distal end of the residual limb. Early attempts to leave flaps or pads of muscles or other tissues across the distal end merely led to atrophy. Grey, a former apprentice of James Potts who developed the coordinated-motion above-knee prosthesis later called the Anglesea Leg, was very critical of such misguided efforts to develop end-weight-bearing.<a></a> Except for the Syme,<a></a> the knee disarticulation, the Gritti-Stokes amputation levels, and some attempts to deliberately plug the end of a long bone<a></a>—all relatively rare—there were few attempts to attain any end contact, let alone end-weight-bearing. For generations most prostheses, especially the typical above-knee, caused considerable constriction in the proximal third of the socket, required trial-and-error fitting, and left relatively unsupported the distal end of the residual limb. Because the residual limb was considered "a bowl of jelly," it was constricted proximally but extruded distally in an attempt to secure a firm grip to assist both axial support and control of bending moments. Fortunately, the common firmly-knitted woolen stump sock between the limb and the prosthetic socket—folded over the socket brim and closed at the distal end—supported the skin, fascia, and internal tissues in resisting this distal extrusion and lengthening. Stump Socks One or more stump socks were typically worn between a hard socket wall and the residual limb. Stump socks were worn for reasonable as well as fallacious purposes.<a></a> Knitted fleece socks provided a slight degree of resiliency and thus redistribution of local radial pressure, especially when freshly laundered. Inevitably, there were mismatches between the residual limb and socket wall caused by slow changes in the limb with edema, atrophy, obesity, or sometimes growth or muscle development. Axial displacement, inaccuracies in the trial-and-error carving of a wooden socket, or even of modification of a plaster model of the residual limb before preparing a plastic socket also led to mismatches. Sock resiliency can overcome minor discrepancies and improve comfort and addition of a sock can help compensate for shrinkage of the residual limb. A major function of the sock is to cling to the residual limb but slide with respect to the socket wall if there are relative motions between stance and swing phases of walking or caused by discrepancy between the natural proximal joint and an external mechanical joint. (This important function is impeded if the socket wall is rough or if a perspiration-soaked sock can stick to the wall but chafe the skin.) The sock should also absorb perspiration, provide wick-like action, and allow for ventilation. The closed end or "toe" should provide some support of the distal tissue. Other than a circular cross-section, addition of one or more socks inevitably distorts the fit. In the triangular below-knee case, although the soft tissues in the posterior portion can change, the bony portions do not, so a spot liner is more appropriate than additional socks. Sometimes the stump sock was misused by patients to compensate for gross changes which required major refitting, or because of misunderstandings or lack of training. About 1947 Dr. John Young of Mellon Institute and this author met a below-knee amputee who wore five firmly packed socks. Though he did not believe in a "green sock," we finally persuaded him to purchase new socks in order to accompany a newly refitted prosthesis adapted to only one or two socks and to wash the socks daily. Such distortions, however, should not distract from the legitimate uses of stump socks. Suction Socket The suction socket above-knee prosthesis was and is routinely fitted with direct contact against the skin of the residual limb. The original suction socket of the Parmelee patent of 1863<a></a> may have been intended as total contact, though the evidence is not clear. A version of the suction socket which came from Germany in 1946-47, was routinely fitted with a "suction chamber" extending below the end of the residual limb. During donning, the tissues were pulled down through a snugly fitted proximal third by a tube of stockinet which was withdrawn through the valve hole in a side wall, thereby creating a significant distortion and elongation of the residual limb. In some cases, the distal end developed chronic edema or discoloration from disturbed return circulation or small hemorrhages. These problems, as well as basic principles, contact dermatitis, blisters and corns from friction, and cysts just proximal to the brim, were among the major difficulties discussed by Barnes<a></a> and Levy<a></a> in their classic treatment of dermatological problems of the amputee. They emphasized the importance of avoiding stasis in the distal residual limb in encouraging total contact and reducing proximal constriction. <h3>Thoughts And Theories</h3> After the issue of Artificial Limbs by Barnes and Levy was published in 1956, this author was appointed Fulbright Lecturer, based at the Orthopedic Hospital in Copenhagen. In an informal memorandum<a></a> based on years of observations and discussions concerning fitting of both dental and limb prostheses, three major themes were developed: <ol> <li> Minimize the stiffness gradient between the rigid socket wall and the flexible skin; i.e., taper flexibility of the socket brim. </li> <li> Approximately match wall stiffness to that of the tissue supported. </li> <li> Provide a porous wall capable of "breathing" slowly. </li> </ol> We may consider each theme in turn. Both theory and practice can be useful. Practice can develop to a considerable extent without theory; we walked before we learned about the biomechanics of locomotion, and Watt built steam engines before Carnot developed the basic cycle for all heat engines or Rankine the cycle for steam engines. Yet theory can guide our efforts toward improvements, show the areas where greatest progress can occur, and point out the ultimate limits so we do not waste our efforts. Tapered Flexibility The first theme was eventually published as the introduction to an extensive series of theoretical and experimental papers by Bennett.<a></a> The series ended with limited clinical trials of sockets with flexible brims made of plastic laminates. These sockets appeared to be helpful for patients previously troubled by chronic or recurrent cysts, but the mechanical durability of the laminate was so poor that the sockets often lasted only six months. After the National Institute of Handicapped Research (NIHR) project at Moss Rehabilitation Hospital began working with polyethylene and polypropylene thermoplastics,<a></a> Bennett collaborated with that group on some attempts to develop more durable flexible-brim sockets using thermoplastics. These appeared to be promising, but the major focus of the project was on light-weight prostheses. There have been numerous recent efforts to produce a thermoplastic flexible (and often transparent) inner socket or liner supported by an outer shell or other structure. The Scandinavian Flexible Socket or the similar Icelandic-Swedish-New York (ISNY) Socket, and two recent designs from the New York University Institute of Rehabilitation Medicine<a></a> are examples. If, as in Figure 5 of "Flexible Prosthetic Socket Techniques" by Lehneis et al., the flexible inner liner projects proximally above the more rigid outer laminate shell, it helps to provide the tapered flexibility and transition from rigid socket to flexible skin which was suggested in theme I,<a></a> and which seemed desirable from Bennett's work. Matching Wall Stiffness to Tissues Supported First, consider the principles. The bony prominences near the surface are very stiff against radial indentation under load, but they do not bulge during walking or change appreciably in size or shape over extremely long periods. In contrast, soft tissues may change much more rapidly by brief displacement of body fluids or in moderate time periods (e.g., weeks) by growth or atrophy. Soft tissues are also much less stiff under loads from internal muscular or hydraulic forces, or from external pressure, provided they can be displaced. Conversely, if fluid-filled soft tissues are sufficiently trapped to avoid displacement, they will behave like an enclosed fluid under hydrostatic pressure. Within the limits allowed by connective tissue, unsupported soft tissue can be displaced a considerable amount, at the expense of distorting blood vessels from their usual circular cross-sections to oval shapes with the same perimeter but a smaller area. Such displacement can also stimulate nerve endings. These displacements may give the illusion of tissue "compressibility." Soft tissue can also accumulate excessive fluid, creating flushing and edema, if free to expand radially from the center of the body mass. External support will assist the "milking" effect from the pulsating action of muscles contracting within fascial compartments in pushing fluid into the veins and lymphatics, while on the contrary either external suction or restriction of the return ducts proximal to the tissue considered will favor edema. Similarly, a localized area, with little or no muscular activity that is free from support within a larger region otherwise firmly supported, will cause "window edema" with bulging of skin and tissue through the opening, as in a small opening in a large plaster cast. Many clinical observations and some systematic tests with sockets, plaster casts, and different designs of prostheses and orthoses relate to this problem of matching socket to residual limb, even though they have been viewed as specific rather than general. The direct comparison of two theories or designs is difficult because methods for preparing the socket and aligning it to the remainder of the prosthesis usually differ. It would seem useful to compare sockets with varying degrees and locations of softness or of flexibility, but similar as to cast, model, and alignment. If different methods or alignments really are needed to optimize results, the reasons should be studied. The original Navy "soft" socket for below-knee amputees of the late 1940's, provided a limited but equal degree of softness in all regions of the circumference. The cast was prepared with the residual limb dipped in relatively dense dental stone while it hardened. Weight was shifted to the cast after the impression was firm but not quite completely set. The socket was formed over a plaster model without modification or contact with the sock-covered distal end of the residual limb. The distal wall was intended to be tangent to the tapering residual limb. The later Navy "closed-end" socket also provided some additional thickness of cellular rubber in contact with the entire distal end of the residual limb, tapering toward the side walls, with the entire socket lined with vinyl. The Schindler soft socket was formed with gores of foam rubber tailored to fit the warped surface of the plaster model, more precisely than was possible with the single sheet wrapped around the model in the simpler Navy technique. The Blevens below-knee socket provided an oval pad of sponge rubber, with tapered edges, trapped between layers of stump sock over the calf region of the residual limb. After this pad was compressed and forced through a snugly fitted proximal portion, it could expand into an enlargement in the rigid socket wall below the popliteal region. It permitted both activity of the remaining remnants of calf musculature, which tended to atrophy in conventional hard sockets, and provided or assisted in support of the prosthesis in swing phase. Its possibilities for control signals remain unexplored. Fabrication Methods Carved sockets obviously required skill of the prosthetist and tolerance of the user, who was initially asked to try to fit the residual limb into an unduly tight space which was gradually enlarged until a tolerable fit was achieved. Did the residual limb become engorged or injured in the process? Did the amputee eventually tolerate a certain amount of discomfort as he "broke in " the hard limb—or perhaps broke down the soft tissues to conform more closely to the not-quite-perfect fit? Or did he become sensitized to discomfort, aware of its location and cause, and even more demanding? Sockets made over plaster models prepared from plaster casts seem more likely than those carved purely from measurements for an immediate accurate fit, or a fit with minimal trials and adjustments. Even so, the prosthetist usually considers that the manual distortion of the wet plaster during the process of taking the cast and "rectification " of the positive plaster model is necessary to avoid an unduly loose fit, often regardless of the resiliency of stump sock or foam lining. Could this view be the result of past experience in preparing casts from residual limbs which have become enlarged from being unsupported while below the body during the preparation period? Would little or no rectification be needed if the amputee were supine with the residual limb elevated for an "appropriate" period immediately before casting? Have a few anecdotal accounts of such attempts leading to excessively tight sockets reflected unduly long elevation times? Did the Navy dip impression allow the denser dental stone, while still fluid, to squeeze fluids from the tissues by an approximately correct amount before solidifying? Because the socket must transmit the necessary axial forces, bending moments, and torques described by Radcliffe<a></a> for all major levels of the lower limb, and Taylor<a></a> for the upper, the socket wall must be reasonably firm in at least some areas and the interior bone(s) must transfer forces through the skin to the wall in both proximal and distal regions. Retention of Fit A precisely made hard socket fit with direct contact (as in the suction socket) or with a single thin stump sock might be effective for a time, but it might encounter difficulties even with muscular activities or large motion of the proximal joint as in sitting and bending. More important discrepancies would occur over longer periods from edema, growth, or atrophy. Completely uniform softness might also be questioned because it does not match just those relatively limited areas which alter cyclically with muscular activity or over some time span. Perhaps more critically, uniform softness allows areas of high pressure, intended to match individual tolerance to high pressure, to sink into the soft material and thus to shift some load to areas where the designer desired lower pressure. Beginning in the prosthetics schools in 1957-58, emphasis upon socket planning based on anatomical and physiological considerations and upon avoidance of erratic constriction and looseness was a healthy development. Some Suggestions The local radial stiffness of the socket wall might be approximately comparable to the stiffness and physiological motion of the tissue which it touches, though changes should occur gradually from place to place to avoid high local shear stresses in tissue. Thus, the wall near bony prominences might be quite firm if precisely fitted to a nonedematous limb. Obviously this notion seems the opposite of the usual concept of cushioning the bony prominences. Much of the traditional objection to a hard socket wall in contact with a bony prominence may be due to two difficulties: (1) unduly concentrated pressure because of poor fitting or displacement from the correct position, or (2) slippage and friction from inadequate suspension or joint location, leading to formation of blisters and bursae. Relatively soft walls opposite soft tissue might allow muscle bulging or tendon tightening at every motion of the limb yet rebound to prevent window edema when relaxed. The stiffness might be chosen to allow deliberate gripping of the wall for control and suspension, somewhat comparable to the German "Haft-prothese"<a></a> with muscular bulging to grip a rigid wall to supplement an above-knee suction socket as well as to help support the Blevens below-knee prosthesis. Some softness opposite tissues which tend to change rapidly might also compensate for slight changes such as growth. Adequate, relatively firm areas must be found for biomechanically necessary forces, including those generating bending moments and torques. In the below-knee case, for example, counterpressure from the posterior wall is needed to hold the condyles anteriorly on their sloping supports. In the above-knee case, the distal lateral and the proximal medial aspects of the femur must generate, yet tolerate, substantial forces to oppose the moment created by body weight acting upon it through the center of gravity appreciably medial to the center of support of the prosthesis during stance phase. The soft tissues, usually present at the distal end, should be encased thoroughly to prevent displacement, extrusion, and edema, yet held precisely in a wall and floor soft enough to prevent localized painful loading. Page,<a></a> an engineer interested in dental prostheses, discussed with this author in 1946 the concept of "muco-static" fitting with tissues trapped so that, much like fluids, they behave almost hydrostatically. The tissues should not be distorted from resting position when the cast is taken, nor should they be displaced towards hollows left by grinding away apparent ridges actually needed to fit into folds in the tissue. Past failures to create end-weight-bearing simply by taking an impression under load or placing a pad of foam rubber on a flat socket floor need not eliminate the possibility of total contact or end-weight-bearing by more sophisticated methods. A socket of the style described might have variable but tapered thickness of resilient material, such as closed-cell foam rubber or plastic. Muscular bulging into such material might be developed as a control signal. Alternatively, but perhaps less precisely, a thin resilient liner might be supported by an outer shell providing firm support where needed but having rounded and outwardly flared windows where expansion should be possible. The thin resilient liner opposite the windows could improve heat transfer, awareness of adjacent surfaces, and comfort when seated. The sockets illustrated by Lehneis, et al.<a></a> seem reasonable steps, though one wonders whether "selected fenestration over pressure sensitive areas " would be as logical as carefully molded and slightly relieved or padded areas. Certainly the transparent socket materials are advantageous for checking fit, supplementing their value in the flared flexible brim. Porous Materials The skin, as Barnes<a></a> pointed out, normally excretes water, gases and various compounds. An impermeable wall pressed tightly against the skin for many hours at a time can lead to dermatological difficulties. Leather allows some absorption and passage of these excretions, but deteriorates from their presence. Organic materials trapped in the fine pores of leather tend to decompose. The Army Prosthetics Research Laboratory (APRL) developed a protective slightly permeable coating for leather consisting of a particular grade of nylon dissolved in isopropyl alcohol. It is not still commercially available, as it was not very widely used. Care had to be taken to avoid traces of oil on the leather in order to be coated. APRL also developed a "starved resin" process, producing a somewhat porous thermosetting plastic laminate. Unfortunately, the irregular holes tended to become plugged with debris from the stump sock, dead skin cells, etc., and no adequate cleansing method was found. Late in World War II, Quamco was developed for raincoats and aviation clothing to resist penetration by rain or sea water yet allow slow transfusion of perspiration. It received brief attention in the early suction socket program. In recent years, Gore-tex has become increasingly popular for sportswear. Though it is difficult to tailor Gore-tex to complex shapes, the recent availability of a molded sports hat may indicate the possibility of considering an individually shaped socket or at least gently warped segments to mount in a fenestrated socket. Simple mechanical perforations of the socket wall were used, for example, with aluminum sockets, particularly in England. The holes had to be small enough so that the tissue, presumably supported by a stump sock, did not bulge through them. At the other extreme, the mechanically or electrically perforated plastics, studied around 1949 by the Mellon Institute, sometimes had such tiny holes that organic materials became clogged in them as in leather. One could imagine a wick-like, minutely perforated liner—and perhaps wall—permitting rapid and effective cleaning and drying. Air flow must permit ventilation yet allow adequate suction suspension, perhaps assisted by muscular gripping as in the Haftprothese, or by a very flexible inner liner collapsing against and adhering to the residual limb, as in a Northwestern University design<a></a> tested upon both upper- and lower-limb amputees. Care must be taken to provide a suitable balance of wicking capillary pressure in excess of negative air pressure so that moisture is not drawn back into the socket during swing phase. Conceivably, a porous supporting liner within an outer supporting structure might provide total contact and biomechanical reactions for the residual limb, but for a small and slowly ventilated chamber between the two, perhaps serving as a suction chamber during swing phase. One hopes that a simple, inexpensive, individually moldable material with appropriate range of perforations will become available. Ideally it would be available in various thicknesses, stiffnesses, resiliencies, and strengths and in a choice of transparency or appropriate skin colors. Of course it must also be nontoxic, noncarcinogenic, and odorless. Until then, however, we must make do with the increasing array of compromise materials and our growing but imperfect understanding of principles of sockets, linings, and interfaces. Bit by bit, we can improve service to the severely disabled patients whom we serve. References: <ol> <li>Marquardt, Ernst, Heidelberg, Germany, personal communication, 1961.</li> <li>American Academy of Orthopaedic Surgeons, Orthopaedic Appliances Atlas, Volume 2, J.W. Edwards, Ann Arbor, Michigan, 1960, esp. Chapters 1, 5, and 6.</li> <li>Gray, Frederick, Automatic Mechanism as Applied in the Construction of Artificial Limbs in Cases of Amputation, London, [the NML catalog card did not indicate publisher], 1855 [1857, second edition]; a copy at National Library of Medicine, Bethesda. See also the advocacy of suturing of the deep fascial envelope, criticism of muscles pulled over the end of the bone, but presumption of no end-weight-bearing in Alldredge, Rufus H., and Eugene F Murphy, "The Influence of New Developments on Amputation Surgery," 11, in Paul E. Klopsteg, Philip D. Wilson, et al., Human Limbs and their Substitutes, Chapter 2, p. 19, McGraw-Hill, New York, 1954; reprint edition with additional bibliography, Hafner, New York, 1968.</li> <li>Harris, R.I., "The History and Development of Syme's Amputation," Artificial Limbs, 6:1, 4-43, April 1961; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</li> <li><a href="http://www.oandplibrary.org/al/1962_02_086.asp">Loon, Henry E., "Below-Knee Amputation Surgery," Artificial Limbs, 6:2, 86-99, June 1962; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</a></li> <li>Murphy, Eugene F., "The Fitting of Below-Knee Prostheses, " Chapter 22 in Paul E. Klopsteg, Philip D. Wilson, et al., Human Limbs and their Substitutes, McGraw-Hill, New York, 1954; reprint edition with additional bibliography, Hafner, New York, 1968.</li> <li>Parmelee, Dubois D., Artificial Leg, U.S. Pat. 37,637, Feb. 10, 1863. See also Murphy, Eugene F., "Patents, Patients, and Patience," commentary on centennial, Artificial Limbs, 7:2, 69-72, Autumn, 1963; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</li> <li>Barnes, Gilbert H., "Skin Health and Stump Hygiene," Artificial Limbs, 3:1, 4-19, Spring 1956; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</li> <li>Levy, S. William, "The Skin Problems of the Lower-Extremity Amputee," Artificial Limbs, 3:1, 20-35, reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</li> <li>"Murphy, Eugene F., "Some Thoughts on Fitting of Prosthetic and Orthopedic Appliances to be Checked and Refined," 10/11/57; mimeographed by Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, New York, 1957, 1961.</li> <li>"Murphy, Eugene F., "Transferring Load to Flesh- Part I: Concepts," Bull. Prosthetics Res. BPR 10-16: 38-44, Fall 1971.</li> <li>Bennett, Leon, "Transferring Load to Flesh," Bull. Prosthetics Res.; Series of Parts: —Part II. "Analysis of Compressive Stress," BPR 10-16:45-63, Fall 1971. —Part III. "Analysisof Shear Stress, "BPR 10-17:38-51, Spring 1972. —Part IV. "Flesh Reaction to Contact Curvature," BPR 10-18:60-67, Fall 1972. —Part V. "Experimental Work," BPR 10-19, Spring 1973. —Part VI. "Socket Brim Radius Effects," BPR 10-20:110-117, Fall 1973. —Part VII. "Gel Liner Effects," BPR 10-21:23-53, Spring 1974. —Summary report at conference research project leaders, with title Transferring Load to Flesh, BPR 10-22, 13-143, Fall 1974. —Part VIII. "Stasis and Stress," BPR 10-23:202-210, Spring 1975. —(See also later progress reports on applying the same concepts under title "Stump Stress Analysis" in BPR 10-24:217-218; BPR 10-25:182-183-inadequate service life despite previous fatigue tests-; BPR 10-26:275-285-fatigue tests of various composites; problems of porosity.)</li> <li>Wilson, A. Bennett, Pritham, Charles, and Stills, Melvin, Manual For An Ultralight Below-Knee Prosthesis, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Temple University, and Drexel University, Philadelphia, Second Edition, 1979.</li> <li>Lehneis, H.R., Chu, Don Sung, and Adelglass, Howard, "Flexible Prosthetic Socket Techniques," Clinical Prosthetics and Orthotics, 8:1, 6-8, Winter 1983-84.</li> <li><a href="http://www.oandplibrary.org/al/1961_01_076.asp">Radcliffe, Charles W., "The Biomechanics of the Syme Prostheses," Artificial Limbs, 6:1, 76-85, April, 1961; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1962_02_016.asp">Radcliffe, Charles W., "The Biomechanics of the Below-Knee Prostheses in Normal, Level, Bipedal Walking," Artificial Limbs, 6:2, 16-24, June, 1962; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1955_01_035.asp">Radcliffe, Charles W., "Functional Considerations in the Fitting of Above-Knee Prostheses," Artificial Limbs, 2:135-60, Jan. 1955; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1957_02_029.asp">Radcliffe, Charles W., "The Biomechanics of the Canadian-Type Hip-Disarticulation Prosthesis," Artificial Limbs, 4:2, 29-38, Autumn 1957; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1955_02_022.asp">Taylor, Craig L., and Schwarz, Robert J., "The Anatomy and Mechanics of the Human Hand," Artificial Limbs, 2:2, 22-35, May 1955; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1955_03_004.asp">Taylor, Craig L., "The Biomechanics of Control in Upper-Extremity Prostheses," Artificial Limbs 2:3, 4-25, Sept. 1955; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York 1970.</a></li> <li>Hepp, Oskar, "Haftprothesen," Zeitschrift fuer Orthopaedic und ihre Grenzgebiete, Band 77, 1947-48, 219-279.</li> <li>Page visited the offices of the Committee on Prosthetic Devices, then at Evanston, Illinois, in 1946.</li> <li>ChiIdress, Dudley S., Billock, John N., and Thompson, Robert G., "A Search for Better Limbs: Prosthetics Research at Northwestern University," Bull. Prosthetics Res., BPR 10-22:200-212, Fall 1974, especially p. 204 on "Self-Contained and Self-Suspended Devices," including atmospheric-pressure suspension. See also Progress Reports, BRP 10- 27:129, Spring 1977, and BPR 10-30, 177-178, Fall 1978.</li> </ol> <div style="width: 400px;">*Eugene F. Murphy, Ph.D. Retired, Veteran's Administration-Director, Office of Technology Transfer and Director, Research Center for Prosthetics </div> <div style="width: 400px;"></div> Page Number(s) 4 - 10 Year 1984 Volume 8 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 Sockets, Linings, and Interfaces Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/9719948f0ff1fbce02da39e6232a4372.pdf 5e4f12bcbae522e74f4012c60724a3a5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_011.pdf Text Any textual data included in the document <h2>Evolution of the AK Socket</h2> <h5>H. R. Lehneis, Ph.D., CPO </h5> The lead article for this issue of C.P.O., "Sockets, Linings, and Interfaces," by Dr. Eugene Murphy represents the culmination of many years of research, writing, and studying the principles of socket design and interfaces. Admittedly, very little advance has been made in AK socket design since the development of the total contact socket. Today, the principles espoused by Dr. Murphy of selective flexibility/rigidity of socket interfaces can be realized in clinical practice. There is a pressing need to re-evaluate the traditional quadrilateral AK socket design in light of the drastic changes over the years in the amputee patient population. Today, the vast majority of AK amputees are geriatrics—a complete reversal from the time of development of the quadrilaterally-shaped socket. Most practitioners would agree that the most prevalent complaint of geriatric amputees is discomfort. This is not surprising, considering that most geriatric amputees suffer from reduced muscle tone, sensation, and vascularity. Thus, it has been proposed by this author to re-examine the cross-sectional configuration of AK sockets to specifically address the physiological alterations in stump shape and consistency of geriatric amputees, to evolve a socket design specific for this patient population. Such new configuration, combined with contemporary interface materials, e.g., silicone, copolymer inserts, and selective flexibility/rigidity, should lead to much improved physiological and biomechanical function and comfort (see <a href="cpo/1984_01.asp">Winter issue C.P.O.—Vol. 8, No. 1</a>). Other attempts to improve comfort are seen in Scandinavian socket designs in which the entire socket is semi-flexible except for the medial wall and a portion of the proximal brim area. In the Ockenfels design, the socket contains selective fenestrations and an inner elastic cloth liner or sock to prevent window edema. The so-called Contoured Adducted Trochanteric Controlled Alignment Method (CAT-CAM), developed by Sabolich, is to not only improve comfort but supposedly the patient's gait pattern. Now that these new developments are emerging, it seems rather puzzling, in retrospect, that there was such a long hiatus in the application of soft or flexible interface materials in AK sockets. And so it appears that we are on the verge of a major breakthrough, particularly in AK socket design and interface materials. Though not universally practiced, these noteworthy developments will change the practice of prosthetics in dramatic ways to improve comfort and function our patients so much deserve. Page Number(s) 11 - 11 Year 1984 Volume 8 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 Evolution of the AK Socket Creator An entity primarily responsible for making the resource H. R. Lehneis, Ph.D., CPO https://staging.drfop.org/files/original/0af497bc37cfab2a9a00a17b1ca6d86f.pdf cf8cb41e194e0ee4499e4051dda5f85e https://staging.drfop.org/files/original/5ea3581f6ee975d42c43106821fad3e2.jpg 313f93afd5728940fede23af77bc8aeb https://staging.drfop.org/files/original/2716c0dfa81b724004f4e14015781792.jpg 6e2dfd49d5e2c1b0b0b628b8a3211b60 https://staging.drfop.org/files/original/576707f40e83237ed35a081d709ab88c.jpg aa88f323501ce5eda2721634bd997f66 https://staging.drfop.org/files/original/581c053fd31ab1f812407ca84373b090.jpg cd646856608dc4c29841ec43ea7d2aa1 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_018.pdf Text Any textual data included in the document <h2>The Application of Ionomer Resins in Definitive Below Knee Prostheses: A Limited Study</h2> <h5>Bruce P. McCleUan, CPO <a style="text-decoration: none;">*</a> Susan Kapp, CP <a style="text-decoration: none;">*</a> Melvin Stills, CO <a style="text-decoration: none;">* </a></h5> <h3>INTRODUCTION</h3> For the past 30 years, polyester resins have been the material of choice for socket fabrication and exoskeletal lamination for all types of prostheses.<a></a> Without question, these thermosetting plastics have proven to be strong, durable, and effective for such application, and, at the time of their introduction, thermosetting plastics provided a quantum leap forward from the age of wood. The advent of plastics allowed for a more hygienic and less bulky prosthesis. More importantly, lamination provided a medium for duplicating a modified replica of the patient's residual limb. Thus, a more intimate fitting socket with greater weight-bearing characteristics was possible. In fact, the use of thermosetting resins continues today as the accepted state-of-the-art. As with any material, the polyester resins have certain characteristics which are not ideally suited for all situations. With this as a basis, the University of Texas Health Science Center at Dallas, in conjunction with the Dallas Rehabilitation Institute, began investigating the use of alternative materials for definitive prosthetic design. One of the most attractive substitutes appeared to be thermoplastics. A clinical study was undertaken to evaluate the group of thermoplastics known as ionomer resins and their role in definitive prosthetic application, as opposed to the polyester resins in use today. <h3>Thermosetting Resins</h3> As indicated, thermosetting-resins such as 4110 laminae have many positive attributes when used in the prosthetic arena. Some of the negative characteristics which prompted the investigation into other materials are equally impressive. The toxicity of the fumes given off during the lamination stage is certainly a matter of concern. The ability to modify a socket fabricated from polyester resin to accommodate residual limb change or pressure on bony prominences is essentially limited to grinding away an area for relief, or adding material to reduce socket dimensions. The cured polyester resin also is fairly rigid in nature—a factor which formed the major emphasis for research into the area of alternative materials. <h3>Ionomer Resins</h3> The thermoplastics which were utilized in this particular study of prosthetic application are classified as ionomer resins. The resins are based on copolymers of ethylene and metha-crylic acid, which are partially reacted with metallic salts to form ionic crosslinks between acid groups of single chain or between neighboring chains.<a></a> The name Surlyn® is the registered trademark of the ionomer resins produced by DuPont and was the material used in the fabrication of the prosthetic sockets. Some of the characteristics which made Surlyn® an attractive option for prosthetic use are as follows: Clarity Surlyn® is virtually transparent even in thicknesses up to 1/4 inch. This allows the prosthetist to evaluate socket fit visually while the patient is standing with full weight bearing on the residual limb (Fig. 1). <a href="/files/original/5ea3581f6ee975d42c43106821fad3e2.jpg">Figure 1</a>. Symes amputee with clear Surlyn® prosthesis. Adjustability The nature of ionomer resins is compatible with heat induced molding which greatly facilitates modifications to the socket. Areas of pressure over bony anatomical structures are simply heated and relieved with no adverse affect on integrity or clarity of material. Surlyn® may also be buffed, sanded, drilled, and riveted in the same manner as the laminates. Ease of Fabrication Surlyn® comes in a sheet form and is heated and softened in an oven to allow drape vacuum forming. Unlike other thermoplastics, Surlyn® can be formed directly over a wet cast with no need for a lacquer coating or nylon stocking interface. This differs greatly from polycarbonates which require prefabrication dehydration and a dry cast for good results. Additionally, no post-fabrication curing is required to drive off skin irritating styrene gas, as in the case of polyester resin which has a greater than 25 percent flexible resin content. Additional fabrication time is required, however, in the case of long below knee and Symes level amputations because of the need to weld the posterior seam of the Surlyn® socket. Flexibility This factor has proven to be the most significant advantage of ionomer resins from the patient's standpoint. Sockets fabricated from Surlyn® have much greater flexibility than those fabricated from polyester resin. Patients report that the socket feels more like a part of them and is appreciably more comfortable. The exact deformation occuring in the socket during ambulation has not been quantitatively measured at this point, but clinical trials indicate that anatomical weight-bearing surfaces are not adversely affected by the dimensional changes. <h3>Clinical Applications</h3> Initially, the ionomer resin sockets were used only as "test" sockets prior to fabrication of an intermediate or definitive prosthesis. Later, use broadened to include intermediate prostheses, and eventually definitive application. The move toward definitive use was prompted by the patients themselves. Those who had been wearing intermediate prostheses made of Surlyn® complained of the rigidity of the laminated socket when their permanent prosthesis was delivered. This provided a significant clue as to the direction which should be taken in regard to providing a more comfortable definitive prosthesis. <h3>FABRICATION PROCEDURE</h3> Though the technique is very similar to standard vacuum forming of orthotic devices, some specific steps are employed when making the definitive prostheses. To prepare the Symes cast for vacuum forming, the Symes foot retainer is attached to the modified positive model with plaster, using the vertical fabrication jig for alignment. A small hole is drilled into the popliteal area and the patellar bar of the cast to assure a good vacuum in these depressions. A piece of cotton stockinette is stapled above the trimline and stretched over the cast mandrel and the holes in the hand drape pipe. Pressure sensitive tape is used to hold the stockinette in place on the pipe. The thickness and dimension of the Surlyn® sheet to be used will vary according to type of prosthesis (i.e., Symes or BK) and the size of the patient. Most Symes casts require no more than a 24" x 24" sheet of 3/16" Surlyn® (for the lighter or less active patient 1/8" Surlyn® may be sufficient). The sheet is heated on a teflon rack for approximately seven minutes in a 350°F oven. The heated sheet is draped over the cast and sealed down the posterior side with the vacuum turned on. Excess plastic is cut away and trimmed almost flush with the socket before it is allowed to completely cool, eliminating the need for excessive grinding. Once cool, the posterior seam is grooved in preparation for welding. Three welds are run over the entire seam. The socket is then removed from the cast and trimmed. The foot is attached and the prosthesis is ready for fitting and delivery. The below knee prosthesis is fabricated in the same manner one would fabricate a thermoplastic test socket. It is frame draped with a 12" x 12" sheet of 1/2" Surlyn.® Care must be taken to not create webs below the trimline. It is then formed onto the Berkley alignment fixture for dynamic alignment. The socket may be permanently incorporated into an endo skeletal system or be finished in an exo skeletal manner using acrylic resin for the outside lamination. Using acrylic resin will not impair the flexibility of the socket to the extent that polyester resin will. <h3>CLINICAL RESULTS</h3> The fittings of the ionomer resin sockets for definitive use began in April, 1982. Of the ten patients who were definitively fitted with Surlyn,® eight were Symes level amputees. The remaining two patients were below knee amputees (Fig. 2). <a href="/files/original/2716c0dfa81b724004f4e14015781792.jpg">Figure 2</a>. Below knee type prosthesis with ionomer resin socket. In the Symes amputee group, five of the eight patients experienced failure of the prosthesis at the ankle/foot juncture (Fig. 3). The shortest use time until breakage was 14 days and the longest was five months, with a mean of 11 weeks for the group experiencing breakage. Two of these patients were refitted with a second Surlyn® definitive, one of which failed again after two months, while the other prosthesis continued to function one year after a modified ankle/foot juncture was devised (Fig. 4). The modification made was one of reinforcing the distal end of the socket with glass cloth adhered with acrylic resin. <a href="/files/original/576707f40e83237ed35a081d709ab88c.jpg">Figure 3</a>. Stress fracture at ankle/foot juncture of Symes prosthesis. <a href="/files/original/581c053fd31ab1f812407ca84373b090.jpg">Figure 4</a>. Closed socket design type now being used with reinforced ankle. Suspension is provided by a closed-cell polyethylene shim or pad encompassing the leg proximal of the malleoli and retained in place with a cast sock. Prosthetic socks are worn beneath the shim as usual. This same method has since been used on two other prostheses in the Symes group. However, over a period of one year, both of these prostheses failed at a level just proximal to where the glass cloth reinforcement stopped. The remaining patient in this group was an elderly lady who is a limited household ambulator and has experienced no known problems to this date. One of the two below knee patients wore his Surlyn® socket prostheses for 11 months before a crack developed. That patient weighed in excess of 230 pounds and participated in sports on a routine basis. His socket developed a crack in the proximal posterio-lateral corner which eventually migrated down the posterior wall. He was subsequently refitted with a polyester laminate socket. The other BK amputee was a 110 pound woman in her twenties who continues to ambulate with her Surlyn® socket prosthesis one year and seven months after fitting. <h3>CONCLUSION</h3> As indicated by Stills and Wilson,<a></a> Surlyn® may not be ideal for applications where high unit stresses are anticipated. Although this seems to have been borne out in this initial group of patients, we still believe that ionomer resins might play an important role in definitive prosthetic fittings. This may be accomplished by reinforcement at crucial stress points, a variation in the ionomer resin itself, or by finding a different material that is better suited to long term stresses. The frame type design being used in the above knee Scandinavian socket may also hold significant promise in a below knee configuration. The potential benefits of ionomer type resins to the amputee population are too great to dismiss without further evaluation and clinical analysis. It is hoped that others in our profession will actively participate in seeking viable materials for definitive socket application. References: <ol> <li>Aylesworth, R. Dean, ed., Manual of Upper Extremity Prosthetics, Artificial Limbs Project, University of California, Los Angeles, 1952.</li> <li>DuPont, E.I. De Nemours and Company (Inc.), Surlyn® Ionomer Resins Industrial Extrusions Manual, p. 3.</li> <li>Stills, Melvin, and A. Bennett Wilson, Jr., A New Material in Orthotics Prosthetics, Vol. 34, No. 3, pp. 29-37, September 1980.</li> </ol> <div style="width: 400px;">Melvin Stills, CO Melvin Stills, CO, Assistant Director, University of Texas Prosthetics-Orthotics Program. Susan Kapp, CP Susan Kapp, CP, Prosthetic Instructor, University of Texas Prosthetics-Orthotics Program. Bruce P. McCleUan, CPO Bruce P. McClellan, CPO, Assistant Professor and Director, University of Texas Prosthetics-Orthotics Program, School of Allied Health Sciences, Health Science Center at Dallas, 5323 Harry Hines Blvd., Dallas, Texas 75235. </div> Page Number(s) 18 - 21 Year 1984 Volume 8 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Application of Ionomer Resins in Definitive Below Knee Prostheses: A Limited Study Creator An entity primarily responsible for making the resource Bruce P. McCleUan, CPO * Susan Kapp, CP * Melvin Stills, CO * https://staging.drfop.org/files/original/7b50b9442fee7b3a075030bce26d5247.pdf c642ea8fa545bc78a7515b88282350b9 https://staging.drfop.org/files/original/1bf96f25f8dad3e8a90a0f93f54b53e3.jpg 5be960caa128ae75975d9e0ace0cc9a0 https://staging.drfop.org/files/original/3c801b7d07539462b4ac10842de5efcd.jpg a96f3e7dc9ed31455ba28a3c1da6dfe8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_022.pdf Text Any textual data included in the document <h2>Follow-up Experience with an Orthosis Combining the Supracondylar Knee Orthosis and the Spiral Orthosis</h2> <h5>Thomas A. Marün, CPO <a style="text-decoration: none;">*</a></h5> Fig. 1, Fig. 2 <a href="/files/original/1bf96f25f8dad3e8a90a0f93f54b53e3.jpg">Fig 1</a>. Side view of orthoses similar to that described by Mr. Martin in his article. (The photographs supplied by Mr. Martin proved to be unusable.) <a href="/files/original/3c801b7d07539462b4ac10842de5efcd.jpg">Fig 2.</a> Posterior view of the same orthoses as in Fig. 1. These photos are supplied courtesy of H. Richard Lehneis, Ph.D., CPO. A seventy-one year old woman, post polio of long duration, presented herself to our facility with a Supracondylar Knee Orthosis<a></a> that had a spiral type AFO<a></a> attached to it over ten years ago. She had fractured the AFO component just proximal to the malleolus, about one year ago. Another facility had attempted to replace the Nyloplex® spiral AFO with polypropylene material. Her ankle was fixed at 120 degrees plantar flexion. Our investigation indicated that her knee went into genu recurvatum despite the SKO, hence the problem-how to attach the spiral unit to the SKO and duplicate the same alignment that she had been comfortable with after all these years. It is noteworthy that the SKO was held in position by a waist strap. It was our opinion that the SKO no longer fit due to laxity within the knee cavity itself. She was quite adamant, however, that her brace system had been working well and it was our job to fix it. She declared that the waist belt was no problem and further stated, in no uncertain terms, that she wanted what she had because it had been of good service for over a decade. Possibly being more persistent than intelligent, we proceeded. We were unsuccessful in our attempts on three separate occasions in reapplying the spiral type AFO. We finally tried #4134-30 percent and #4110-70 percent polyester resin, laminated with four layers of fiberglass and two layers of glass, and used 1/16" polypropylene welding rods that ran the entire length, one inch apart. Using the old holes of the SKO, we were unsuccessful in obtaining satisfactory alignment when attaching the spiral unit. Therefore we were forced to tape the two units together until we had a compatible arrangement. Once the two components were riveted together, she had some problems in gait, especially between heel strike and foot flat, clearly indicating that the SKO was affecting the knee by not allowing it to go into recurvatum. In summary, we feel that in using the resin as opposed to the Nyloplex® (we used the same plaster mold) we may have compromised some flexibility, but gained, through rigidity, a successful duplication of past gait patterns. Presently this woman is walking better than formerly and is quite satisfied with our results. References: <ol> <li>Dr. H. Richard Lehneis, CPO, "Bio engineering Design and Development of LE Devices, " Institute of Rehabilitation of Medicine, New York University Medical Center, p. 55, October, 1972.</li> <li>ibid., p. 60.</li> </ol> <div style="width: 400px;">*Thomas A. Marün, CPO President Baja Orthotic and Prosthetic Services, 205 Church Street, Chula Vista, California 92010 </div> Page Number(s) 22 - 22 Year 1984 Volume 8 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1984_03_022/1984_03_022-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_03_022/1984_03_022-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Follow-up Experience with an Orthosis Combining the Supracondylar Knee Orthosis and the Spiral Orthosis Creator An entity primarily responsible for making the resource Thomas A. Marün, CPO * https://staging.drfop.org/files/original/6390d2b802a51debf473b9656b992a03.pdf 5239891523840188e87e90863af212cf 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_002.pdf Text Any textual data included in the document <h2>The Parents Experience</h2> <h5>James R. Cuchna <a style="text-decoration: none;">*</a> Anna Mae Cuchna <a style="text-decoration: none;">*</a></h5> A new birth . . . another miracle . . . a baby is born . . . but why is our baby not made perfect like our friends and relatives? Life began, but it was not surrounded by complete joy. We were confronted with the inevitable—"Your child was born with spina bifida. She will, probably, live no longer than a week." We were asked, "Do you want to put her in an institution or leave her in the hospital?" Try to imagine the feeling that would rush through your mind at the onset of this occasion. It is unbelievable. Our immediate and only reaction was to take this child and love her just as if she were born "perfect." We accepted our daughter and were determined to treat her as if nothing was wrong. We had faith that God would help us through the problems we might encounter. This happened on March 21, 1966. Today, Cindy is 18 years old and is entering her first year of college. We also have a 17 year old daughter and a 9 year old daughter. We feel we have been richly blessed. Even though our first child was the one born with a physical problem, spina bifida, we really don't feel she has ever been "the problem." Society in general . . . everyone else's opinion, the medical profession, the people in government passing legislature, etc. are "the problems." Everyone thinks they know what "life is going to be like" for these children, what a "burden" they will be on the family. These statements infuriate us. Having had other children helped us substantiate our thoughts and feelings that a child born with a physical problem is "no different" than a child born "normal." We have had to deal with medical problems, hospital stays, doctors visits, etc. with all our children—maybe not as many problems as with Cindy, but, all have been traumatic for us. We have also had parents inflicted with cancer and have cared for them. To us, life is what a person makes of it. It is the positive attitude that surrounds any child or person that is so important. One can only try to make the best of things and live each day to the fullest. We are concerned for the babies that have doctors who perceive spina bifida as a dreadful defect/disability and make the decision of whether to treat or not. Cindy was not treated at birth but survived. Thoughts arise as to what more she could do had she been treated. Would her degree of paralysis and the kidney damage be less severe? We'll never know. Some doctors hesitate on treating babies born with spina bifida, but wouldn't give a second thought to treating victims of automobile, industrial or other accidents even though the outlook may be very bleak. An example of this is the president's aide, James Brady. What makes the difference? Another concern lies in the high cost of the medical supplies and equipment she will need the rest of her life. It doesn't seem fair that urostomy bags bought 11 years ago cost $13.95 and today are $42.50, that a set of full braces is $5,000 or more, that a wheelchair is over $1,000, that vans with lifts are $20,000, or that urine analysis that were $2.00 are now $10.00. Most of the people with physical problems have limitations in job opportunities. Very few will be able to hold high paying jobs. Where will the money come from to pay for their needs? Some places now want the money first and then they will bill your insurance. Where will she get the start to save money when she needs something? What happens when our 80 percent group insurance coverage lapses because she is an adult and then she cannot get insurance of her own because of her medical/physical involvement? Cindy feels good about herself and has accepted her handicap. She realizes that she has limitations but that these should not preclude her from being able to achieve the goals she sets. The fact she is paralyzed from the waist down and requires orthopedic bracing brought Cindy to the realization that she would have to work very hard for what she wants very early in life. She knows that nothing is going to be handed to her on a silver platter and does not think that she deserves special treatment because she is "physically challenged." All she wants is an equal opportunity to contribute to society and earn her way. Cindy has been a constant source of strength, love, and courage for us. As we watch her grow and see her achieve, our admiration for the child/young lady/soon-to-be woman grows. We truly believe that we have been more dependent on Cindy than she has been, or ever will be, upon us. We have been very fortunate in having benefitted from the professional services of very dedicated, talented, competent, and caring people in the areas of medicine, education, and orthotics. Yes, there have been differences of opinions between themselves as well as with us. There were goals that took longer than anticipated to be reached. But, can't we all say this happened to us also in our "normal" lives. It is one of our dreams and goals to see more medical professionals get involved with the National Spina Bifida Associaion of America and its local chapters. We don't need people to be afraid of spina bifida. We need help to spread a positive image, to achieve the establishment of a hospital for research and for the needs of all people with spina bifida. People need to know that children who are physically challenged don't need sympathy and things done for them. What they need is the opportunity to live, learn, grow in love and be loved—just as we all do. *Anna Mae Cuchna Mr. and Mrs. Cuchna reside in Ohio and are the parents of Cynthia Cuchna. *James R. Cuchna Mr. and Mrs. Cuchna reside in Ohio and are the parents of Cynthia Cuchna. <div style="width: 400px;"></div> Page Number(s) 2 - 3 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 The Parents Experience Creator An entity primarily responsible for making the resource James R. Cuchna * Anna Mae Cuchna * 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 <a style="text-decoration: none;">*</a></h5> 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. 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. 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. 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. 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. 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. 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. *Cynthia L. Cuchna 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. <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/0fd16e6b909f7130aea2a750ca50a40a.pdf 853cb1beca60fbae264611089e78bb36 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_005.pdf Text Any textual data included in the document <h2>A Need for Information</h2> <h5>Kent Smith </h5> April 6, 1971. My wife and I were eagerly anticipating the birth of our second child. I accompanied her to the hospital in suburban Chicago. It had been a normal pregnancy, much like the pregnancy two years earlier when our daughter was born. Shortly after midnight the joyous moment arrived. The doctor came to the father's waiting room; he was not smiling. Our son was born with a birth defect known as spina bifida. As we look back on that moment, we've realized how much the birth of our son Stephen has affected our lives. As a news writer/producer for a major television station in Chicago, I had access to a great deal of information. I had been trained to ask the right question, investigate the story thoroughly, and report both sides equally. My wife had received her education in library science and enjoyed the research involved in establishing a library and developing good reference systems. Nowhere in our professional experience had either of us come across information on the birth defect spina bifida, nor were we to realize how difficult it would be to get the information that should be so readily available to new parents of a spina bifida child. Parents find themselves very vulnerable after having given birth to a child with spina bifida. The hospital and medical staff appeared intimidating. We knew little about birth defects in general and nothing about our own child's specific needs. We looked to the "experts" whom we hoped would help. Our first attempt to get information was through the local chapter of the March of Dimes. Their personnel were courteous, sympathetic to our needs, but could not answer specific questions on how other families were coping with a child with spina bifida. We tried to gain understanding on a variety of terms. How did it affect our Stephen? Were we unique with this problem? What was the outlook for our son's future? Those questions went unanswered, although we did receive some pages copied directly from a well-known book on birth defects. Good friends stood by us trying to provide a sympathetic ear. They couldn't answer questions, but wanted to do the best for our family, even encouraging us to look at places where our child could be placed and be raised in a loving atmosphere; then we could go on with our own lives. This only frustrated us, for we wanted to help our son, who—by some quirk of fate—had problems that we knew were serious but we didn't understand. He was part of our family and we wanted to provide him with the best medical care available. As parents, we had to depend on others for guidance. The most obvious person to turn to is the family physician. Clearly, new parents of a disabled child need information on the disability and its treatment, as well as the names of agencies and support groups available to assist the family unit. Other parents who have faced the same situation can share their knowledge and give comfort and assistance. My wife and I were steered to a support group of parents and adults with spina bifida. This group met every month at the hospital. Our physician had been working with this parent group. Although he could not share the parental experience of raising a handicapped child, he respected the support that was freely given by parents "sharing their experiences." From our point of view, it was the best medicine that he could provide. It gave us hope that our son might make advances similar to other children. Information is the key to knowledgeable parents raising their children with spina bifida. My wife and I became active in this parent support group to learn more about the birth defect. From those adults with spina bifida we learned some problems they had faced and how we could help our son. Our involvement with a national organization wasn't something we planned, it evolved. In 1979, I was asked to establish a central office to provide information to new parents and be a resource to chapters consisting of parents, adults, and professionals in many cities. Under a letter of agreement with my employer, the American Broadcasting Company, I took a year's leave of absence to establish the office. I've never gone back to ABC. The leadership of Spina Bifida Association of America (SBAA) comes from the active participation of adults with spina bifida and parents working together. When SBAA was formed as a volunteer group in 1972, the greatest need was to provide printed information written in lay language. Today, the Association has 11 booklets directed to educators, new parents, adults with spina bifida, and to children. As a journalist, I was able to work with the writers in developing a distribution system that now has over 50,000 pieces of literature circulated each year. One concern we have is the misinformation that others continue to tell new parents regarding the current treatment or the lack of potential of people born with the birth defect today. In 1979, the SBAA established a policy that encourages early evaluation and medical/surgical treatment of every infant with spina bifida, and recommends that the evaluation be performed by professionals experienced in that care and treatment. Improved medical treatment within the last 25 years minimizes the disabling effects of spina bifida. Recent statistics from major treatment centers in New York, Pittsburgh, Chicago, Seattle, and elsewhere indicate that approximately 90 percent of those infants born today with spina bifida can lead a competitive life with some adjustments for physical disabilities. The majority of infants who receive aggressive treatment early do not suffer mental retardation. Lack of bowel and bladder control can be dealt with and should not take the "opportunity for life" away from the child. Some amount of paralysis often occurs, but the degree of involvement varies widely and cannot be determined at birth. The SBAA also sponsors an Adoption Referral program which offers a viable alternative to parents who feel unprepared to raise a child with a disability. The program has placed 70 babies in loving homes and has a waiting list of parents willing to take infants with spina bifida. During these last five years I have met hundreds of parents with similar stories, all with a commitment to provide information to a new parent who, like each of us, needed someone or some group to answer questions. The adults with spina bifida hold challenging jobs, and in general make worthwhile contributions to society. They have devised innovative ways in which to overcome their disabilities. Each represents a realistic goal which our child born with this birth defect can hope to achieve. If you would like further information on Spina Bifida and our Association, please call 1-800-621-3141. Page Number(s) 5 - 6 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 Need for Information Creator An entity primarily responsible for making the resource Kent Smith https://staging.drfop.org/files/original/f2f2342e1e6c5a7524fbbb113dcd429d.pdf b5a27a06fe4080ab7de494f9ef3f12a2 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_006.pdf Text Any textual data included in the document <h2>What is Spina Bifida?</h2> <h5>Jeannie Gruse </h5> I have chosen to do this report on spina bifida because of little Stephen Smith, a happy, loving, well-adjusted boy, who was born thirteen years ago with this condition. Stephen's parents are friends and neighbors, and I well remember the day that Kent came over to tell us about the birth of their first son. When he described their handsome baby boy, and then explained that he had a birth defect called spina bifida, I had no idea what he was saying; I had never heard of this condition. Pam and Kent knew very little at that time, either, but in nine years of surgery, emergencies, difficult care, exercising, training, and learning, this has certainly changed for them. Kent is currently the Executive Director of The Spina Bifida Association of America, dedicated to "making the public, professional and all governmental agencies more aware of this worldwide health problem and assisting parents in helping their children." The program is also directed toward improving comprehensive medical care for children and adults with spina bifida, and expanding research programs which will search for the cause of this birth defect. Spina bifida is a serious condition, and until thirty years ago, few babies born with it survived beyond infancy. The treatment techniques developed within the last two decades make it possible for the majority of these children to grow to adulthood and live happy, productive lives in spite of their disability. Spina bifida is not a new birth defect; it was referred to 2,000 years ago, and was described by a Dutch physician, Nicholas Tulp, friend of Rembrandt, in 1652. The technical terms, spina bifida aperta or spina bifida manifesta relate to a structural defect caused by failure of the neural plate to develop into a tubular structure. In the area where this occurs, the defect is technically referred to as myelomeningocele (G. myelos = marrow; meninx = membraine; kele = hernia). In development, plates of bone fail to close over the defective area of the spinal cord and there is a short spine on each side of open spinal cord rather than a single one in the midline, therefore the term spina bifida. If the bony plate does not close over the spinal cord during infancy, this defect is referred to as spina bifida occulta (hidden). This type generally causes no problems. The newborn baby will have an obvious lump or cyst-like lesion on the back. It may be covered with skin, or more often wholly or partially covered with translucent bluish or white membranes. There may be a flat plate of imperfectly formed spinal cord on the surface of the cyst which may be leaking cerebro-spinal fluid. While there are many claims or suggestions of causes of spina bifida, it is generally considered to be caused by an unknown environmental agent interacting with genetic factors, according to Dr. Swinyard, Stanford University authority on spina bifida. Multiple complex problems presented by newborns with spina bifida have discouraged some physicians from applying the available intensive medical care and technologies to preserve lives of the more severely defective newborns. A number of physicians have advocated strongly that such treatment be withheld from newborns, presenting certain criteria with the expectation that these babies would soon die. This presents serious moral and legal problems, obviously, relating to rights of the children and the rights of parents to make such decisions, and since the predictability of death is quite uncertain, those who survive may have unnecessarily serious and lasting damage. There are many problems associated with spina bifida besides the obvious surgery necessary, often immediately, to correct the condition. There is loss of awareness of touch, pain, pressure, and heat or cold in those areas of skin normally innervated by nerves involved in the spinal cord defect. There is muscle weakness in the lower limbs and lower trunk, the latter often resulting in weakness in muscles of the bladder and bowel, preventing normal control. Nearly 70 percent of infants with spina bifida develop an associated defect known as hydrocephalus, causing a rapid enlargement of the head from the abnormal accumulation of fluid inside the brain. Although it does not occur in all of the infants, this problem is potentially a life threatening one which requires prompt attention of a neurosurgeon, and even then may often result in varying degrees of brain damage. The degree of severity of these conditions associated with spina bifida varies widely. Some children will be able to walk without assistance, others may need braces or a wheelchair. Because spina bifida is such a complex condition, these cases are usually referred to a pediatric neurosurgeon who is part of an organized team. He will decide on the surgical closure of the myelomeningocele, carefully watch for signs of hydrocephalus, and be responsible for the management of this condition if it occurs. Development of hydrocephalus would involve a serious neurosurgical emergency, as severe brain damage or death could result from the pressure of the fluid within the brain. A shunting procedure is used to reduce this condition, which consists of inserting one end of a flexible tube info a brain ventricle and passing the tube through a small opening in the skull. It is then passed underneath the skin from the head, either to the heart or to the abdomen, and includes a one-way valve which prevents the backward flow of spinal fluid. Even this procedure, a vital one to prevent pressure on the brain, is not totally free of dangers, as shunts can be obstructed or collapse, and revision is often necessary. However, it is the best procedure, and the only effective treatment currently available to allow the brain to develop more normally. Besides the neurosurgeon, spina bifida children will be seen by a number of different specialists. A urologist may be necessary to control urinary infections, and to keep the lack of bladder control from becoming a problem. The pediatrician will watch the child's general health and work on management of the problems relating to lack of bowel control. The orthopedic surgeon will have as his primary concern the growth and development of the bones and muscles. Children with spina bifida often have hip dislocation, club feet, scoliosis, kyphosis or lordosis. He will suggest surgery, braces or crutches when needed. An orthotist will fill the surgeon's prescriptions and work with the child as he grows. In conjunction with the orthotist, a physical therapist will also help carry out the plans made by the orthopedic surgeon and will suggest others designed to strengthen weak muscles. Finally, an occupational therapist may also aid in carrying out the physician's suggestions. She will work primarily with motor coordination and preceptual-motor impairment, and will assist in helping the child adapt to his physical environment in activities. Even with all of these trained experts' help, it is obviously the parents who are chiefly involved in the daily training and care of spina bifida children. I feel fortunate to have been involved, along with my daughter, friends, relatives, and church member volunteers in a program of "patterning" with little Stephen a few years ago. The theory of the program was that an infant's ordinary body movements stimulate brain development through sensory-motor input. Gradually the child's movements become coordinated in cross-patterned crawling, creeping, and walking. By stimulating the body in various ways it was hoped we could "wake up" and condition the pathways to the brain and activate the millions of unused cells within the brain. The method involved artificially recreating patterns of movement in hopes of reaching the brain and having the brain take over these same movements on its own. With three people helping three or four times a day, we helped Stephen and his mother go through his prescribed exercise schedule according to the training his mother had previously received. While some individuals with spina bifida have average or above average intelligence, those who also have hydrocephalus may, as a result, have some degree of mental retardation. The best school placement and curriculum planning will depend also upon physical limitations. The main consideration is mat the child be placed in a flexible situation for effective learning. Since many spina bifida children do have learning problems, teaching must be individualized, based on strengths and weaknesses. This may be possible in a regular classroom, mainstreamed partially, or in a self-contained situation, depending on the severity of the physical condition and the extent of the learning disability. When Stephen was nine years old, he was completing first grade work, and beginning second, at the Fullerton School, in Addison. He was in a structured, protective environment with reinforcement of one full-time teacher and an aide to six or seven students; this was a self-contained room called Orthopedic-Learning Disabilities, with mainstreaming for music and art. Having spina bifida means different things to different people. The actual physical condition varies greatly from person to person. How a person manages in life depends not only on the severity of the actual physical condition, but also upon the support he gets from others, the adaptations in the environment, and most of all, how the person feels about himself. With the tender, loving care and dedication of parents such as Pam and Kent Smith, spina bifida children like Stephen have a chance to grow up, able to cope with their own limitations, and to manage very well in life, feeling good about themselves. References: <ol> <li>Anderson, Elizabeth M., and Spain, Bernie, The Child With Spina Bifida, London: Methuen and Co. Ltd., 1977.</li> <li>Kieran, Shari Stokes, Ed.D., and Connor, Frances Partridge, Ed.D. "Mainstreaming Preschoolers," Children With Orthopedic Handicaps, U.S. Department of Health, Education, and Welfare.</li> <li>Klein, Stanley D., Ph.D., Psychological Testing of Children. The Exceptional Parent Press, 1977.</li> <li>Lindsay, Carolyn N., M.Ed., An Educator's Guide to Spina Bifida, U.S. Department of Health, Education, and Welfare, 1978.</li> <li>Osman, Betty B., Learning Disabilities, A Family Affair, New York: Random House, 1979.</li> <li>Pieper, Betty, By, For and With . . . Young Adults With Spina Bifida, Chicago: Spina Bifida Association of America, 1979.</li> <li>Pieper, Betty, Sticks and Stones, The Story of Loving a Child, Syracuse: Human Policy Press.</li> <li>Pieper, Betty, The Teacher and the Child With Spina Bifida, Chicago: Spina Bifida Association of America, 1979.</li> <li>Pieper, Betty, When Something is Wrong With Your Baby. Chicago: Spina Bifida Association of America, 1977.</li> <li>Reid, Robert, My Children, My Children, New York: Har-court Brace Jovanovich, 1977.</li> <li>Swinyard, Chester A., M.D., Ph.D., Decision Making and the Defective Newborn, Springfield: Charles C. Thomas, 1978.</li> <li>Swinyard, Chester A., M.D., Ph.D., The Child With Spina Bifida, Chicago: Spina Bifida Association of America, 1977.</li> </ol> Page Number(s) 6 - 8 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Expert 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 What is Spina Bifida? Creator An entity primarily responsible for making the resource Jeannie Gruse https://staging.drfop.org/files/original/16eacc2e24fa11ba24117d1fb85c931c.pdf de0c0a58e9193f24569f1c879ad120b2 https://staging.drfop.org/files/original/606a6c31866c4d006f77d0445e543cae.jpg f4ab710fe6f916f4722e405866dc107d https://staging.drfop.org/files/original/91cd0ddfaca05e2bdc88e8aef7411353.jpg 7a64b2419fe01ec7ad868c5979c7bfa3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_009.pdf Text Any textual data included in the document <h2>Orthotic Philosophies of Treatment</h2> <h5>Wallace Motloch, CO <a style="text-decoration: none;">*</a></h5> In situations when a medical condition places a physical limitation on a growing child, the orthotic treatment and devices are aimed at minimizing that limitation. Through the combined knowledge and skills of the orthotist, medical team, and family, as well as the child, the orthotic program maximizes that child's assets. To illustrate how the various aids and braces work within the orthotic program, one can compare the developmental milestones of a child with normal body to that of a child with spina bifida (<a href="/files/original/606a6c31866c4d006f77d0445e543cae.jpg">Fig. 1</a>). As the developmental need for sitting, crawling, and ambulating is encountered, an orthotic device is introduced to the spina bifida child who cannot accomplish these tasks well. Depending on the availability of funds and clinical resources, the orthotic care may start at infancy with the fabrication of devices for safe handling of the newborn, modifying equipment for play, bathing, and safe transportation. The orthotic involvement continues for the rest of that person's life as various braces for ambulation, support of the spine, contracture management, and general development of a lifestyle are designed and manufactured. <a href="/files/original/606a6c31866c4d006f77d0445e543cae.jpg">Figure 1</a>. Comparison of the developmental milestones of a normal child to a spina bifida child. As the children progress from one developmental milestone to another and their needs change, so must orthotic devices. Often these needs overlap, calling for a "wardrobe" of devices (<a href="/files/original/91cd0ddfaca05e2bdc88e8aef7411353.jpg">Fig. 2</a>). To illustrate this point let's imagine a person developmentally ready to crawl. To accomplish such exploration safely one will best be served by a wheeled device called a Caster Cart. While the Caster Cart is not a brace per se, it provides a vital part of the program by helping in a way that no brace or wheelchair can. It allows the child to move around safely, positions him close to the floor, allows for retrieving playthings from the floor, and it aids in "hand-free" sitting. <a href="/files/original/91cd0ddfaca05e2bdc88e8aef7411353.jpg">Figure 2</a>. Wardrobe of devices for a child who is ready to stand and ambulate (brace and walker). At the same time, the child retains a Caster Cart for exploration and Body Jacket for support of collapsing spine. Even though the Caster Cart has so many advantages, many parents are hesitant at this juncture, primarily because they imagine braces or some other bionic devices as restoring greater normalcy to their children. The orthotist must be very aware of the great pressure that drives the parents. They are desperate to do something! They are anxious to get the child into the best braces. They want to see the child up and ambulating. They want to see what it will be like—and that is the most normal behavior of any person. The orthotist must be compassionate at this point. He must know the dynamics of this situation. This is the most crucial moment in the parent-orthotist relationship; it will set the stage for many future meetings and achievements. Having seen several hundred Spina Bifida children and their parents go through this stage, personally I believe that not one but three devices are in order: a Caster Cart, Standing Brace (It should be pointed out here that the name "Standing Brace" is a misnomer as the device facilitates much more than standing), and Parallel Walker. The reason that this combination works the best is that crawling is very quickly followed by standing and ambulation. Oftentimes these are not demarcated clearly, and as the functions are accomplished, the devices continue to be used in an overlapping fashion—so why not have all three at once and let the child dictate the progress. While the actual design of braces can vary at this stage, as long as the child is upright safely and can stand "hand-free," the purpose is achieved. As the child gets older (two to three years), another crucial bracing decision has to be made. It has to be decided if the child is capable of ambulating with a reciprocal gait (one leg in front of the other) or whether he/she must ambulate by swing-to, swing-thru, or pivoting. It has been my experience that whenever possible the Reciprocal Gait Brace (Dual cable type) should be considered, as it has particular importance for the Spina Bifida person. The Reciprocating Gait Brace (RGB) is a dynamic orthosis unlike any conventional device made. It provides: <ul> <li> Standing Balance and Support: Wearers can have their hands free for activities of function while standing. </li> <li> Automatic Hip Joint Locking: This provides for ease of locking the brace with hands on crutches or walkers. </li> <li> Efficient Ambulation: Compared to conventional orthosis, RGB was tested (distance walked with same increase in heart rate) to be two to three times more efficient. This saves energy for people with muscle weakness, and for people likely to gain weight, it encourages more physical activity. </li> <li> Dynamic Hip Reciprocating: The special hip mechanism couples the hip joint motion so that flexing of one side causes forced extension of the opposite side (a mechanical hip extensor). This function facilitates walking, but in people prone to hip flexion contractures it also stretches the hip contractures with every step. </li> </ul> Around the age of ten another crucial decision comes up: the use of the wheelchair. There are many reasons for this. A few are: lack of physical strength for ambulation, cosmetic appearance and peer pressure, ease of assistance from others and general convenience of getting around. Many people with Spina Bifida find that ambulation in braces becomes quite energy consuming and that in the school setting in particular, it makes the carrying of books inconvenient. Many slowly, but surely, drift to greater use of the wheelchair. They find that their shorter stature in braces doesn't serve them as well as the sitting posture in a wheelchair. Also, it is harder for them to get help from others now that they are bigger and heavier. When need for assistance arises, say to go up ten steps, it is harder to help a brace wearer than a wheelchair rider. In any case, because many people choose a wheelchair in addition to, or instead of, braces, the orthotist stays involved in design and fabrication of special pressure sore prevention aids like contoured seat cushions and Suspension Body Jackets. Unfortunately, for many spinal cord injured teenagers and adults we do not have braces that can compete effectively with the wheelchair's efficiency and convenience. As things are, while there are a fair number of devices to choose from for the under-ten-years-old group, the choice is very limited for the older group. Much more ingenuity and research is needed to develop designs that will prove useful to the latter group. References: <ol> <li>W. Motloch, "Human Needs and Orthotic Goals for Spina Bifida Patients," Canadian Ortho-Pros., Summer 1975.</li> <li>W. Motloch, "Wardrobe Devices," Inter-Clinic Information Bulletin, January 1974.</li> <li>W. Motloch, "Crutchless Standing," Canadian Ortho-Pros., Spring 1973.</li> <li>W. Motloch, "New Items for Spina Bifida Programs," Inter-Clinic Bulletin, July 1970.</li> <li><a href="http://www.oandplibrary.org/al/1971_02_036.asp">W. Motloch, "Parapodium: an Orthotic Device for Neuro-Muscular Disorders," Artificial Limbs, Autumn 1971.</a></li> <li>W. Motloch, "Analysis of Medical Costs Associated with Healing of Pressure Sores in Adolescent Paraplegic," B.S. Thesis, University of San Francisco, February 1978.</li> <li>W. Motloch, "Seating and Positioning for the Physically Impaired," Orthotics and Prosthetics, June 1977.</li> <li>Personal communication with E. Hamilton, S. Walder, C. McLaurin, Dr. N. Carrol, and others from Ontario Crippled Children's Centre.</li> </ol> *Wallace Motloch, CO Wallace Motloch, CO is the Director of the Center for Orthotic Design, Inc. Page Number(s) 9 - 11 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_009/1984_04_009-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_009/1984_04_009-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthotic Philosophies of Treatment Creator An entity primarily responsible for making the resource Wallace Motloch, CO *