5 20 371 https://staging.drfop.org/files/original/f705a88b62579919ebd280734cc87c01.pdf b9eacb74fddcfd81decdd065a6705fdd https://staging.drfop.org/files/original/e05b257845dff7213c7f075b57cf5fcc.jpg bd523911342105f9a2128e78a1aeb6cb https://staging.drfop.org/files/original/11cd3f8a84385221430f3e8c6b68d7a8.jpg b96e00d451e355e664197cf1f6c096b8 https://staging.drfop.org/files/original/81be0b0e594f36536b95cc888ea0798a.jpg 23da1b6dc1872b1b5797b235a956b7c7 https://staging.drfop.org/files/original/3791a0eb792a4d25c7f40b60c75e5b2d.jpg bad29a39e144a9990815beb05f7bbdc6 https://staging.drfop.org/files/original/a2c4d5480f72caa73d1807874cb70fce.jpg 8a15ca8c6b8342bd3cf706868a599486 https://staging.drfop.org/files/original/6f0562d37d37b957ceba489c2e2ca39b.jpg 96e365de47b09be1e0e2dd80223633ac https://staging.drfop.org/files/original/b01cfe724a87500df31cadb5038854e7.jpg bddf845abdebf1a394bf9fd15257f9db https://staging.drfop.org/files/original/3de6676506062bef75f71a38287a7578.jpg 2445d12e95b2289f26c3cbd6f2a18c05 https://staging.drfop.org/files/original/74f77a4af134297887250161d208c62c.jpg 8c549b1b71dbc8c982018a1cee1545fb https://staging.drfop.org/files/original/070812cad4152c89454a35f884e2e3e9.jpg 2a7a6bb1dd1ed4f8098878287bc3d4e8 https://staging.drfop.org/files/original/a2fe1d3281087c6ce407dd3a40dd4c21.jpg f1f8ea956fc5d035040e0eefd468e990 https://staging.drfop.org/files/original/5cab3bf9dca0d59b832e1adb6cb078dd.jpg b7419f891e57061df0c34997b04d0bd5 https://staging.drfop.org/files/original/70128bff2c284b7089ab9d7941dd8170.jpg 3cf6e7ffb74689f5ef7610709e4932dd https://staging.drfop.org/files/original/35d21b8cabb98a340036e5d94c747608.jpg 4372e34ed61e9169c31341fc400b42d2 https://staging.drfop.org/files/original/8e48f7a2f951dd4704f7f69bc1d7c09c.jpg e1364dfabd6d579d4acd84dc43569812 https://staging.drfop.org/files/original/53aa38977adfa885dd4446a080079bea.jpg 047c02beb59db92227b8a507b687614f https://staging.drfop.org/files/original/680e550c3416ad1257bf7172cd07a96b.jpg 0dbe82e84dd46cc9172de94cf4cb754c https://staging.drfop.org/files/original/0018b73701a2a03adb1202951eb9890e.jpg 2bd534a213d889b949b9f5e556cdf482 https://staging.drfop.org/files/original/341143f786b503326091116f2cafa449.jpg af22ca80378e8cdccdf571b5f1d5e0ad DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_065.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 65 - 72 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_065.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_065.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Direct Forming of Below-Elbow Sockets</h2> <h5>Gennaro Labate <a style="text-decoration:none;">*</a><br />Thomas Pirrello <br /></h5> <p>The following equipment and materials are required for this direct-forming procedure:</p> <ul> <li> Polysar<a style="text-decoration:none;">*</a> X-414 tubing</li> <li> Hot plate (thermostatic control optional)</li> <li> Tote pail and cover (height 22 in.; diameter 10 in.)</li> <li> Rubber casting sleeves</li> <li> Silicone spray</li> <li> Manila folders</li> <li> Pressure-sensitive tape</li> <li> Trichloroethylene</li> <li> Heat gun and adapter</li> <li> Cosmetic covers</li> </ul> <p>All the prosthetics information required to fabricate a conventional socket is necessary for forming a socket with Polysar synthetic rubber.</p> <p> 1. A rubber sleeve that will best conform to the stump is selected. (The three sizes which will accommodate most below-el-bow stumps are 3 in. x 6 in. x 14 in., 3 1/2 in. x 6 in. x 14 in., and 4 in. x 6 in. x 14 in.) The rubber sleeve is pulled snugly over the stump, and the proximal end is fastened with Yates clamps to a figure-eight harness. The sleeve is lubricated generously with silicone spray. <b>Fig. 1</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 2. Tubing whose circumference 2 in. from the distal end is closest to <i>but less than</i> the circumference of the stump is selected. (The three tube sizes which accommodate most below-elbow stumps are 4 3/4 in., 5 1/2 <i></i> in. and 6 1/4 in.) The tubing is cut 3 in. longer than the measurement from the lateral epicondyle to the stump end. The inner surface of the tube is cleaned to remove loose particles. <b>Fig. 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 3. The tube is immersed in water heated to approximately 180 deg F. (The tube may float when it is completely soft and ductile.) <b>Fig. 3</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 4. The softened tube is removed from the water and the entire inner surface is lubricated with silicone spray. <b>Fig. 4</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 5. After the tube has cooled to skin tolerance, it is drawn up on the stump to a point where the proximal brim is about 1 in. above the olecranon. <b>Fig. 5</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 6. The tube is encircled at the distal end of the stump with nylon cord, and the cord is gently pulled until the tubing conforms to the end of the stump and is completely sealed. <b>Fig. 6</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 7. The excess tubing is cut off close to the cord. <b>Fig. 7</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 8. The tube is molded on the stump to produce the desired contours. The working time is approximately 5 minutes. <b>Fig. 8</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 9. While the tubing is still soft, a trim line is marked according to the socket plan and the tube is trimmed. The socket is cooled before removing it from the stump: the covered stump is immersed in cold water, and hand and finger pressure are used to maintain the socket contours while it is immersed. <b>Fig. 9</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>10. The socket is removed from the stump and trimmed to its final shape. Large areas requiring reshaping may be resoftened by immersion in hot water. Smaller areas may be softened by use of a heat gun and reshaped on the stump. (When using a heat gun on Polysar X-414, it is advisable to use a conical adapter.)</p> <p> 11. The forearm extension is made over a manila folder formed into a conical tube, incorporating the desired wrist fitting. The length of the tube is equal to the epicon-dyle-to-ulnar-styloid measurement. The tube is adjusted so that the proximal end flares into the socket approximately 3 in. over the distal end. <b>Fig. 10</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 12. A length of Polysar tubing is cut approximately 2 in. longer than the manila tube and immersed in hot water until soft. <b>Fig. 11</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 13. A section of 2-in. stockinet which is twice the length of the Polysar tube is pulled through the softened tube. <b>Fig. 12</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 14. With the stockinet used as a "pull sleeve," the softened tube is pulled down until the proximal edge overlaps the proximal end of the manila tube by 1 in. The tube extension is cooled by immersion of the entire assembly in cold water. <b>Fig. 13</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>15. Realignment reference lines are marked on both the socket and the extension, and the extension, manila tube, and wrist fitting are removed.</p> <p>16. The socket surface covered by the extension is sanded lightly, and the socket and the extension are wiped with trichlo-roethylene.</p> <p> 17. The extension tube is replaced on the socket and realigned according to the reference lines. The proximal 3 in. of the extension are heated until soft. <i>(The socket is not allowed to become soft.)</i> The softened end of the extension is compressed until it adheres evenly to the socket, then the socket and extension are immersed in cold water. <b>Fig. 14</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 18. The epicondyle-to-ulnar-styloid measurement is checked, and the extension is trimmed if necessary. <b>Fig. 15</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 15.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 19. One inch of the distal end of the extension is immersed in hot water until soft. The wrist fitting is inserted into the softened extension and the tube compressed around the wrist fitting with pressure-sensitive tape. The alignment is again checked and adjusted if necessary, and the tube is cooled in cold water. <b>Fig. 16</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 20. The extension and socket are flared by sanding. The wrist fitting is secured with four 3/8-in. #6 self-tapping pan-head sheet-metal screws. <b>Fig. 17</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>21. The proximal socket brim is buffed with a felt wheel and wiped with trichlo-roethylene to produce a smooth surface.</p> <h4> <i>Finishing</i> </h4> <p> Below-elbow prostheses fabricated with synthetic-rubber sockets are best finished with prefabricated flexible cosmetic covers. Although the sockets may also be finished by conventional laminating procedures, laminates tend to reduce the yielding property of Polysar X-414, and therefore are not recommended. Three cosmetic coverings are illustrated: contoured vinyl sleeve, armlet stockinet, and tubular rubber sleeve. <b>Fig. 18</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 18.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The contoured vinyl sleeve (A) is pulled over the arm after softening in hot water. The cover is trimmed approximately 1/4 in. above the proximal socket brim. </p> <p> The armlet stockinet <i>(B)</i> is sewn closed at the unfinished end. A small opening in the sewn end is made to accommodate the threaded stud of the terminal device. The armlet is pulled over the prosthesis. (The proximal end is not cut.) </p> <p>The tubular rubber sleeve (C) must be bonded to the prosthesis, as follows.</p> <p> 1. A length of 3-in. stockinet is used as a "pull sleeve." The stockinet is inserted into a rubber sleeve cut one and one-half times the length of the prosthesis. <b>Fig. 19</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 19.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 2. The stockinet is pulled over the prosthesis until the rubber sleeve extends 1 in. past the proximal socket edge. <b>Fig. 20</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 20.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 3. Approximately half of the rubber sleeve is rolled back, and the stockinet is trimmed. <b>Fig. 21</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 21.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 4. The exposed portion of the socket is coated with rubber cement, and the rubber sleeve is unrolled while the cement is still wet. <b>Fig. 22</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 22.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 5. The cementing procedure is repeated at the proximal end after removal of the remaining stockinet. When the cement is completely dry, the excess rubber sleeve is trimmed. <b>Fig. 23</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 23.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> <i>Hinges and Transmission System</i> </h4> <p>Metal or leather joints are aligned and fastened with Speed rivets. All other components are installed in the conventional manner.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of th ePolymer Corporation Limited.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gennaro Labate </b></td></tr><tr><td class="clsTextSmall">Veterans Administration Prosthetics Center, New York, N.Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Direct Forming of Below-Elbow Sockets Creator An entity primarily responsible for making the resource Gennaro Labate * Thomas Pirrello  https://staging.drfop.org/files/original/785f66484a457dd5ea36486281669c63.pdf 2a13be21d16b3cba581d0f5c39829307 https://staging.drfop.org/files/original/de0295080d2342091ee8d35f8b9eb492.jpg 67f6018770a74ed03cb90a1fdcf80b22 https://staging.drfop.org/files/original/a2e780143e6e8508bc090f38eec6847b.jpg ce791d7bd02f539672bfd6aafc1c7955 https://staging.drfop.org/files/original/01140c6f2bcd0a25691175b8982667e4.jpg e646a27436a751e896353b213a2dacc9 https://staging.drfop.org/files/original/039eec2639e19736a06618dc61593eb5.jpg 8c7aaa7044354c386391909637bb056e https://staging.drfop.org/files/original/2acaa9f6178a16d99894a0ec19c23ef7.jpg 4a7f9f5704a2518e642edd71b92c8c87 https://staging.drfop.org/files/original/fb289d965166e603e52ef903cea429f0.jpg 5c402e4e8983f7fc34a947dfa7335046 https://staging.drfop.org/files/original/d63440c21a0f69b8b5fb63b022e61190.jpg 66831f497f8cdab5da95d86117ef5763 https://staging.drfop.org/files/original/85b340c5dff8d0a0258af2bdad391640.jpg e637b228d06590314f7d668b4f83decf https://staging.drfop.org/files/original/3db34f12dfb1ec30ad911b4f9f24f9b3.jpg 47a226f4750a71f160e119ae48cff694 https://staging.drfop.org/files/original/20eafe5419c83630cf610007cac7a089.jpg 1863122494926efc5d49d2ad8f203365 https://staging.drfop.org/files/original/874cfc1d92441810888b9aa4c0d9f3ae.jpg da650953df53e1189a6777e2c01b1726 https://staging.drfop.org/files/original/7dc88dda4cf9dc97e0c41a5b9d4df0d9.jpg cad29965382e0be70dcc5c64fea49d17 https://staging.drfop.org/files/original/4ad6c948c583a6f956dd404eb175790b.jpg 78415e090cb4b1a74fd776db498158fb https://staging.drfop.org/files/original/41b685212583f4394899d15ff59a4ff5.jpg a6bbba17a745d1a8aed594e0f6dd0292 https://staging.drfop.org/files/original/65118f6ccc79f81819690361de395d17.jpg 9e265f25fc1297f5a01dd3614e1cd25e https://staging.drfop.org/files/original/194efbb8bfd7cd41bd9e251cf5345c21.jpg cf723eb59e370d89b74acefbeb52cb82 https://staging.drfop.org/files/original/df9ae6774a07620814409dcd6667d120.jpg 47ea548a6ed55d80d656723d22946d5f https://staging.drfop.org/files/original/0ca4197cba7b3be9c1adb317f610eeb7.jpg f97971b37ea237eb8c1ce8cbaef544a9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_057.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 57 - 64 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_057.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_057.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Direct Forming of Below-Knee PTB Sockets with a Thermoplastic Material</h2> <h5>Anthony Staros <br />Henry F. Gardner <br /></h5> <p> Prior to forming the socket, a careful evaluation of the stump must be made. The usual prosthetics data must be noted, especially any stump characteristics which would require special considerations for socket comfort. </p> <p> With the patient seated, a lightweight cast sock is applied snugly <b>Fig. 1</b> to maintain tension. The top of the sock is clamped to a strap encircling the patient's hips. The strap is made of two halves of mating Velcro for easy adjustment behind the patient's back, and the two free ends are equipped with Yates clamps, which are placed medially and laterally at the top of the sock. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Application of a lightweight cast sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A strip of 1/4-in. felt, cut to form a tib-ial-crest relief, is positioned from the superior border of the tibial tubercle to <i>and over the end of the stump </i><b>Fig. 2</b>. The portion of the pad over the tubercle is made approximately 1 1/4<i> </i>in. wide, tapering to a 5/8-in. width for the entire length of the tibial crest relief. All edges are carefully skived. If adhesive-backed felt is not available, medical adhesive may be used to attach the pad. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Placement of the relief for the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A second lightweight cast sock is pulled snugly over the tibial relief and fastened in the same manner as the first sock <b>Fig. 3</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Stump with second cast sock applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Using the VAPC knee caliper, the anterior-to-posterior knee measurement at the level of the patellar tendon is taken <b>Fig. 4</b>. The medial-to-lateral dimensions of the epicondyles of the femur are measured in the same manner. These dimensions are useful in determining the accuracy of the socket. The maximum depth of the patellar ledge is determined by the A-P measurement. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Measuring stump dimensions with the VAPC caliper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Socket Forming </h4> <p> A section of Polysar<a style="text-decoration:none;">*</a> X-414 synthetic rubber tubing with a 1/4-in. wall is selected. The diameter of the tubing should be one-third of the mid-stump circumference. The tube length should be approximately one and one-half times the distance measured <i>from the top of the knee to the end of the stump </i><b>Fig. 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Determining the proper length of tubing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A section of Helenca stockinet 36 in. long is used to pull the heated tube over the stump. One end of the stockinet is pulled up on the stump as shown in <b>Fig. 6</b>. The other end is passed through the heated tube. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The stockinet in position over the stump for pulling on heated plastic tubing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The inside surface of the tube is thoroughly cleaned to remove all plastic dust. (When heated, the dust would cohere to the inner walls, causing undesirable irregularities.) </p> <p> The dust-free tube is softened by immersing it in water heated to 180 deg F, or just under the boiling point, for four to six minutes. Because the inner walls of the tube would cohere instantly if permitted to touch when heated, <i>the tube is placed on its end in the water container.</i> </p> <p> To facilitate slipping the tube over the knee, the upper half is enlarged by spreading (hands together, palms out). The end of the stockinet hanging from the stump is pulled through the heated tube. The tube is pushed on the end of the stump and carried up over the stump by a continuous pull on the stockinet <b>Fig. 7</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Pulling the heated tube over the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Twists or folds in the stockinet should be avoided while drawing the stockinet and plastic tube over the stump. </i>The forming pressures which compress the soft thermoplastic produce a slight imprint of the stockinet material on the inner surface of the socket, and any folds or twists in the stockinet will cause undesirable irregularities in the inner socket wall. The top of the stockinet is then clamped in the same manner as the cast socks. </p> <p> The upper socket borders are trimmed with bandage scissors, leaving the posterior borders approximately 1/2<i> </i>in. higher than the required measurement, for later rolling out of the material to form a relief for the hamstrings <b>Fig. 8</b>. The remainder of the socket border is cut transversely above the superior edge of the patella. The lower tube end and the stockinet are trimmed to provide an extension of 3 in. beyond the stump. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Trimming the upper socket borders before molding. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The stump is held relaxed in 5 to 10 degrees of flexion. Starting approximately 1/2<i> </i>in. above the stump end, a snug wrap of 1-in. elastic pressure-sensitive tape is applied over the tube in a continuous anterior-to-medial spiral, with increasing </p> <p> tension approaching the level of the medial tibial flare and continuing over the knee <b>Fig. 9</b>). The tension is controlled best if one steadies the socket while the other wraps half of the circumference. The hands then change functions to wrap the other half of the circumference. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Application of pressure using an elastic pressure-sensitive-tape wrap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The section of soft tubing extending below the stump will tend to sag. This must be prevented by supporting this section until it cools while molding the material. Approximately 10 minutes are required for the material to harden. During this time, the socket is molded to provide freedom over the anterior end of the tibia by massaging the taped surface of the socket to define the tibial crest and medial flares of the tibia <b>Fig. 10</b>. During the molding process, all surface irregularities may be pressed out of the socket. The socket should not be removed from the stump until the thermoplastic is no longer deformable by hand. The tape is removed, and with the knee flexed to at least 90 degrees, the socket is forced from the stump. Later, pressure-sensitive fiberglass or nylon tape may be put on the socket as a circumferential (barrel hoop) reinforcement, usually required only around the proximal brim. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Hand molding to define the medial tibial flare and tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The resulting open-end socket will permit easy attachment of the shank. Once the socket extension has been secured to the shank, the end of the socket chamber is filled with foam, or another type of resilient end pad is provided. </p> <h4> Socket Modifications </h4> <p> To modify the socket, heat is focused with a heat gun fitted with a cone <b>Fig. 11</b>. With one hand placed inside the socket against the surface to be modified, heat is directed to the <i>immediate area from close range </i>until the heat is sensed by the fingers through the socket wall. <i>Large areas should not be heated, nor should heat be directed against the socket for a prolonged period of time, because excessive temperature will cause the plastic to boil and discolor. </i>When molding for a pressure point, one finger should press from inside the socket, and the surrounding areas should be supported on the outside of the socket with the fingers of the other hand. After the molded area has cooled sufficiently to retain its shape, the socket should be chilled with cold water or refrigerated for a short interval to reset the plastic. <i>Caution must be exercised to avoid heating the entire socket. The heat should be concentrated on the one spot until the pressure applied with the fingers inside the socket causes the material to yield.</i> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Heat gun with modified cone for control of heated area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A similar procedure is followed to shape the patellar-tendon ledge. For patients who have previously worn prostheses, the A-P measurements obtained by caliper are used to determine the depth of the ledge. For recent amputees, the patellar-tendon ledge is not molded to the maximum depth in one adjustment. Instead, three or more adjustments should be made at intervals of one month until the required A-P dimension is reached. </p> <p> The proximal posterior socket border is heated and rolled out to form a smooth radius for comfortable knee flexion <b>Fig. 12</b>, the border being maintained at approximately the patellar-ledge level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Rolling out the softened posterior socket wall. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> An adjustable pylon is prepared with a wood socket-attachment block 1 V'2 in. thick and 3 in. in diameter, with a Vi-in. deep circumferential groove at the midpoint of the block. The block is tapered to a slightly smaller diameter around the bottom, then fastened permanently to the pylon with bolts and cement <b>Fig. 13</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. The pylon and socket ready for assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The tube end extending distally from the socket is heated, then fitted over the wood pylon-attachment block, with the groove helping to make a good bond. <i>A 1-in. space between the stump end and the attachment block must be maintained. </i>The tube is taped tightly to the wood block and permitted to cool <b>Fig. 14</b>. Any excess tubing extending below the wood can be trimmed while the plastic is still soft. When hardened, the tube is fastened permanently to the wood block with four screws set at 90-degree angles to one another. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. The heated socket bottom is joined to the pylon with elastic-tape wrap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Suspension </h4> <p> To provide for suspension, the socket can be trimmed at the regular PTB level and a separate cuff used above the knee. Of the several kinds of PTB suspension that can be provided with this socket, suprapatellar-supracondylar suspension is described. </p> <p> The patient is seated in a chair with his knee flexed at approximately 45 degrees, and the stump is covered with two cast socks. The upper socket walls above the level of the upper border of the patella are softened by holding the socket (bottom up) in hot water. When the socket top is heated, the stump is pushed into the socket. The plastic is molded against the thigh over the condyles by wrapping tightly with pressure-sensitive tape and hand molding. </p> <p> After the patient has been fitted and the prosthesis aligned, the bottom of the socket chamber should be foamed to obtain a total-contact fitting. To avoid difficulty in quickly inserting the stump into the socket, the stump is covered with a lightweight sock and a powdered PVA bag. Three 1/8-in. holes are drilled through the lower socket wall at the level at which the stump begins to taper inwardly, away from the socket wall. A foam mixture is prepared and poured into the socket <b>Fig. 15</b>. The patient's stump is inserted into the socket and the patient stands still until the foam has set. The. foam mixture may vary, depending upon the type of stump and condition of the distal tissues. Usually a combination of foam and RTV rubber is used. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Pouring the foam mixture to form the total-contact socket bottom. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Shaping and Finishing</h4> <p> A leg shape can be made from prefabricated sections of semirigid foam, Koroseal Spongex.<a style="text-decoration:none;">*</a> Beginning at the level of the patella, a paper pattern is cut to fit around the socket at this level. The pattern is traced upon one foam section <b>Fig. 16</b>. The foam is carefully sanded to form a hollow for the socket. It is necessary to obtain a tight, gap-free fitting of the foam to the socket; best results are obtained from a slight stretch fit. For this, the foam is heated in an oven at 180 deg F before placement over the socket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Foam blocks prepared for fitting over the pylon and socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To cover the remaining part of the pylon, a foam block is cut to correspond to the measurement between the bottom of the foam surrounding the socket and the top of the foot plus 1/4 in. A hole is made through the length of the block large enough to receive the pylon tube. Since the foam is semirigid, the areas for the alignment coupling and ankle plug of the pylon are cut slightly undersize to permit a snug fit about the pylon <b>Fig. 17</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Foam blocks fitted over the socket and pylon and rough-shaped. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A 1/2-in. hole is bored transversely through the foam block to permit entry of a screwdriver to fasten the tube clamp. The two foam sections are <i>not </i>glued together, in order to facilitate removal for alignment adjustments. Compression of the foam block between the socket base and the foot will prevent any movement of the block. </p> <p> The blocks are shaped with a band saw or knife and sanded with a drum or cone sander. For cosmesis, either a flexible poly-urethane coating over the foam or a stocking cover is recommended <b>Fig. 18</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The prosthesis with a flexible plastic coating over stocking-covered foam. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">B.F. Goodrich Co.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of the Polymer Corporation Limited</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-18.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 Direct Forming of Below-Knee PTB Sockets with a Thermoplastic Material Creator An entity primarily responsible for making the resource Anthony Staros  Henry F. Gardner  https://staging.drfop.org/files/original/3a52a8d4775fa3efd09318a22cf6e7b3.pdf 820ff6a0c1135f0effa1bae156a7f712 https://staging.drfop.org/files/original/a1127c14978be6ddba76a103d184fb20.jpg be7afb490777286577070fbfccb774fc https://staging.drfop.org/files/original/78848ce98a4983ca8bf83352f38fd5eb.jpg 254b27df04281f573e9df2cee9c33abc https://staging.drfop.org/files/original/6825c3c6eea1009afaf91c7abf8227ca.jpg 166a7fea19db92181e6cbf2a89d08b40 https://staging.drfop.org/files/original/aaf817a225ef897343a8c2a894b1cb69.jpg 537a989bf8ed7128316bdca570ab2915 https://staging.drfop.org/files/original/14f06bf8a55bb3dfed87489cacd1e28a.jpg fac89206bdc9aba86a21e615d9c70faf https://staging.drfop.org/files/original/f985278fc90ed029c1cc392206138e17.jpg 228d46ddc1545dc9fe5b34cf26bc0a72 https://staging.drfop.org/files/original/dab6c070737e365ed5aabce3fcf2bde1.jpg 6305700f03605ff97f24df6a08155562 https://staging.drfop.org/files/original/2d289146083105144b69c9c79a98b25a.jpg 5fd23e93a85b7ff731445a12a77fad61 https://staging.drfop.org/files/original/b63a1c7506812aa1f371254f1f53b919.jpg e3d7a7321d595d0fdfa23dd3c162429d https://staging.drfop.org/files/original/6cc643811deadfa2ead2f26357104ceb.jpg 5b94dac9a6d3f5727b81c3abfb6f7875 https://staging.drfop.org/files/original/2e7a46fb0b770171b5189860ba9f368d.jpg e82ff8d146f3473fbc167b759af9a148 https://staging.drfop.org/files/original/23562bc9cb410180cad1610a008e5cc1.jpg ff7b7f3b0ce7d6269d5364de3956538e https://staging.drfop.org/files/original/d92a31d65ae1a659d76f5e29b10d470d.jpg 25398ed94e7c48ac3b146aa62c192d24 https://staging.drfop.org/files/original/57a0d24e094a84654d83bd92944f70dc.jpg 3262f1eacd42160e24ca088febd063c8 https://staging.drfop.org/files/original/f40eee279da314366168879def856866.jpg 842e6fcd496ecdbae607d0554dea8d78 https://staging.drfop.org/files/original/3a999ee1d480ce73e8f934dd4e2117a2.jpg 2e3f15ea4f5f19befc8183e0723376d8 https://staging.drfop.org/files/original/e0315e1fb3761348b30e9c2a1a2d86d8.jpg 3cc0d759597ea5812be8ae99b3c204fb https://staging.drfop.org/files/original/8c2dc6b9dac90d6aa61cae8c1791afd5.jpg 56951aad21e6f648183614a200b26b17 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_031.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 31 - 42 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_031.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Dynamic Alignment of Artificial Legs with the Adjustable Coupling</h2> <h5>Anthony Staros, M.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p> Since World War II one of the most significant advances in limb prosthetics has been the introduction of rational principles for fitting and aligning artificial legs.<a></a> The University of California (Berkeley-San Francisco), sponsored by the Veterans Administration, has been primarily responsible for the steady improvement in methods and devices used by prosthetists in artificial-leg construction. </p> <p> To assist the prosthetist in carrying out these principles, a number of mechanical aids or tools were devised. The two adjustable legs-one for above-knee cases (<b>Fig. 1</b>), the other for cases below the knee (<b>Fig. 2</b>) and an alignment duplication jig (<b>Fig. 3</b>) were developed by the University of California, and are now recognized as important tools of the prosthetist.<a></a> And dynamic alignment of artificial legs is a standard part of the curriculum of prosthetics schools<a></a> and standard operating procedure in most limbshops. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. An above-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 2. A below-knee adjustable leg used in current practice. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alignment duplication jig. A, Adjustable leg mounted in jig. B, Adjustable leg has been removed and wooden set-up substituted. Prosthetist is sawing shank to proper length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> But there have been problems. For one, the limbshop must have a minimum of two adjustable legs for adult cases, and two smaller ones for child cases. A shop of any size requires multiple quantities because frequently a given unit must remain attached to a socket for a particular amputee for an extended period of time. And to make best use of the adjustable legs an alignment transfer jig is needed. </p> <p> Other limitations in the above-knee adjustable leg appeared when knee units or knee-shank-foot units with fairly complex functions were introduced. Use of the UC adjustable AK leg, with its single-axis, constant friction joint for achieving alignment which is to be transferred to a permanent leg having a somewhat different type of function, is a questionable procedure; i.e., alignment suitable for a constant friction unit may not make proper use of the functions provided by more sophisticated devices. Some prosthetists have learned to accommodate for the required deviations by rules of thumb, but essential are some method and some tool for dynamic alignment to be made directly on the knee or knee-shank-foot mechanism to be used in the final prosthesis. </p> <p> Ideally, the device should be of simple design and useful for both above-knee and below-knee cases. For the above-knee case, such a device should be inserted between the socket and permanent prosthetic knee for "functional" alignment. </p> <p> If the unit were simple enough, it would be expected that more generalized use of alignment tools might result, and that facilities in other countries, where it is difficult to procure adjustable legs, could enjoy the advantages of dynamic alignment. Moreover, the alignment-transfer process needed scrutiny to see if simplifications in the equipment necessary might result. </p> <p> For these reasons, the VA Prosthetics Center developed the Adjustable Coupling, sometimes termed the "Staros-Gardner Coupling." </p> <h4> Description of the Adjustable Coupling </h4> <p> The adjustable coupling (<b>Fig. 4</b>) consists essentially of two plate assemblies held together by a central toggle pin. Mounted to a middle or intermediate plate but part of one plate assembly are four screw subassemblies, spaced 90 deg. apart, which contain independently adjustable, knurled screws used to "lock" the entire coupling as well as to provide adjustment for adduction-abduction and flexion-extension. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The adjustable coupling assembled. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In <b>Fig. 5</b> are illustrated the major assemblies of the coupling. The single-flange part of the toggle and the top plate constitute the top assembly. The bottom assembly contains the "box" part of the toggle, the bottom plate, the intermediate plate, the four tilt-screw subassemblies, and the toggle pin. The bottom and intermediate plates both contain "A" and "P" marks to indicate the anterior and posterior sides, respectively. The two assemblies contain countersunk holes for screws used for attachment to the prosthesis. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Major assemblies and parts of the adjustable coupling. The toggle pin is permanently located in the semi circular channel just above the AA marks on the intermediate plate.<a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The top assembly, primarily offering medio-lateral and tilt adjustability, contains a 1-1/4 in., 1/8 in. increment scale for gauging medio-lateral adjustments (with an index on the single-flange toggle which is free to slide with respect to the top plate). A tilt scale<a style="text-decoration:none;">*</a> is provided by markings on the threaded bushings of the four tilt-screw subassemblies. The indexes for tilt scaling are the lower surfaces of the knurled screws. Scale sensitivity for tilt adjustment is 2 deg. </p> <p> The bottom assembly provides rotation about the vertical axis and anteroposterior adjustability because the intermediate plate (and toggle "box") is free to move with respect to the bottom plate. On the anterior surface of the bottom plate is the 20-deg. (2-deg. increment) rotation scale. The index is located on the intermediate plate. The anteroposterior adjustment scale consists of a series of arcs, 1/8 in. apart for 1-3/4 in., etched on the top surface of the bottom plate. The index for this scale is simply the outer contour of the intermediate plate. </p> <p> The coupling, made primarily from an aluminum alloy (except for the toggle assembly which is steel), weighs 12 oz., is 3-3/4 in. in diameter, and is 1-1/8 in. thick when the plates are parallel. Ranges of adjustment are as follows: </p> <ol> <li><i>Mediolateral: </i>Total Range-1-1/4 in. <ul> <li>Increment of Scale Markings-1/8<i> </i>in. </li> </ul></li><li><i>Anteroposterior: </i>Total Range-1-3/4 in. <ul> <li>Increment of Scale Markings-1/8 in.</li> </ul></li><li><i>Tilt: </i>Total Range-10 deg. <ul> <li>Increment of Scale Markings-2 deg.</li> </ul></li><li><i>Rotation: </i>Total Range-20 deg. <ul> <li>Increment of Scale Markings-2 deg.</li> </ul></li></ol> <p> The coupling is disassembled by first lowering each of the four tilt screws two increments on the tilt scale. This operation loosens the entire assembly because it is held together as a result of the forces produced by tightening the force screws, and the toggle pin can thus be disengaged from the toggle box and flange. The top assembly and bottom assembly can then be separated. </p> <p> Installation of the coupling into a prosthesis is made with the coupling so separated. </p> <h4> Installation of the Coupling for Dynamic Alignment<a></a> </h4> <p> (<b>Fig. 6</b> and <b>Fig. 7</b>) show the coupling in position for dynamic-alignment trials. When installed, the coupling should be located as close as possible to the distal end of the stump. A piece of material may have to be added to accommodate the wood screws without affecting the socket sealing plate itself. By so locating the coupling, small tilt adjustments on the coupling will produce major changes in the geometrical relationship of stump to prosthetic components distal to the coupling. When the "bench" or static alignment is reasonably close, the 10 deg. range of tilt adjustment is more than adequate. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The coupling installed in an above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The coupling installed in a below-knee prosthesis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the socket is constructed and the components approximately dimensioned<a style="text-decoration:none;">*</a> lengthwise, the top assembly of the coupling is attached to the bottom of the socket using as many wood screws as possible (<b>Fig. 8</b>). The bottom assembly then is attached to the top assembly by placing the single-flange part of the toggle within the "box" part and pushing the toggle pin through the holes in both toggle parts. One must make certain that the "A" marks (or "P" marks) are located properly with respect to the socket. The coupling is then set with all adjustments on "neutral" so that top plate and bottom plate are parallel and coaxial, care being taken to ensure that the intermediate plate is not rotated with respect to the bottom plate.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Attaching the top assembly of the coupling to the bottom surface of the above-knee socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The socket with the coupling attached is then temporarily placed on the above-knee setup (knee-shank-foot) or on the below-knee setup (shank-foot). A height check<a style="text-decoration:none;">*</a> is made with the amputee standing on the prosthesis. </p> <p> Since the coupling has not been fully assembled into the prosthesis, the prosthetist must, of course, assist the amputee in maintaining stability. After the height check has been made, the section of the prosthesis below the coupling (on the knee block or shank) can be sanded to obtain the correct height. </p> <p> One must consider the desired static or bench alignment before fully attaching the bottom plate assembly to the prosthesis. A recently published chart<a></a> shows recommended guides for "bench" alignment when the SACH foot is used. In any case, care should be exercised in locating the bottom assembly to assure that the ranges of adjustment available in the neutrally set coupling will not be exhausted during dynamic alignment. </p> <p> When the bottom plate is being installed, the countersunk clearance holes are made accessible by shifting the intermediate plate with respect to the bottom plate (<b>Fig. 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Attaching the bottom assembly of the coup ling to the top surface of the knee block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Dynamic alignment can begin when the coupling is reassembled and "locked" in the neutral position. This procedure should ordinarily be carried out in the following fixed sequence, making the linear adjustments first and the lilt adjustments second: </p> <ol> <li>With the amputee seated, loosen only the two front tilt screws and make the anteroposterior adjustment. Tighten the two front screws.</li><li>With the amputee seated, loosen only the two front till screws and make the mediolateral adjustment. Tighten the two front screws.</li><li>With the amputee standing, provide tilt adjustment by turning down one of the two tilt screws on the side to be depressed (The screw should be turned down only as far as needed for the angular adjustment desired.) Then tighten the till screw diagonally opposite to establish the angular adjustment desired. Next loosen (the same amount) the second screw on the side to be depressed and tighten the screw diagonalh" opposite to complete the angular adjustment and "lock" the coupling.</li><li>rotation may be established or reestablished before the screws are completely tightened in any of the above three adjustments. The rotation scale reading may be recorded before making any adjustment so that the position of rotation may be readily restored.</li></ol> <h4> Alignment Transfer </h4> <p> No special jig is required for alignment transfer with the coupling. Actually, alignment is not "transferred" but rather "maintained" while the coupling is replaced with a permanent material. </p> <p> Around the periphery of the bottom plate of the coupling, there are ten radial holes located 36 deg. apart that serve as centers for a special compass which is used for scribing reference marks on the socket after dynamic alignment has been completed. The alignment compass is inserted in each of the holes in the periphery of the bottom plate, and small arcs are drawn or scribed on the socket base (<b>Fig. 10</b>). The <i>tops </i>of these arcs are then connected bv a circumferential line which will be exactly 2 in. above the bottom surface of the bottom plate and parallel to it. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 10. Use of the special compass for an alignment-transfer reference. The vertical reference lines will be used to reestablish anteroposterior, mediolateral. and rotation positions. The horizontal line tangent to the tops of the compass arcs will reestablish tilt. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At least four vertical reference lines (90 deg. apart) are made on the socket and continued onto the distal component (knee block or shank). </p> <p> The toggle pin of the coupling is removed and the top and bottom plate assemblies are detached from the socket and from the knee block (or shank). </p> <p> A saw cut is then made in the socket base<a style="text-decoration:none;">*</a> <i> just below </i>the horizontal circumferential line (<b>Fig. 11</b>) and the socket base is sanded to the line (<b>Fig. 12</b>). A 2-inch-thick wood or foam block (with parallel top and bottom surfaces) is then placed between the socket and the knee block (or shank). The wood or foam block is then firmly attached (with cement, resin, and/or other fastening media) to both socket and knee block (or shank), care being taken to restore the coincidence of the vertical reference lines on the assembled components (<b>Fig. 13</b>). Although not necessary, an apparatus for holding the parts together during cement or resin cure can be used. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Using the band-saw to cut the socket immediately below the horizontal-circumferential reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Sanding of the socket to the horizontal-circumferential reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Replacement of the coupling with a 2-in. wood block. Coincidence of the vertical reference lines must be restored in the alignment-transfer process. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> If one wishes, the standard alignment transfer jig may be used instead. Following standard procedures, the prosthesis with the coupling may be fixed in the jig and then the coupling removed. Saw cuts through the socket base and knee block (or shank) and substitution of an appropriately sized block of wood will be needed. In the above-knee limb transfer, one saw cut in the socket base will be sufficient if the prosthesis is mounted in the jig with the bottom plate of the coupling perfectly perpendicular to the long axis of the jig. </p> <h4> Experience with the Coupling </h4> <p> The coupling, although primarily designed as a simple device for alignment of "permanent" lower-extremity prostheses, can also be used for temporary, or interim, prostheses. </p> <p> The coupling has been in routine use in the Limb and Brace Section of the VA Prosthetics Center since March 1961. The numbers of permanent prostheses aligned with the coupling in the 22-month period ending December 31, 1962, were as follows: </p> <table> <tbody><tr> <td>Hip_disarticulation............</td> <td>13</td> </tr> <tr> <td>Above-knee....................</td> <td>130</td> </tr> <tr> <td>Knee-bearing...................</td> <td>16</td> </tr> <tr> <td>"Bent" Knee.....................</td> <td>3</td> </tr> <tr> <td>Below-knee....................</td> <td>192</td> </tr> </tbody></table> <p> In addition, 34 above-knee and 22 below-knee sockets were replaced on existing prostheses by use of the coupling. </p> <p> Experience indicates some economic benefits in use of the adjustable coupling. Starting at the same point in an above-knee prosthesis fabrication (with the socket roughly fitted), the adjustable leg-transfer jig procedure takes, on the average, slightly over 1/2 hr. more than the coupling-compass procedure. The end point for this time measure, in both procedures, is completion of alignment transfer with the prescribed prosthetic components assembled. </p> <p> A more significant advantage of the coupling accrues from its use in aligning above-knee prostheses when special knee or knee-ankle mechanisms have been prescribed. A prosthesis system with functional features providing more than just a mechanical-friction control at the knee may require some deviation from that alignment which might be used with only mechanical friction. Even an extension bias strap will affect the alignment to be used. Thus, for such devices as the Bock Safety Knee, the Hydra-Cadence (with a relatively free plantar-flexion control), the Mauch hydraulic devices, polycentric linkages, and others, it is well to align the prosthesis with the prescribed special-function system installed. The coupling is designed primarily for dynamic alignment of such systems. </p> <p> Added to the economic advantage of one device for both below-knee and above-knee use is the simple and inexpensive process for alignment transfer. For a new shop, this means that investment in an expensive jig is not mandatory. Also, because of the comparatively low cost of the coupling itself, many more alignment devices can be available in the shop. Thus, shifting alignment apparatus already installed in a setup awaiting an amputee trial may not need to be as frequent as formerly. </p> <p> The coupling also facilitates the alignment of replacement sockets. Fitting problems often require the fabrication of a completely new socket before the remaining parts of the prosthesis need replacement. The new socket and coupling can be installed on the "old" prosthesis for dynamic alignment and replacement-socket fitting. This process is more expeditious than one in which the adjustable leg is used and then transfer is made to the "old" components. Also, proper fairing of new socket to "old" components can be assured by the coupling method of realignment because fairing problems can be readily observed and immediately corrected. When the adjustable leg is used, fairing problems can be noted only at the time of transfer. Major corrective procedures may then be necessary. </p> <p> Many foreign practitioners have read and appreciated the various United States' documents which have emphasized the importance of dynamic alignment. But also, many have felt frustrated for, even though they have realized the value of dynamic-alignment apparatus, economic or technical handicaps prevented them from enjoying the use of the devices the practitioners in the United States had readily available. The coupling, therefore, because of its simplicity, can make a significant contribution to the benefit of the disabled all over the world, particularly in developing areas. </p> <p> The coupling was introduced into Yugoslavia in 1961.<a></a> At about the same time, Denmark became interested in its use. E. Lyquist of the Orthopaedic Hospital, Copenhagen, has published a report on the coupling<a style="text-decoration:none;">*</a> and on the apparatus he designed for clamping the prosthesis on a band-saw bed for alignment transfer<a></a>. See (<b>Fig. 14</b>). Dr. B. Zotovic of Belgrade has kindly offered the photograph (<b>Fig. 15</b>) of a prosthesis with the coupling now in use in Yugoslavia. In 1962, the coupling was introduced into Argentina. Still more applications to foreign use are anticipated. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Special band-saw jig used by Danes during alignment transfer. This jig holds components of the prosthesis in a fixed position to allow parallel band-saw cuts on both sides of the coupling. Subsequent clamping after cementing of wood block to replace coupling is also facilitated by this device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A Yugoslav above-knee prosthesis incorporating the adjustable coupling tor dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Many clinicians have realized the importance of temporary or interim prostheses<a></a> for preliminary trials by an amputee. When temporary limbs which have alignment adjustability are used, dynamic stump conditioning and, especially for geriatric cases, evaluation of an amputee's ability to cope with a prosthesis are possible before a final prosthesis is ordered. Of utmost importance in temporary limb use is that prosthesis <i>"function</i>not be seriously compromised".<a></a> A well-fitted, soundly designed socket must be used, and all parts should be continually maintained in proper alignment. Straps provide additional reinforcement of socket to coupling assembly- mostly for horizontally directed loads. For plaster sockets, they are especially helpful since they can be contained within an outer, reinforcing plaster wrap.</p> <p> There are now available several devices which might be used for temporary prostheses.<a></a> Among these is the coupling. (<b>Fig. 16</b>) illustrates a temporary or interim above-knee. prosthesis incorporating the coupling and making possible the use of the type of knee (and function) anticipated for a permanent prosthesis. Now, not only fit and alignment can be '"tuned" to each other, but both can be "tuned" to function. And, if necessary, function can possibly be altered by a rather rapid change from one knee-shank mechanism to another. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. The adjustable couplingused with a plaster -of-Paris above-knee temporary sockel and an unfinished knee shank. The three straps are eaeh 1/8 in by 3/4 in. low-carbon steel. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> (<b>Fig. 17</b>) shows the coupling used in a below-knee temporary, or interim, prosthesis. For this level of amputation, the practitioner has the choice of the coupling or the Northwestern Adjustable Below-Knee Pylon shown in (<b>Fig. 18</b>). This apparatus also has sufficient alignment adjustability available for most below-knee applications in both temporary and permanent prostheses. When attached to a "permanent" (plastic or wood) socket, its advantage is that it can remain in the prosthesis after the dynamic-alignment process is complete. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig, 17. The adjustable coupling used with a plaster-of-Pa.ris below-knee temporary socket and unfinished shank. The three straps have the same cross-section as those used with the above-knee socket. The position of the carbon steel straps in both the above-knee and below-knee sockets should be reinforced with an extra plaster-of-Paris bandage wrap, as illustrated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. A temporary or interim prosthesis with the Northwestern adjustable below-knee pylon, plaster-of-Paris patellar-tendon-bearing socket and SACH foot, The three straps are similar to those of the previous two illustrations. An adaptor plate must be provided to iittach the straps to the pylon. In addition to the alignment adjustability available in the pylon, the position of the socket can still be altered if necessary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Further Development </h4> <p> The Northwestern Adjustable Below-Knee Pylon demonstrates a design principle long sought in alignment apparatus. With it, adjustments needed for dynamic alignment can be made as usual during the early stages of prosthesis fabrication, but the adjustable apparatus is now made a part of the limb obviating a transfer process but sometimes causing a slight increase in limb weight. At a later date, if the cosmetic-shank design allows it, readjustment of alignment can be made without a complete alteration of the prosthesis. Use of a relatively flexible cosmetic cover will probably be best for this purpose; if a plastic-covered foam shank is used, only destruction of the shank before realignment and a foam replacement and plastic finishing after realignment will be required. </p> <p> Most desirable would be one apparatus, perhaps coupling-like, which could be used in above-knee and below-knee prostheses alike. The present adjustable coupling is both too heavy and too expensive for this purpose. A. B. Wilson, Jr.<a style="text-decoration:none;">*</a> and Victor T. Riblett<a style="text-decoration:none;">*</a> have designed a simple and inexpensive plastic, tapered-disc device which might remain in the prosthesis after the primary alignment trials (<b>Fig. 19</b>). At present the device usually must be partly trimmed during the shaping of the limb for cosmetic finishing. Therefore, it could probably not be used at a later date for realignment purposes. But still this device will obviate transfer after initial alignment. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Schematic drawing of the "Wilson-Riblett wedge," as applied to the VAPC coupling. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In eliminating only the primary-transfer process, a so-called "leave-in" alignment device must be priced at a level which would offer some gain to the prosthetist-user. If, at least with the regular coupling, alignment transfer involves an investment of approximately $5.00 in labor and materials by the limbshop, then the <i>one-time, </i>"leave-in" alignment device should cost somewhat less. But even so, possible saving per prosthesis or additional profit is of a very low order of magnitude. </p> <p> Needed is a device (and prosthesis design) which would allow realignment at a later date without major reconstruction of the prosthesis. Economic benefits would accrue to prosthetist and amputee alike; at least some of the major cost-saving in the realignment process can be passed along to the customer. Perhaps many prostheses now condemned for alignment reasons would not need to be. </p> <p> But most of all, such a device would offer convenience, allowing almost immediate accommodation to an amputee's needs. Instead of major delays in receiving a new alignment in a new or grossly altered older prosthesis, rather prompt prosthetist attention can be focused on an alignment problem in the existing limb. The prosthetist, if uncertain of an amputee's over-all fitting problem, can start with realignment of the existing prosthesis in his progressive analysis of the situation. He might be able to overcome what may seem to be socket-fit difficulties without major changes there. But, in any case, he would have readily available the mechanism for study of the problem and the problem's dependency on alignment. </p> <p> Prosthesis design must of course be changed to accommodate the permanent installation of such a unit. A below-knee shank should preferably be a pylon-cosmetic-cover type, somewhat similar to the Northwestern device. Preferably, the lower part of the above-knee limb thigh (where this device would be placed) should have an easily removable cosmetic cover. Perhaps a simple plastic finish over foam forced into the spaces around a lightweight, inexpensive coupling would be adequate. The foam would need to be cut away (or possibly dissolved by appropriate chemical means) when realignment was necessary. But even with present plastic-laminate finishing methods, realignment would involve only destruction of the laminate and then refinishing. </p> <p><b>References:</b></p> <ol> <li>Anderson, Miles H., John J. Bray, and Charles A. Hennessy,<i> Prosthetic principles, above-knee amputations (edited by Raymond E. Sollars)</i>, Charles C Thomas, Springfield, Illinois, 1960. See especially pp. 179-241. </li> <li>Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, <i>The locomotor mechanism of the amputee</i>, Chapter 16 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954. </li> <li>Lyquist, Erik, <i>Jusieiingsapparat type VAPC oj overforingsapparat type OHK.14.01</i>, Publikation NR 1/62, Ortopaedisk Hospital, Kobenhavn. </li> <li>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954, p. 20. </li> <li>Radcliffe, Charles W., <i>Functional considerations in the fitting of above-knee prostheses</i>, Artificial Limbs, January 1955, p. 35. </li> <li>Radcliffe, Charles W., Norman C. Johnson, and James Foort, <i>Some experience with prosthetic problems of above-knee amputees</i>, Artificial Limbs, Spring 1957, p. 41. </li> <li>Staros, Anthony, and Henry Gardner, <i>Report on orthotics-prosthetics research developments in Yugoslavia</i>, Department of Health, Education, and Welfare, 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Suggestions for fitting and aligning the SACH foot</i>, a chart, May 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Temporary prostheses for lower-extremity amputees</i>, Technical Report 1, September 1, 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Use of the alignment coupling</i>, a chart, July 1962. </li> <li>Wagner, Edmond M., <i>Contributions of the lower-extremity prosthetics program</i>, Artificial Limbs, May 1954, p. 8. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Supervisor, Mechanical Development Branch, Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Forest Glen Section, Washington 12, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Technical Director, CPRD, NAS-NRC, 2101 Constitution Ave., Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Lyquist, Erik, Jusieiingsapparat type VAPC oj overforingsapparat type OHK.14.01, Publikation NR 1/62, Ortopaedisk Hospital, Kobenhavn. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Lyquist (in November 1962) reported that the coupling was being used in all patellar-tendon-bearing fittings at the Orthopaedic Hospital. Some above-knee use was also reported.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry Gardner, Report on orthotics-prosthetics research developments in Yugoslavia, Department of Health, Education, and Welfare, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Normally, if there is enough material here for the wood screws to attach the coupling, there will be enough material for this saw cut and the subsequent sanding without disturbing the socket itself.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Suggestions for fitting and aligning the SACH foot, a chart, May 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall"> With especially long above-knee stumps, the knee center must be dropped during alignment trials because of the thickness of the coupling. Later, during transfer, true or near-true knee-center height can be restored.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The over-all length of socket, knee unit, shank piece, and foot, plus 1-1/8 in. for the coupling, should be slightly larger than the amputees dimensional requirements. Later sanding after a height check will produce accurate longitudinal dimensioning.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">All scales have neutral positions highlighted. The neutral positions on the tilt scales are most important in establishing the middle position of tilt, when top and bottom plates are parallel, or for disassembly, when it is important to unlock the coupling by having all four tilt screws down at least two increments below neutral.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, Miles H., John J. Bray, and Charles A. Hennessy, Prosthetic principles, above-knee amputations (edited by Raymond E. Sollars), Charles C Thomas, Springfield, Illinois, 1960. See especially pp. 179-241. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954, p. 20. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomotor mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954, p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Anthony Staros, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Chief, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York 1, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-034.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-035.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-036.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-037.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-038.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-039.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-039b.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-041.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-042.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-043.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-044.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-045.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-046.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-047.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-048.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-048b.jpg Figure 18 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-050.jpg Figure 19 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-051.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 Dynamic Alignment of Artificial Legs with the Adjustable Coupling Creator An entity primarily responsible for making the resource Anthony Staros, M.S.M.E. * https://staging.drfop.org/files/original/4ebe6c9358e369d2dfcc780525f71744.pdf 01ca7a3bb92c5f91b306060769848ed9 https://staging.drfop.org/files/original/fd2a976afd43f432a91856fbb3542adb.jpg 4cd388f1bb2e5bb5c7d6e8658721feb3 https://staging.drfop.org/files/original/5ea20b480864b5662268ba574fb4df90.jpg 404b82d99bc176c0c3b47905d236e7ef https://staging.drfop.org/files/original/2c56957b9735b01a9f5c9fe75689c927.jpg 57e264451217b8c83f7667a500f4caca https://staging.drfop.org/files/original/0939c6a9623e986d55b567dbe6f9704f.jpg 3da4ca037b4b925d204360e54d41830b https://staging.drfop.org/files/original/83f69a234f7756caf1d51f0b94e4ce93.jpg efc5c9cd7ee1708de022357d15829c4a https://staging.drfop.org/files/original/7b3ddab93a637e18d8e2ceb0c867ea1a.jpg d263fb414ce5d3e085085e28830834eb https://staging.drfop.org/files/original/135a37db3f3673e23afdb5ba5411f6b0.jpg 34b6fbf004c0a0ea762ecccc0a6e38fb https://staging.drfop.org/files/original/38ea4d432e4466c58292d70162ecd0a2.jpg 8150ce6a83ac114ca162be9ae6615263 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_049.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 49 - 58 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_049.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_049.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Dynamic Structure of the Human Foot</h2> <h5>Herbert Elftman <a style="text-decoration:none;">*</a><br /></h5> <p>The foot is one of the most dynamic structures in the human body. The lively interplay of forces which makes its function possible is easily forgotten and it is too often treated like the graven image of a static structure. The success of modern therapeutic measures in solving other problems has owed much to close cooperation between Nature working from within and assistive devices from without. The forces within the foot can be powerful allies in such a partnership.</p> <p>The human foot acts in concert with the rest of the body during standing and movement. It provides man with his most effective physical contact with the environment and is especially responsible for successful regulation of initial and final contact of the body with the ground. The foot must also provide adjustable support during the characteristic human occupations of manipulating the environment or of simply standing in line.</p> <p>Human bipedality was made possible by the redesign of an ancestral foot with five long toes used for the grasping of the limbs of trees. We still testify to our heritage by having a big toe larger than the rest but no longer opposable. The heel bone was brought down into contact with the ground to provide additional area of support. Each of these changes traded an old advantage for a new one and the barter is still going on.</p> <h3>The Foot in Motion</h3> <p>Walking is more characteristic of human movement than running, since man has substituted cunning in the management of external devices for fast movement of body parts when speed is desired. The foot must constantly adjust to the varying loads imposed upon it. Particularly important are the stresses it must withstand at the initiation of contact with the ground and again at its termination.</p> <h4>Initiation Of Contact</h4> <p>The heel is the first part of the foot to touch the ground in walking. It is consequently entrusted with the delicate mission of gradually bringing the foot to rest on the ground. In running this can be done without the help of the heel since the limb is already in the midst of its backward swing with respect to the body and the ball of the foot can touch the ground at zero velocity.</p> <p>In walking, the advanced leg has barely started its backward swing with respect to the body when the heel touches the ground. The initial velocity of the ankle after contact is only slightly less than that of the hip joint, making heel-roll imperative. As the ankle approaches zero velocity at ball contact, the forward velocity of the hip joint is preserved by ankle and knee flexion (<b>Fig. 1</b>). Failure to do this properly is one of the most common deficiencies of assistive devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Forces acting on the foot during two important phases of its activity: (1) completion of heel roll; (2) initiation of rolling off on the hall. From Elftman, 1967. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The normal human heel is specialized for the part it plays in walking. Resilience is supplied by the construction of the connective tissue under the heel. The collagenous fibers are arranged so as to produce cylindrical compartments filled by more fluid tissues. Since the fluid changes volume only slightly in compression, pressure is accommodated by elastic deformation of the surrounding connective tissue. While this elastic deformation is taking place the foot rolls forward on the heel. The character of this movement is determined by the contour of the calcaneous combined with the shape which the heel-pad assumes under pressure. Artificial heels can be of assistance if properly shaped, usually achieved when wear erases original design.</p> <h4>Termination Of Contact</h4> <p>Although the foot moves only slightly in the interval between ball contact and heel rise, it is subjected to constantly changing stresses. As the body moves forward over the ankle until the knee becomes almost straight, tension is built up in the calf muscles in preparation for the critical events which terminate ball and toe contact. In this phase of walking the transformation of the ape foot into a human foot shows its functional worth. With grasping no longer the chief function of the toes, they have been shortened and the connective tissue pad beneath the ball has become stronger. The great toe has lost its opposability and is permanently aligned parallel to the others. This relieves the peroneus longus muscle of its ancestral responsibility of adducting the hallux and enhances the aid which it gives to the tibialis posterior in resisting splaying of the foot. The first metatarsal and its attendant phalanges retain the size which they had attained in the ape. This led to the accentuated use of this toe during push-off and the important role which the flexor hallucis longus plays in terminal contact with the ground.</p> <p>Rolling over the ball of the foot has a function similar to that of the heel but acting in reverse. It must control the gradual acceleration of the ankle so that the lower limb as a whole is moving forward with body speed close to the time at which the advanced heel makes contact and double support begins. Here again knee flexion adjusts the relative velocities of the limb segments and allows the calf muscles to push off the limb as it begins its forward swing.</p> <h4>Control Of Foot Position By Hip And Knee</h4> <p>Primary control of foot position is exercised at the hip joint with assistance from the knee when it is flexed. After the primary position of the foot is determined by these distant factors, fine control is added by joints of ankle and foot. The forces and moments which act on the foot are largely determined by the disposition and accelerations of other parts of the body. The importance of knee and hip joints in controlling the spatial relationships of the foot is emphasized frequently by unwelcome responses in these joints to abnormal stresses in the foot.</p> <h3>Fundamental Architecture of the Foot</h3> <p>The foot consists of 26 bones controlled by 42 muscles and is held together by an almost unbelievable number of ligaments. Fortunately, in the normal performance of its major functions, many of these parts co-operate so closely that an initial workable concept of the foot can be based on very few units. The talus is the uppermost of these. When it is removed, the subtalar part of the foot reveals two major divisions: the calcaneus and, articulating with it by the calcaneocuboid joint, a semirigid constellation of bones terminating in the ball of the foot. This leaves the toes jutting out, to become of importance in activities which require forward extension of the base of support beyond the ball.</p> <h4>The Ankle-Joint Complex</h4> <p>The talus is a bony meniscus which allows the movements of the foot with respect to the shank to be divided between a pair of articulations: the subtalar below and the ankle joint above. Since the same external forces act on both joints, the normal body is interested in their combined movement but the clinician is frequently faced with the results of differential insult.</p> <p>In the ankle joint, normal pressure is transmitted from the tibia to the trochlear surface of the talus and lateral bending moments are resisted, within limits, by the malleoli and ligaments. When the joint is compressed, as in weight bearing, the instant axis is determined by the curvatures of the surfaces in contact at the moment. The classical concept of an invariant axis passing horizontally through the lateral malleolus to emerge just below the medial malleolus has been revised in recent years. Barnett and Napier (1952) have described the difference in curvature between the parts of the talus used as movement progresses. Close and Inman (1952) have emphasized a component of vertical rotation conforming to the curved lateral surface of the talus. Both of these factors are sufficiently variable to require assessment in each individual.</p> <p>Even more variable is the orientation of the axis of the ankle joint with respect to the foot and to the transverse axis of the knee. The situation in any individual can be estimated by observing the position of the malleoli; the results of such measurements recorded by Elftman (1945) are shown in <b>Fig. 2</b>. It is obvious that the orientation of the ankle joint determines the plane in which dorsi- and plantar flexion occur and this influences the amount of movement required in the subtalar joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Range of variation in the orientation of the axis of the ankle joint. Two-thirds of the individuals measured were within the limits shown here. From Elftman, 1945. ties. Indispensable for our ancestors in tree climbing, it is still our chief accommodation to rough terrain. Its large component of vertical rotation gives us the possibility of transverse rotation at the ankle under gravitational control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The subtalar joint is guided in its movement, when it is under compression, by the areas of contact between the calcaneus and the lower surface of the talus. These surfaces are beautifully sculptured to form parts of a helical or screw-shaped surface. The helix is right-handed in the right foot; the resulting advance of the talus during eversion is important for the control of the transverse tarsal joint, but may be neglected during consideration of the ankle. For this purpose the major axis of the helix, also called the compromise axis, suffices. Its position in one foot is shown in <b>Fig. 3</b>. This axis emerges from the talus so as to pierce the tendon of the tibialis anterior; its other end is variably located on the lateral surface of the calcaneus. The movements about this axis are called inversion and eversion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The instant axis for the combined movement in the upper ankle joint and the subtalar joint lies in the thin disc represented by the dashed circle. Attention is also called to another variable functional feature, the arc of the ball of the foot. From Elftman, 1954. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The obliquity of this axis confers on the subtalar joint its most significant properties. Indispensable for our ancestors in tree climbing, it is still our chief accommodation to rough terrain. Its large component of vertical rotation gives us the possibility of transverse rotation at the ankle under gravitational control.</p> <p>Since the ankle joint and the subtalar joint are not subject to independent regulation, the resultant movement when the two are combined is of greater practical value than the separate components. The location of this resultant axis is indicated in <b>Fig. 3</b>. If the two joint axes actually intersected, the resultant would lie in the plane determined by the two axes. Since they almost intersect, but not quite, the resultant is confined within a thin disc which may be treated as a plane for practical purposes. Once this plane is determined, the problem of substituting new artificial axes for the old ones is simplified.</p> <p>Movement in the ankle-joint complex is controlled by: (1) moments due to the ground reaction; (2) constraints due to joint surfaces and ligaments; and (3) moments produced by the leg muscles which pass over the ankle. The part played by the ankle muscles can be studied quantitatively from the data shown in <b>Fig. 4</b>. This is essentially an oblique section through the ankle oriented so as to include the axes of the ankle joint and the subtalar joint. The lever arms of the muscles with respect to these axes can be read from the diagram; the relative maximum strengths of the muscles are proportional to the areas of the circles which represent them. The resultant moment of various muscle combinations can then be found. Important points to note are: (1) the tibialis anterior is a dorsiflexor and not an in-vertor in this position; (2) the gastrocnemius and soleus are strong invertors as well as plantar flexors; (3) the peroneal muscles are stronger for eversion than for plantar flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Muscular control of the ankle. The figure is essentially a section through the right ankle in the plane of the disc shown in Figure 3 and includes the ankle-joint axis (TC) and subtalar axis (ST). The circles representing the muscles are proportional in area to the physiologic cross sections. The muscles may be identified by their initials, e.g., triceps surae (TS). From Elftman, 1960. The calcaneocuboid joint was described as a saddle-shaped joint by Adolf Fick in 1854; only one other joint of this type is present in man, at the base of the first metacarpal. More than a century elapsed before an adequate description of this joint was provided by Elftman in 1960. For practical purposes a simplified description will suffice. The principal axis (labeled CC in Fig. 5) passes obliquely through the calcaneus in such a fashion that an extension of it would almost intersect the subtalar axis in the neck of the talus. Associated with the major movement of rotation about this axis is a slight translation parallel to the axis. The total movement is known as supination and pronation. The man in the street calls these raising and lowering of the arch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Transverse Tarsal Joint</h4> <p>The part of the foot which lies immediately in front of the talus and calcaneus forms a semirigid unit articulating with the rear part of the foot by means of two joints, the calcaneocuboid and the talonavicular. Since they act together much of the time, it is convenient to call the combination the transverse tarsal joint.</p> <p>The calcaneocuboid joint was described as a saddle-shaped joint by Adolf Fick in 1854; only one other joint of this type is present in man, at the base of the first metacarpal. More than a century elapsed before an adequate description of this joint was provided by Elftman in 1960. For practical purposes a simplified description will suffice. The principal axis (labeled CC in <b>Fig. 5</b>) passes obliquely through the calcaneus in such a fashion that an extension of it would almost intersect the subtalar axis in the neck of the talus. Associated with the major movement of rotation about this axis is a slight translation parallel to the axis. The total movement is known as supination and pronation. The man in the street calls these raising and lowering of the arch.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Transverse tarsal joint, pronated at left, supinated at right. The joint axes are labeled as follows: AJ, ankle joint; ST, subtalar; CC, calcaneocuboid; TN, talonavicular. When the heel is placed on the ground in the supinated position, inversion in the subtalar joint restores the vertical orientation of the shank and rotates the head of the talus so as to lock the transverse tarsal joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The talonavicular joint is the controlling element in the transverse tarsal joint complex. The head of the talus is a cam of ellipsoidal shape which is not concentric about the subtalar axis but makes a considerable angle with respect to it. As a consequence of this, rotation of the head of the talus during rotation about the subtalar axis changes its orientation, and movement in the transverse tarsal joint ensues to bring the navicular concavity to a conformable position. The important thing to remember is that inversion produces supination and eversion causes pronation. At the extremes of this range of association, the transverse tarsal joint becomes independent of the subtalar in extremely pronated (flat) feet and the subtalar motion can occur alone at extreme supination.</p> <h4>Ball Of The Foot</h4> <p>The structures which allow the heads of the metatarsals to transmit pressure to the ground consist of connective tissue and skin which have been modified in the human foot to spread the pressure in the hope of preventing painful concentrations. When weight is not borne by this region, a transverse metatarsal arch is visible. Even slight pressure is sufficient to bring the heads of the metatarsals in alignment with the ground and the arch disappears. The extreme variability in the lengths of the metatarsals has important consequences for foot action. The distribution of pressure as the heel is raised is very closely dependent on the contour of a line connecting the metatarsal heads, as shown in <b>Fig. 3</b>. Morton (1935) has stressed the difficulties resulting from first metatarsals which are short or have posteriorly located sesamoids. Equally disastrous effects can come from contours which are sharply curved or hairpin in shape.</p> <p>Among a number of variable features in this part of the foot is the extent to which the base of the fifth metatarsal transmits weight to the ground. Another condition, splaying of the foot, can result when the cooperative efforts of the tibialis posterior and the peroneus longus are insufficient to give transverse stability.</p> <h4>Toes</h4> <p>Although human toes can be used for grasping when occasion demands, their customary use is accessory to the ball of the foot which lies behind them. The toes are the anchors for the long flexors which play an important part in managing the ankle-joint complex. By differential contraction of the flexors of the toes it is possible to adjust the distribution of pressure between parts of the ball of the foot. Because of the strength of the big toe and the long flexor attached to it, this part of the foot is usually the last to leave the ground and contributes the final touch to the control of movement.</p> <h3>Control of the Foot by the Heel</h3> <p>When the body rolls forward on the heel until the foot rests on the ground, the position which the foot assumes is determined by the manner in which the calcaneous rolls forward. Proper contouring of the sole of the shoe where the heel nests in it will not only provide assistive forces but will also originate sensory feedback to stimulate better foot alignment.</p> <p>If the heel cup is so constructed that its anteromedial quadrant is elevated, the calcaneus will come to rest with a predetermined amount of inversion about the subtalar axis. This places the contact area of the calcaneus more nearly under the vertical thrust of the body, decreasing its rotational moment. Since the ankle-joint axis strives for a horizontal position, the talus is forced into inversion and this drives the transverse tarsal joint into supination. Sensory feedback, in the course of a few steps, will encourage the hip joint to bring the foot down in a slightly toed-in position, thus restoring the knee joint to its usual orientation.</p> <p>The details of the sculpturing of the heel cup need not be left to chance since the desired conformation of the internal architecture of the foot is almost identical with that which it assumes when the subject stands on an inclined plane. Instant orthotics can be achieved by placing the proper compound in the shoes and having the subject stand in them, with heels supported at a proper elevation, to impress the functional shape.</p> <h3>Measurement of Foot Function</h3> <p>The foot is sandwiched between the pressure of the ground below and the weight and inertia forces of the body above. Since these are the forces to which the foot must accommodate, their measurement assumes primary importance.</p> <p>The total pressure of the ground on the foot and the point at which its resultant is applied can be measured easily when the individual is standing. The only equipment needed consists of three reasonably accurate scales and a ruler. The usefulness of the information which can be obtained should not be underestimated; it is sufficient to tell whether many therapeutic devices achieve their objectives.</p> <p>When the body is in motion, measurement of the ground reaction is more important and becomes more difficult. This can be accomplished by means of force plates, the earliest results of which are shown in <b>Fig. 6</b> from Elftman (1939). From data such as this and photographic determination of the location of joint axes, muscle moments and joint forces can be obtained.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Force plate record of the ground reaction acting on the foot of J. T. Manter during a step described by Elftman, 1939. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In foot problems the distribution of the ground reaction over the foot is frequently of greater interest than its total value. Many interesting methods of making such measurements have been recorded and some are still useful; they have been reviewed by Elftman (1934). Since the distribution of pressure changes in the course of movement, instantaneous recording is of value. This can be accomplished by means of the barograph, introduced by Elftman in 1934. The changes in area of a pressure transducer placed under the foot are recorded photographically. <b>Fig. 7</b> shows two phases of a step; when the pressure is on the ball of the foot the structural characteristics of this region reveal themselves. Calibration of the pressure transducer allows the derivation of quantitative data from the photographic record. In <b>Fig. 8</b> it is even possible to recognize the concentration of pressure under the sesamoid bones beneath the head of the first metatarsal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Barograph record of the distribution of pressure at two phases of the step. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Load distribution on the human foot during one step of J. T. Manter. (Isobars at 4 lb. per sq. in.) The records made on the original barograph and published in Elftman, 1934, were measured after calibration of the pressure transducer. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li>Abramson, E., <i>Zur Kenntnis der Mechanik des Mit-telfusses</i>, Skand. Arch. Physiol., 51:175-234, 1927.</li> <li>Berlemont, M., <i>Notre experience de I'appareillage precoce des amputes des membres in-ferieurs aux Etablissements Helio-Marins de Berck</i>, Ann. Med. Phys., Tome IV, No. 4, October-November-December 1961.</li> <li>Bamett, C. H., and J. R. Napier, <i>The axis of rotation at the ankle joint in man</i>, J. Anat., 86:1-9, 1952.</li> <li>Basler, A., <i>Bestimmung des auf die einzelnen Schlen-bezirke wirdenden Teilgewichtes des menschli-chen Korpers</i>, Alderhalden's Handbuch der biologischen Arbeitsmethoden-Abt 5 Teil 5A, Heft 3, 559-574, 1927.</li> <li>Basmajian, J. V., and J. W. Bentzon, <i>An electromyographic study of certain muscles of the leg and foot in the standing position</i>, Surg. Gynec. Obstet., 98:662-666, 1954.</li> <li>Blechschmidt, E., <i>Die Architektur des Fersenpol-sters</i>, Morph. Jahr., 73:1-68, 1934.</li> <li>Bohm, M., <i>Das mechschliche Bein; seine normale Entwicklung und die Entstehung der Wuchsfehler</i>, Enke, Stuttgart. 1935.</li> <li>Braus, H., <i>Anatomie des Menschen, I Band: Bewe-gungsapparat</i>. Springer, Berlin, 1921.</li> <li>Bressler, B., and F. R. Berry, <i>Energy characteristics of normal and prosthetic ankle joints</i>, Prosthetic Devices Research Project, University of California, Berkeley, Series 3, Issue 12, 1950.</li> <li>Carlsoo, S., <i>Influence of frontal and dorsal loads on muscle activity and on the weight distribution in the feet</i>, Acta Orthop. Scand., 34:4:299-309, 1964.</li> <li>Close, J. R., <i>Some applications of the functional anatomy of the ankle joint</i>, J. Bone Joint Surg., 38A:761-781, July 1956.</li> <li>Close, J. R., and V. T. Inman, <i>The action of the ankle joint</i>, Prosthetic Devices Research Project, University of California, Berkeley, Series II, Issue 22, 1952.</li> <li>Close, J. R., and V. T. Inman, <i>The action of the subtalar joint</i>, Prosthetic Devices Research Project, University of California, Berkeley, Series II, Issue 24, 1953.</li> <li>Dempster, W. T., <i>Space requirements of the seated operator</i>, WADC Tech. Rep. 55-159, pp. 83-84, 102-104, 173-178, 1955.</li> <li>Donitz, A., <i>Die Mechanik der Fuszwwzel</i>, Dissertation, Berlin, 1903.</li> <li>Du Vries, H. L., <i>Surgery of the foot</i>, Ed. 2, C. V. Mosby, St. Louis, 1965.</li> <li>Elftman, H., <i>A cinematic study of the distribution of pressure in the human foot</i>, Anat. Rec, 59:481-491, 1934.</li> <li>Elftman, H., and J. Manter, <i>The axis of the human foot</i>, Science, 80:484, 1934.</li> <li>Elftman, H., and J. Manter, <i>The chimpanzee and human feet in bipedal walking</i>, Amer. J. Phys. Anthrop., 20:69-79, 1935.</li> <li>Elftman, H., and J. Manter, <i>The evolution of the human foot with especial reference to the joints</i>, J. Anat., 70:56-67, 1935.</li> <li>Elftman, H., <i>Forces and energy changes in the leg during walking</i>, Amer. J. Physiol., 125:339-356, 1939.</li> <li>Elftman, H., <i>The orientation of the joints of the lower extremity</i>, Bull. Hosp. Joint Dis., 6:139-143, 1945.</li> <li>Elftman,.H., <i>Torsion of the lower extremity</i>, Amer. J. Phys. Anthrop., n. s. 3:255-265, 1945.</li> <li>Elftman, H., <i>The transverse tarsal joint and its control</i>, Clin. Orthop., 15:41-46, 1960.</li> <li>Fick, A., <i>Die Gelenke mit sattelformigen Flachen</i>, Z. rat. Med. V. 9, 1854 (also reprinted in A. Fick, Gesammelte Schriften. V. 1, Wiirzburg, 1903).</li> <li>Fick, R., <i>Uber die'Bewegungen und die Muskelarbeit an den Sprungelenken des Menschen</i>, Sitzungs-berichte der Preuss. Akad. der Wiss. Physik.-mathem., Kl., XXIII:458-495, 1931.</li> <li>Gardner, E., D. J. Gray, and R. O'Rahilly, <i>The prenatal development of the skeleton and joints of the human foot</i>, J. Bone Joint Surg., 41A:847-876, July 1959.</li> <li>Harris, R. I., and T. Beath, <i>Army foot survey</i>, National Research Council of Canada, Ottawa, 1947.</li> <li>Helfet, A. J., <i>A new way of treating flat feet in children</i>, Lancet, 1:262-264, Feb. 11, 1956. Henke, W., Die Bewegung des Fuszes am Sprung-bein, Z. rat. Med., 7:225-234, 1859.</li> <li>Hicks, J. H., <i>The mechanics of the foot, I. The joints</i>, J. Anat., 87:345-357, 1953.</li> <li>Hicks, J. H., <i>The mechanics of the foot, II. The plantar aponeurosis and the arch</i>, J. Anat., 88:25-30, 1954.</li> <li>Hicks, J. H., <i>The mechanics of the foot, III. The foot as a support</i>, Acta Anat., 25:34-45,1955.</li> <li>Hicks, J. H., <i>The mechanics of the foot, IV. The action of muscles on the foot in standing</i>, Acta Anat., 27:180-192, 1956.</li> <li>Hohmann, G., <i>Fuss und bein; ihre Erkrangungen und deren Behandlung</i>, Bergmann, Miinchen, 3 Aufl., 1939.</li> <li>Hutter, G. G., and W. Scott, <i>Tibial torsion</i>, J. Bone Joint Surg., 31A:511-518, July 1949.</li> <li>Jones, F. Wood, <i>Structure and function as seen in the foot</i>, Bailliere, Tindall and Cox, London, 1946.</li> <li>Jones, R. L., <i>The human foot, An experimental study of its mechanics, and the role of its muscles and ligaments in the support of the arch</i>, Amer. J. Anat., 68:1-39, 1941.</li> <li>Jones, R. L., <i>The functional significance of the declination of the axis of the subtalar joint</i>, Anat. Rec, 93:151-159, 1945.</li> <li>Karpovich, P. V., and L. B. Wilklow, <i>A goniometric study of the human foot in standing and walking</i>, U.S. Armed Forces Med. J., 10:885-903, 1959.</li> <li>Keith, A., <i>The history of the human foot and its bearing on orthopaedic practice</i>, J. Bone Joint Surg., HA:10-32, January 1929.</li> <li>Kolb, H.,<i> Morphologische und funktionelle Analyse des m. tibialis anterior</i>, Z. Anat. Entwicklungs-gesch., 106:770-781, 1937.</li> <li>Lanz, T., and W. Wachsmuth, <i>Praktische Anatomie, I Band, 4 Teil; Bein und Statik</i>, Springer, Berlin, 1935.</li> <li>Lease, G. O'D., and F. G. Evans, <i>Strength of human metatarsal bones under repetitive loading</i>, J. Appl. Physiol., 14:1:49-51, 1959.</li> <li>Levens, A. S., V. T. Inman, and J. A. Blosser, <i>Transverse rotation of the segments of the lower extremity in locomotion</i>, J. Bone Joint Surg., 30A:859-872, October 1948.</li> <li>MacConaill, M. A., <i>The postural mechanism of the human foot</i>, Proc. Roy. Irish Acad., 50B:265-278, 1945.</li> <li>Mann, R., and V. T. Inman, <i>Phasic activity of intrinsic muscles of the foot</i>, J. Bone Joint Surg., 46A: 469-481, April 1964.</li> <li>Mann, R., and V. T. Inman, <i>Structure and function</i>, in Du Vries' <i>Surgery of the foot</i>, Ed. 2, C. V. Mosb'y, St. Louis, 1965, pp. 1-44.</li> <li>Manter, J. T., <i>Movements of the subtalar and transverse tarsal joints</i>, Anat. Rec, 80:397-410, 1941.</li> <li>Manter, J. T., <i>Distribution of compression forces in joints of the human foot</i>, Anat. Rec, 96:313-322, 1946.</li> <li>Marsk, A., <i>Studies on weight-distribution upon the lower extremities in individuals working on a standing position</i>, Acta Orthop. Scand., Suppl. 31, 1958.</li> <li>Meyer, H., <i>Statik und mechanik des menschlichen fusses</i>, Jena, 1886.</li> <li>Morton, D. J., <i>The human foot</i>, Columbia University Press, New York, 1935.</li> <li>Paul, J. P., <i>Forces transmitted by joints in the human body</i>, Paper No. 8, Proc Instr. Mech. Engrs., 181:3:8-15, 1966-67. (Joints of the foot are included in the discussion.)</li> <li>Pfitzner, W., <i>Beitrdge sur Kenntnis des menschlichen Extremitdtenskelettes, VII. Die variationen in Aufbau des Fuszskelettes</i>, Morph. Arb., 6:24-528, 1896.</li> <li>Rose, G. K., <i>Correction of the pronated foot</i>, 1, J. Bone Joint Surg.,. 40B:674-683, November 1958.</li> <li>Rose, G. K., <i>Correction of the pronated foot</i>, 2, J. Bone Joint Surg., 44B:642-647, August 1962.</li> <li>Rydell, N. W., <i>Forces acting on the femoral head prosthesis</i>, Acta Orthop. Scand., Suppl. 88, 1966. (Forces acting on feet during locomotion measured by means of an electronic walkway.)</li> <li>Scherb, R., <i>Kinetisch-diagnostische Analyse von Gehstorungen</i>, Technich und resultate der myo-kinesigraphie, Beilageheft Z. Orthop. Bd. 82, 1952.</li> <li>Schwartz, R. P., and A. L. Heath, <i>Foot function correlated with anatomic, clinical, and laboratory data</i>, New York J. Med., 41:447-451, 1941.</li> <li>Skinner, B. M., <i>Notes on the relative lengths of first and second toes of the human foot</i>, J. Anat., 66:123-4, 1932.</li> <li>Smith, J. W., <i>The act of standing</i>, Acta Orthop. Scand., 22:2:159-168, 1953.</li> <li>Smith, J. W., <i>Muscular control of the arches of the foot in standing: an electromyographic assessment</i>, J. Anat, 88:152-163, 1954.</li> <li>Smith, J. W., <i>The forces operating at the human ankle joint during standing</i>, J. Anat., 91:545-564, 1957.</li> <li>Smith, J. W., <i>The relationship of epiphyseal plates to stress in some bones of the lower limb</i>, J. Anat., 96:58-78, 1962.</li> <li>Strasser, H., <i>Lehrbuch der Muskel- and Gelenk-mechanik, III Band, Spezieller Teil Die untere Extremitat, II Fuss und Unterschenkel</i>, 1917, pp. 156-309.</li> <li>Straus, W. L., Jr., <i>The growth of the human foot and its evolutionary significance</i>, Contrib. Embryol. Camegie Inst., 19:93-134, 1927.</li> <li>Straus, W. L., Jr., <i>The foot musculature of the highland gorilla</i>, (Gorilla beringei), Quart. Rev. Biol., 5:261-317, 1930.</li> <li>Thomas, D. P., and R. J. Whitney, <i>Postural movements during normal standing in man</i>, J. Anat., 93:524-539, 1959.</li> <li>Thoren, O., <i>Os calcis fractures</i>, Acta Orthop. Scand., Suppl. 70, 1964.</li> <li>Volkov, T., <i>Les variations squeletique du pied chez les primates et dans les races humaines</i>, Bull. Mem. Soc Anthrop. Sci., 5T4-632, 1903; 5:1:201-331, 1904.</li> <li>Weidenreich, F., <i>Der Menschenfuss</i>, Z. Morph. Anthrop., 22:51-282, 1921.</li> <li>Weidenreich, F., <i>Evolution of the human foot</i>, Amer. J. Phys. Anthrop., 6:1-10, 1923.</li> <li>Wetzenstein, H. A., <i>A new method for assessment of the status and dynamic weight bearing of the foot</i>, Acta Orthop. Scand., 30:2:91-100, 1960.</li> <li>Wetzenstein, H., <i>A new method for assessment of the status and dynamic weight bearing of the foot</i>, 75, 1964.</li> <li>Whitney, R. J., <i>The stability provided by the feet during manoeuvers whilst standing</i>, J. Anat., 96:103, 1962.</li> <li>Wright, D. G., S. M. Desai, and W. H. Henderson, <i>Action of the subtalar and ankle-joint complex during the stance phase of walking</i>, J. Bone Joint Surg., 46A:361-382, March 1964.</li> <li>Wright, D. G., and D. C. Rennels, <i>A study of the elastic properties of plantar fascia</i>, J. Bone Joint Surg., 46A:482-492, April 1964.</li> <li>Wyller, T., <i>The axis of the ankle joint and its importance in subtalar arthrodesis</i>, Acta Orthop. Scand., 32:4:320-328, 1963 </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Herbert Elftman </b></td></tr><tr><td class="clsTextSmall">Department of Anatomy, Columbia University, New York, N.Y. 10016 The foot is one of the most dynamic structures in the human body. The lively interplay of forces which makes its function possible is easily forgotten and it is too often treated like the graven image of a static structure. The success of modern therapeutic measures in solving other problems has owed much to close cooperation between Nature working from within and assistive devices from without. The forces within the foot can be powerful allies in such a partnership.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_049/spring69-45.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_049/spring69-46.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_049/spring69-47.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_049/spring69-48.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_049/spring69-49.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_049/spring69-50.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_049/spring69-51.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_049/spring69-52.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 Dynamic Structure of the Human Foot Creator An entity primarily responsible for making the resource Herbert Elftman * https://staging.drfop.org/files/original/7a7cd68d5bd0095b317a4f44affc0941.pdf d7e865477f5445c4a9c985354cc6bd99 https://staging.drfop.org/files/original/8f0c35d069948e0004acb926243104e3.jpg d66267d487f5ad7b5cb149ee357ca97d https://staging.drfop.org/files/original/153e5ba3b516d61a2c180b74512debd5.jpg 181b23a4816351a5231a249d74444720 https://staging.drfop.org/files/original/88f27d9100c85efdefc153a74675137b.jpg 81d4538609ad379bbc4a53f1a5928edc https://staging.drfop.org/files/original/f98e862183e5762fac48c707098889f5.jpg c474c3993fb68bf29c0fdae290d520fb 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_015.pdf Text Any textual data included in the document <h2>Dynamics and the L3 Through L5 Myelomeningocele Child</h2> <h5>John Glancy, CO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Since 1970, the orthotic management of myelomeningocele children treated at Indiana University has focused primarily on musculoskeletal deformities that develop after birth. Much of our effort has been directed to children with L3 through L5 lesions, because of their potential to be community walkers.<a></a> The decision to direct our attention to the problems that these lesion levels present also relates to the fact that they constitute the majority group among the myelomeningocele population. The range of orthotic dysfunctions, in kind or degree, that children with these lesion levels are prone to today, are identical to the orthotic dysfunctions that like youngsters had to endure in 1970.</p> <p>Myelomeningocele remains "the most complex, treatable congenital anomaly consistent with life."<a></a> What has changed, in the interim, is our understanding of the pathodynamics acting upon the musculoskeletal systems of children with L3 through L5 lesions. The introduction of thermoplastic materials, along with vacuum forming techniques, now allow orthotists greater freedom of design. Consequently, there is a gradual change occurring in orthotic management, from the traditional approach based upon statics, to a growing appreciation of dynamics as a means of preserving function by preventing the formation of secondary dysfunctions caused by gravity, growth, and time. How may one describe the benefits these changes portend for the L3 through L5 myelomeningocele child, present and future? It now appears that while present-day children with L3 through L5 lesions may have the same vulnerability to secondary dysfunctions as the children of 1970 . . . they may not have to endure them, in kind or degree.</p> <p>Those concerned with the care of these children face the same dilemma today as was experienced in 1970-how to provide long-term protection from secondary dysfunctions without introducing unacceptable inhibitions to daily activities. Fortunately, some of the specific challenges within the makeup of this dilemma have been satisfactorily met:</p> <ul> <li> <p><b>The polypropylene Solid-Ankle Orthosis<a></a></b> offers long-term protection to the foot/ankle complex. The Carlson, Berglund technique<a></a> adds to the efficiency of this orthosis.</p> </li> <li> <p><b>Lightweight KAFO's</b> that utilize a unilateral upright with offset free knee joint, modified quadrilateral thigh cuff and dynamic knee extension assist<a></a> offer long-term protection to myelomeningocele knees.</p> </li> <li> <p style="text-align: left;"><b>A polypropylene thoracopelvic unit<a></a></b> offers a promising foundation for achieving acceptable, long-term control of the trunk with L3 through L5 lesion levels, without having to extend the exoskeletal system below the anatomic hip joints (<a href="/files/original/f98e862183e5762fac48c707098889f5.jpg"><b>Fig. 4</b></a>).</p> </li> </ul> <p>Since the 1976 report on the dynamic orthotic system was published,<a></a> we have refined the modular aspects of the system for two primary reasons: (1) To ensure that each component meets the requirements for which it is designed, i.e., providing no more, nor no less control than needed, and (2) To encourage the night use of the daytime system by the utilization of quick releases, in order to remove any components unrelated to the areas requiring night-time dynamic control (<a href="/files/original/8f0c35d069948e0004acb926243104e3.jpg"><b>Fig. 1</b></a>). These modular refinements were also prompted by our recognition of a correlation between early application and night-time dynamic control, to success in the prevention of secondary dysfunctions. Due to the complexities of the pathodynamics involved, particularly in the hip complex and lumbopelvic regions, an efficient night-time unit must be equally as functional as the daytime unit, hence the economic necessity that a single system provide both day and night protection against secondary dysfunctions.</p> <strong><a href="/files/original/8f0c35d069948e0004acb926243104e3.jpg">Figure 1.</a> Features of modular system: (A) Assembled system for fitting: elastic components to knee and pelvic extension assist are not attached. (B) Modified quadrilateral thigh cuff; showing Nylon receptacle and locking nut for quick release of AK module. (C) Solid-ankle AFO with lateral off-set knee joint and pivotable attachment portion of knee extension assist assembly. Shockcord is not shown. (D) Thoracopelvic unit; receptacles for the quick release of the KAFO's and reinforcing horizontal bar are visible. Note: The combination polycentric and lateral motion joint shown in A. The lock joint shown in B is used for post-op cases.</strong><br /> <p>The importance of night-time use became even more evident with an awareness of the startling amount of regression that often occurs during short periods of time when the system is not worn. Rapid regression occurs with discouraging frequency about the hips and lumbopelvic regions especially. Such 'down time' often is more frequent within the three-to-six month periods between orthotic checkup visits than we understood to be the case. For example, in addition to the usual childhood diseases, colds, etc, these children are subject to episodes of kidney and/or bladder infection and periodic revisions to their shunts. The success or failure of the dynamic orthotic system appears to be proportional to the frequency and duration of these occurrences. Without an appreciation for the circumstances just described, orthotists will experience constant frustration as they seek explanations for the gradual regression their patients present, because they will unintentionally attribute the cause to often non-existent weaknesses in the design of a given orthotic system.</p> <p>The answer lies not only with better control of the hip and lumbopelvic regions, but also with constancy of control. We must be as persistent with our applications of biodynamics as nature is with the pathodynamics acting upon these regions. There are three needs that must be considered, which hopefully can be met by a single dynamic thoracopelvic design. They are:</p> <ol> <li> <p>A reliable method of eliminating jack-knifing of the trunk during ambulation without the use of locks.</p> </li> <li> <p>Control of the lumbopelvic and hip regions in a manner which does not require extensions to the lower extremities. The need to protect the growing child's lumbar spine when his gluteous maximum muscles are paralyzed, but his hips and/or knees do not require protection (L4 and L5 levels), has yet to be met.</p> </li> <li> <p>The controls in 1 and 2 above, must operate with the same efficiency during night-time wear as they do during the day, in order to reverse the inevitable regression resulting from unavoidable periods when illness prohibits wearing the orthosis.</p> </li> </ol> <p>Granted, these design criteria demand a major breakthrough in the state-of-the-art. Nevertheless, using our current thoracopelvic unit as a point of departure, an acceptable solution seems within our grasp. <a href="/files/original/153e5ba3b516d61a2c180b74512debd5.jpg"><b>Fig. 2</b></a>, <a href="/files/original/88f27d9100c85efdefc153a74675137b.jpg"><b>Fig. 3</b></a>, and <a href="/files/original/f98e862183e5762fac48c707098889f5.jpg"><b>Fig. 4</b></a> show our progress to date. A resolution to this problem would have broad orthotic applications-it should be vigorously pursued. Our work on this project is ongoing, and we invite our readers' active participation.</p> <strong><a href="/files/original/153e5ba3b516d61a2c180b74512debd5.jpg">Figure 2</a>. (A &amp; B) Sitting stability and comfort is enhanced by the flat, posterior surfaces of the modified quadrilateral cuffs, abduction motion and polycentric feature of the hip joints. (C) Posterior view: Thoracopelvic unit on casts with the new pelvic extension assist showing right rubber strap detached from the upright. (Note how the model has dropped on the right side.) (D) Side view showing how rubber strap attaches to upright. AK and BK quick releases and Delrin fitting for shockcord of the knee extension assembly. (E) Posterior view with both rubber straps of the pelvic extension assist attached to the uprights. (Note the horizontally level suspension of the cast, demonstrating the force the rubber straps generate.)<br /></strong><br /><strong><a href="/files/original/88f27d9100c85efdefc153a74675137b.jpg">Figure 3.</a> Most recent prototype: (A) Dacron straps with slide-bar buckles serve as a passive, adjustable 'pelvic band.' Puhient weighs 43 lbs. Each rubber strap is set to generate 14 force pounds equal to 62 inch pounds of extension moment which resists the first 20 degrees of forward flexion of the lumbar spine. Any voluntary forward flexion of the trunk beyond 20 degrees overrides the dynamic extension. (Note: Posterior polypropylene bar must be slotted at pelvic end (drawn in) to permit forward rotation of lumbar spine, as the dacron straps check unwanted forward rotation of the pelvis.) (B) Side view: Lock used for 2-3 months post-op. Dynamic extension is fully operative even with locks. Patient has 45 degree hip contractures, which explains posterior gap of thigh cuff in post-op alignment. (C) Anterior view: Note Nyloplex stud medial to hip joint which is the pivotal attachment point for slide-bar buckle. (D) Posterior view of Plastazote® lining showing the sealed 'pockets' at waistline level. Pockets are filled with #382 Elastomer. (E) Model shown in seated position. Although 28 force lbs. (both rubber straps) are acting to extend the lumbar spine when sitting, this force has no effect upon the lower extremities. (F) Bottom view: showing 'shelves' formed with the lining and filled with Elastomer via the pockets shown in photo D. Their effectiveness in transferring the weight of the thorax to the uprights is well demonstrated. This technique prevents pressure sores to insensitive skin.<br /><br /><a href="/files/original/f98e862183e5762fac48c707098889f5.jpg">Figure 4</a>. Schematic lateral view of normal lumbopelvic relationship to the horizontal. Shaded areas show the optimum sacral angle of 30 degrees, with respect to the center of the hip joint, during normal standing posture. The normal amount of postural lordosis resulting from the optimum sacral angle is also depicted. The unshaded outline shows the pelvis rotated 20 degrees about the hip joint in an anterior direction, taking the entire trunk with it, indicated by arrow in upper left. The downward oblique line, originating from hip center, indicates the maximum distal point (gluteal fold), relevant to the horizontal at hip level, which is feasible as an attachment point for passive pelvic control when fitting small children (see A &amp; B, Figure 3). The arrow between the horizontal and oblique lines, to the right of the figure, demonstrates that beyond 20 degrees of forward rotation of the pelvis, the distal attachment point will rise <i>above</i> the horizontal. The contribution of the passive pelvic control, relative to forward rotation of the pelvis above the horizontal, is nil. However, the intimate fit of the thoracopelvic unit (especially the abdominal position) ensures that the optimum relationship between the lumbar spine and the rotating pelvis is passively maintained throughout the full range of pelvic A-P rotation. Consequently, any <i>involuntary</i> forward rotation of the trunk about the hips (within the first 20 degrees) can be controlled as a single body segment. The functional status of the abdominal and particularly the hamstring muscles, may be expected to be crucial contributors to the system's success. <i>Unless the pelvis and lumbar spine can be passively placed in a normal standing posture to begin with, neither can be controlled in an upright position without locks.</i></strong><br /> <h3>Acknowledgment</h3> <p>I wish to express my thanks to John G. Patsko, CO, whose fine photography adds so much to the text.</p> <p><b>References:</b></p> <ol> <li>Glancy, J. and R.E. Lindseth, "A dynamic orthotic system to assist pelvic extension: A preliminary report," <i>Orthotics and Prosthetics</i>, 29:1, pp. 3-9, March, 1975.</li> <li>Bunch, W.H., A.S. Cass, A.S. Bensman and D.M. Long, "Modern management of Myelomeningocele," Pub. Warren H. Green, Inc., St. Louis, 1972.</li> <li>Glancy, J. and R.E. Lindseth, "The polypropylene solid-ankle orthosis," <i>Orthotics and Prosthetics</i>, 26:1, pp. 14-26, March, 1972.</li> <li>Glancy, J., "A dynamic orthotic system for young myelomeningoceles: A preliminary report," <i>Orthotics and Prosthetics</i>, 30:4, pp. 3-15, December, 1976.</li> <li>Carlson, J.M. and G. Berglund, "An effective orthotic design for controlling the unstable subtalar joint," <i>Orthotics and Prosthetics</i>, 33:1, pp. 39-49, March, 1979.</li> </ol> <div style="width: 400px;"><b>*John Glancy, CO </b> John Glancy, CO., is Assistant Professor and Director of Orthotics in the Orthotics Division at James Whitcomb Riley Hospital for Children, Room 1100, Indiana University Medical Center, 702 Barnhill Drive, Indianapolis, Indiana 46223.<br /><br /><br /></div> Page Number(s) 15 - 23 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_015/1984_04_015-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_015/1984_04_015-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_04_015/1984_04_015-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1984_04_015/1984_04_015-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Dynamics and the L3 Through L5 Myelomeningocele Child Creator An entity primarily responsible for making the resource John Glancy, CO * https://staging.drfop.org/files/original/760e13aa1dc8e1275a4a9976de2db4cb.pdf 71a8cfac282278de7ae518edde8b0333 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_01_004.pdf Text Any textual data included in the document <h2>Editorial: Metal vs. Plastic AFO - A Therapist's View</h2> <h5>Donald G. Shurr, LPT, MA&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Ankle foot orthoses are generally prescribed for patients who are able to ambulate without an orthosis, but for whom an orthosis allows a safer, and often more cosmetic, gait. Traditional "bracing" in these cases calls for a combination of metal and leather, often a spring-assisted ankle joint, and a so-called posterior stop, which simulates the motion of ankle dorsiflexion and prevents toe drag during swing phase.</p> <p>More recently, molded plastic ankle foot orthoses have become available. These lighter weight orthoses provide a nearly invisible option to the conventional metal, riveted to the shoe devices. Presently, little agreement exists as to the indications, the timing of the application, or the overall outcome anticipated with the use of plastic AFOs.</p> <p>The physical therapist plays an important function in the team approach to the care of patients with orthotic needs. Because the physical therapist spends considerable time working with these patients, he or she has an opportunity to continuously evaluate the patient's progress. This constancy is critical to the orthotic decision-making process as changes in patient symptoms may well alter orthotic needs. For this reason, it is often the responsibility of the physical therapist to recommend an appropriate orthotic device. In order to do this, the therapist must not only use the current physical findings, but must accurately predict future changes in these data. He/she must choose a device which will not only facilitate early ambulation, but will also meet the patient's future needs. Thus arise the dilemmas of when to fit which device, and whether to use temporary or longer-lasting orthotic devices.</p> <p>In the past, metal AFOs were considered more adjustable and more temporary. These devices were to act as the precursor to the more definitive, more cosmetic, lighter, and therefore "better" plastic AFOs. However, experience with plastic AFOs revealed problems with lack of adjustability, thus necessitating multiple fittings in order to accomodate the patient's changing clinical picture.</p> <p>The therapist must decide how to most effectively provide devices which not only meet the adjustability requirements demanded for early ambulation, but also provide a more cosmetically appealing, definitive device. Questions that need answering are: can an adjustable orthosis be fitted to allow for early ambulation? When should we recommend the more definitive (presumably plastic) devices? How can this be done with a minimum of dollars spent?</p> <p>In 1971, Lehneis and Sarno made the following statement: "It is clear in the function of our clinic that there is no longer any indication for prescription of the conventional double bar BKO." It would be interesting to know if the authors still feel this way despite evidence to indicate that the double bar device is still routinely being fit.</p> <p>The reason for the continued popularity of the bichannel, double upright AFO in our clinic is its adjustability. This allows for medial-lateral control in both swing and stance phase, as well as knee control during stance. The extension moment generated by an anterior pin stop and long foot plate allows good control of knee flexion. Similarly, knee hyperextension can be controlled by adjusting the posterior pin.</p> <p>The timing for the fitting of such a device should allow a sufficient training period so that the patient can be discharged with skills in the proper and safe use of the orthosis. Frequent return visits or home care sessions are necessary to continue to evaluate progress and provide necessary orthotic changes.</p> <p>In many situations, the cost of the orthotic care for the patient is the smallest total dollar amount spent during the rehabilitation phase, yet it seems to receive a disproportionate amount of discussion. In those cases where early ambulation is indicated and expected changes in condition dictate an adjustable orthosis, the device of choice would seem to be the conventional, double adjustable, double upright, metal AFO. Later, as the condition stabilizes and the need for adjustability subsides, a plastic, more cosmetically acceptable AFO may be fitted. Even with the fitting of two devices, the total dollars spent for orthotic care will remain a small part of the overall cost of rehabilitation.</p> <p>This discussion would be incomplete without specific mention of the polypropylene AFO. Since the arrival of the custom-made poly AFO, manufacturers have saturated the market with standard sized, stamped poly AFOs. Many therapists use such devices and compare them with other types of custom-fitted metal and plastic AFOs. If one inspects these devices, it is apparent that they fit very few patients. They do not provide the necessary dorsiflexion assist without a considerable amount of modification, and often never produce the desired effect. Additionally, they provide little knee extension assistance, which is often necessary for many early ambulators.</p> <p>The choice of plastic vs. metal AFOs should be considered with all aspects of the patient's present and expected future condition in mind. The type of orthotic device prescribed should meet all the needs of the patient, with cosmetics being only one element. Multiple plastic or a combination of metal and plastic orthotic fittings can be justified in order to attain early, safe, and independent ambulation.<br /><br /><em><b>*Donald G. Shurr, LPT, MA </b> Director of Physical Therapy University of Iowa Hospitals and Clinics Iowa City, IA<br /><br /><br /></em></p> Page Number(s) 4 - 4 Year 1983 Volume 7 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Metal vs. Plastic AFO - A Therapist's View Creator An entity primarily responsible for making the resource Donald G. Shurr, LPT, MA * https://staging.drfop.org/files/original/5482be4ae060a01e68f831179c03541a.pdf c4183c71a23a893c1ee48207ff643511 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_01_005.pdf Text Any textual data included in the document <h2>Editorial: Orthotics For Spinal Deformity - 1980 View</h2> <h5>Robert B. Winter, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Thirty-three years ago the Milwaukee brace made its first appearance, originally designed as a postoperative immobilizing and corrective device. Soon thereafter, it began to be used as a non-operative treatment method for both scoliosis and kyphosis. Between 1950 and 1970, the brace was gradually improved and the system of non-operative treatment became more refined, with more knowledge of the indications and contraindications.</p> <p>In Europe in the 1960's and in North America in the 1970's, a wave of new braces appeared, all attempting to control spinal curvatures without surgery. The corset Lyonnaise, the Riviera brace, the Pasadena brace, and finally the Boston brace and the Wilmington jacket were all basically "underarm" orthoses, although most could be extended up to a neck ring for special circumstances.</p> <p>The "underarm" orthoses were, of course, more aesthetically&nbsp;pleasing to the child, but there was considerable controversy as to whether they could achieve the same quality of curve control as was achieved by the Milwaukee brace.</p> <p>About this time, i.e. 1975, relatively long-term studies of the Milwaukee brace experience began to appear, not just what the curve was at the time of brace stoppage, but what was happening to those curves five and ten years later. It became increasingly apparent that there was a wide spectrum of brace results, even when ideal circumstances of brace manufacture, curve selection, and patient cooperation existed. The average result was a curve the same at the end as at the beginning.</p> <p>Why then use an orthosis if there is to be no correction? The answer is obvious: to prevent progression. We have learned through experience that orthoses are not designed to make large curves permanently into small curves. Orthoses <em>are</em> designed to keep small curves small.</p> <p>Should all small curves, therefore, be braced? The answer is "no," since many small curves are nonprogressive and do not need treatment of any kind. An 18° thoracic idiopathic scoliosis in a pre-menstrual 13 year-old girl has a 63 percent chance of being nonprogressive without treatment and a 4 percent chance of spontaneously improving without treatment. There is only a 33 percent chance of her curve progressing, and therefore she needs treatment only if progression is well-documented.</p> <p>What kind of a brace is best? It depends on multiple factors as to which brace is best for which patient. All too often, proponents of a particular design will claim that their design is best and will solve all problems. As in all phases of medicine, there is a spectrum of diseases and a spectrum of solutions. The pendulum of enthusiasm swings first one way (the Milwaukee brace only), and then the other (underarm orthoses only), and finally settles in the middle.</p> <p>The current "middle ground" of orthotic management is best expressed by that sophisticated program in which the orthotist and orthopaedic surgeon work together to design an orthosis for the specific child's curvature problem. For a lumbar or thoracolumbar curve, they will use an orthosis that exerts correctional and stabilizing forces on the curve, but does not extend up to the neck, i.e., some type of underarm orthosis. If there is a decompensation problem, a trochanteric extension will be employed.</p> <p>If the curvature is in the thoracic spine, i.e., the apex is at T7, an orthosis is needed which will give a maximal effect at that area. The best orthosis is still the Milwaukee brace, regardless of whether the curve problem is a kyphosis or a scoliosis.</p> <p>Why is a Milwaukee brace best for such thoracic curves? It is best because it is designed to apply its forces in that area without negative effects on other areas. Those who suggest that an underarm orthosis can achieve the same result are looking only at the roentgenogram, not at the patient. It is of no benefit to create a "good looking" roentgenogram, if at the same time the patient has decreased lung function, permanent alteration of rib cage dimensions, skin sores, digestion problems, or any of the other secondary effects which improper bracing can create.</p> <p>In summary, we have reached a point of professional advancement in which children with progressive curvatures are being detected early enough to permit non-operative control (not "correction") by orthoses. We are sophisticated enough not to overtreat small curves, nor to attempt to orthotically treat curves needing surgery. We now have a wide selection of orthotic devices from which to choose for the individual patient and her or his specific curve problem. We must stop looking just at an anteroposterior roentgenogram and begin to look at the patient as a three dimensional individual. Finally, we must recognize defeat - sometimes the orthosis just doesn't work and the patient needs surgery.</p> <em><strong><b>*Robert B. Winter, M.D. </b></strong>Professor of Orthopedic Surgery University of Minnesota</em><br /> <div style="width: 400px;"></div> Page Number(s) 5 - 5 Year 1981 Volume 5 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Orthotics For Spinal Deformity - 1980 View Creator An entity primarily responsible for making the resource Robert B. Winter, M.D. * https://staging.drfop.org/files/original/6438c2935f8cb41a327a7110da0804b6.pdf fed62d2cec4e0a2356a7a35ce7281034 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_02_006.pdf Text Any textual data included in the document <h2>Editorial: Prosthetic and Orthotic Support - The 1982 Budget</h2> <h5>Charles H. Epps, Jr., M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The past year has seen a series of legislative successes by the Reagan Administration in its efforts to reduce the federal budget. The budget for the current fiscal year totals roughly $720 billion of which almost $270 billion will go for defense and interest on the national debt. It is estimated that almost four out of five of the remaining dollars will go for entitlement programs. The balance comprises the part often referred to as the controllable budget and includes items such as high wages, veterans hospitals and medical research.<a></a> The experts at this point have been unable to fully sort out the impact of the proposed cuts but it is estimated that almost $20 million will be in health and human service programs. The cuts will not stop here as the Administration in September proposed another 12 per cent reduction in human services to offset the extra $25 billion budget deficiency caused by the personal income tax cut.<a></a> One does not have to be an economist to realize that the proposed changes will fundamentally alter the scope of federal programs, particularly health and human services.</p> <p>It also becomes apparent that prosthetic and orthotic services as well as training, research, and development in those areas will be affected. Historically, the level of federal involvement and support has been substantial when one considers that laboratories engaging in prosthetic-orthotic research were operated by the Army, the Navy and the Veterans Administration. The Veterans Administration alone and in parallel with other agencies has supported a number of projects with universities, industrial laboratories, and in recent years has sponsored intramural projects in Veterans Administration Medical Centers. The office of Vocational Rehabilitation and its successor, the National Institute of Handicapped Research, (NIHR), supported Rehabilitation Engineering Centers and projects throughout the United States.</p> <p>The budget reconciliation process has been utilized in the Congress to fashion this new reduction of the federal role. Funds administered through the NIHR vitally affecting prosthetic and orthotic research and training have been exposed to this budgetary process. The Appropriation Committees of the House and the Senate have reviewed this aspect of the budget.</p> <p>The programs for crippled children, which reach many children requiring prosthetic and orthotic devices, have not escaped budget cuts. Maternal and Child Health (MCH) and Crippled Children's Services (CC) have been consolidated into a block grant to the states under Title V of the Social Security Act. Included in this particular block grant are: supplemental security income for disabled children; lead-based paint poisoning prevention; sudden infant death syndrome; hemiphelia treatment centers, and adolescent pregnancy. The House-Senate Conference agreement currently under the continuing resolution provides for an authorization of $347.5 million for fiscal 1982 for the MCH block grant. This amount is 25 per cent less than the 1981 appropriation of $456.2 million. It is hoped that support will continue for valuable programs presently funded at least in part at CAPP in Los Angeles, the Area Wide Amputee Center in Grand Rapids, and at New York University. Presently there are five projects funded at a level of $1.3 million. It is proposed to accomplish a reduction of 77 percent to a level of $300,000 in fiscal 1982. These projects, considered an aspect of technology transfer, constitute an activity of vital national concern. A reduction of this magnitude (77 percent) will substantially impair the programs.</p> <p>These are areas where private initiatives and voluntarism cannot replace the federal support. The private sector has been unwilling or unable to support totally even the more glamorous and highly visible activities such as symphony orchestras, art and scholarship support. Prosthetic and orthotic projects pale by comparison in their ability to attract private support when compared to other highly visible programs. It remains, therefore, the task of each of us to write or wire our Representatives and Senators requesting support of action in the Appropriation Committees of Congress that will insure at least a continuation of the present level of support, if not an increase in the funding for prosthetic and orthotic research and training. The present level of funding will deprive patients of needed services and cripple the research and training efforts perhaps beyond recovery.</p> <p><b>References:</b></p> <ol> <li>Editorial: "Who will Be Entitled?" <i>The Washington Post</i>, January 22, 1982, p. A14.</li> <li>England, M.J.: "The Health and Social Service Picture," <i>Journal AMWA</i> 36:350, 1981.</li> <li>"Health Programs Are Being Slashed," <i>The Nation's Health</i>, January 1982, p.1.</li> </ol> <em><b>*Charles H. Epps, Jr., M.D. </b> Professor and Chief, Division of Orthopaedic Surgery Howard University Hospital Washington, D.C.<br /><br /></em> Page Number(s) 6 - 6 Year 1982 Volume 6 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 Editorial: Prosthetic and Orthotic Support - The 1982 Budget Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/b07addbca7cb05cba5493373ba37e4d5.pdf beaed1b03564c538ee3e1e8ec6019f68 https://staging.drfop.org/files/original/3315a246e37eef6187bbc4b8ea89f1ba.jpg 2cd16c71b05ac05e1bf1a8dec6934bc5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_04_005.pdf Text Any textual data included in the document <h2>Editorial: Special Prostheses Enhance Rehabilitation</h2> <h5>Charles H. Epps, Jr., MD&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In the case of a child, conventional wisdom has held that success of prosthetic rehabilitation can be measured by the ability of the child to play, as play may be considered child's work. In the adult, ultimate success was evidenced by the patient's return to his former job or to some other gainful employment. Special acclaim and attention have been given to amputees like Pete Gray, who succeeded as a professional baseball player. Today another criterion can offer a more valid assessment of success. The ability of the patient, child or adult, to participate in life's activities is a better measure. This assessment should include sports and athletic activities, especially those activities formerly enjoyed in the case of an acquired amputee. Fortunately, today's prosthetic armamentarium includes special techniques, components and prostheses that make participation possible in a variety of activities. On the basis of the experience gained in treating more than 700 juvenile amputees, R.C. Hamilton<a></a> formulated the conclusions about their role in competitive sports as shown in <b>Table I</b>. Most amputees are not interested in competition, but desire to engage in recreational athletic activities.</p> <strong>Table I. Suggested Areas of Athletic Participation by Unimembral and/or Uncomplicated Amputees</strong><br /><img src="/files/original/3315a246e37eef6187bbc4b8ea89f1ba.jpg" p="" width="399" height="473" /> Beginning in Europe in the late 1940's, skiing was one of the first sports to be "adopted" for amputees. In the United States there has been a great interest in this activity, as manifested by the formation of the National Amputee Ski Association. Special ski boots and outriggers have been developed. The unilateral below-knee amputee can ski with or without a prosthesis. The bilateral below-knee uses the four track technique with two prostheses, two skis and outriggers. The unilateral above-knee usually must ski on the intact leg using the three track technique. The bilateral above-knee can use short prostheses without knee mechanisms. Cross-country skiing is recommended solely for the below knee amputee. According to Bernice Kegel, the average amputee can learn to ski intermediate and expert slopes in one fourth the time an abled-bodied skier needs, and with a far greater degree of proficiency.<a></a> <p>Swimming is an activity that can be enjoyed by amputees of all ages. If the swimmer is able to stay afloat safely without a prosthesis, opportunities are plentiful as swimming facilities are fairly common in our society. For the amputee who wishes to enjoy aquatic activities, several options are available:</p> <ol> <li> <p>Swimming without a prosthesis</p> </li> <li> <p>Peg legs for use on the beach and possibly swimming</p> </li> <li> <p>Sockets attached directly to swim fins</p> </li> <li> <p>The utility or beach prosthesis used to ambulate on the beach but not for swimming</p> </li> <li> <p>The swimming leg worn while in the water<a></a></p> </li> </ol> <p>Water skiing is another activity that can be enjoyed by amputees.</p> <p>Wheelchair sports have been organized for amputees, also. A rather detailed classification of degrees of disability has been developed to maintain fairness in competition for men and women. Competition is now commonplace in wheelchair basketball, marathon races, bowling, field events, table tennis, and archery; there are even international events.</p> <p>Special prosthetic adaptations have been developed for the lower extremity amputee who is interested in participating in the following activities.</p> <ol> <li> <p>Golfing—a rotor in the shank<a></a></p> </li> <li> <p>Flying—portable hand controls and a special SACH foot<a></a></p> </li> <li> <p>Boating<a></a></p> </li> <li> <p>Horseback riding<a></a></p> </li> </ol> <p>In the upper extremity, special adaptations may be necessary for certain activities. The standard terminal device may be used for given activities, especially in the case of the unilateral amputee. For other activities the amputee may find it more convenient to remove the prosthesis completely. By and large the ability of the bilateral upper limb amputee is dependent upon the strength and mobility of the residual limbs. For the upper limb amputee, M.D. Robb<a></a> has grouped activities into those requiring closed or open skills. When the environment or activity is highly unpredictable and constantly changing, open skills are needed to adjust to and/or regulate the environment. Closed skills are those such as swimming, bowling, and golf activities which are performed in a comparatively stable environment. Among the recreational activities for which adaptive devices have been developed are:</p> <ol> <li> <p>Rein bar for horseback riding<a></a></p> </li> <li> <p>Special terminal device for fishing<a></a></p> </li> <li> <p>Terminal device for bowling<a></a></p> </li> <li> <p>Fletcher-Motis adapter for archery<a></a></p> </li> <li> <p>Universal joint terminal device for golf<a></a></p> </li> <li> <p>Additional devices adapted for hockey,<a></a> skiing,<a></a> and driving<a></a></p> </li> <li> <p>Baseball glove terminal device for the unilateral below elbow (this has always been a popular item among teenage boys in our clinic)<a></a></p> </li> </ol> <p>Swimming can usually be accomplished without prostheses and special appliances. However, it may require minor adaptations of stroke techniques, kick modifications and a special breathing pattern.<a></a></p> <p>It should be apparent even to the casual observer that there are benefits to be derived from the use of secondary prostheses or adaptive devices by amputees. The physiological benefits will flow to the cardiopulmonary system as the result of the physical activity.</p> <p>However, there is another even greater benefit—the psychological uplift—realized by the patient who achieves new heights of pleasure, pride, and increased self esteem by participation in physical recreation and/or competition. This aspect is so important to the total treatment and rehabilitation of the amputee patient that we must educate clinicians and third party carriers so that ordering such devices will become routine for all who have the ability and desire to use them. Furthermore, third party carriers should pay for them as routinely as the standard prostheses. In this manner we can give our patients the opportunity to participate in and enjoy life more fully—the essence of rehabilitation.</p> <p><b>References:</b></p> <ol> <li>Hamilton, R.C.: The juvenile amputee in athletics. Inter-Clinic Info. Bull., 6(1):1, 1966.</li> <li>Kegel, Bernice: Prostheses and assistive devices for special activities. Chapter 29, Atlas of Limb Prosthetics, American Academy of Orthopaedic Surgeons, St. Louis, C.V. Mosby, 1981.</li> <li>Racette, W., and Beraken, J.W.: Clinical experience and functional considerations of axial rotators for the amputee. Orthot. Prosthet. 31(2): 29,1977.</li> <li>Hughes, H. N. and Helmuth, G.: A modified prosthetic foot for pilots. Orthot. Prosthet. 29(1): 33,1975.</li> <li>Robb, M.D.: The dynamics of motor skill acquisition. En-glewood Cliffs, N.J., Prentice-Hall, Inc., 1972.</li> <li>Larkins, C: Horsemanship for the physically handicapped. Inter-Clin. Info. Bull., 9(7): 4-11, 1970.</li> <li>Sabolich, L.J.: An adapted fishing rod for arm amputees. Inter-clin. Info. Bull., 12(2): 13-15,1972.</li> <li>Kay, H.W.; Lewis, S.L.; and Steward, W.A.: A bowling device for bilateral arm amputees. Inter-Clin. Info. Bull., 9(7): 13-16, 1970.</li> <li>Bender, L.F.: Prostheses and rehabilitation after arm amputation. Springfield, Illinois, Charles C. Thomas, 1974.</li> <li>Redford, J.B.: Prostheses for hockey-playing upper limb amputees. Inter-Clin. Info. Bull., 14(6): 11-15,1975</li> <li>Stanek, W.F.: Report of the juvenile amputee ski program. Inter-Clin. Info. Bull., 8(9): 1, 1969.</li> <li>Wuttke, W.: New German foot-control system enables armless persons to drive. Rehabilitation World, pp. 12-13. Winter 1978-79.</li> <li>Shearer, J.D.; Buckner, M.L.; and Bowker, J.H.: Prostheses and assistive devices for special activities. Chapter 16, Atlas of Limb Prosthetics, American Academy of Orthopaedic Surgeons, St. Louis, C.V. Mosby, 1981.</li> </ol> <div style="width: 400px;"><em><b>*Charles H. Epps, Jr., MD </b> Professor and Chief Division of Orthopaedic Surgery, Howard University Hospital, Washington, DC<br /><br /><br /></em></div> <div style="width: 400px;"></div> Page Number(s) 5 - 6 Year 1982 Volume 6 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1982_04_005/1982_04_005-1.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 Editorial: Special Prostheses Enhance Rehabilitation Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., MD * https://staging.drfop.org/files/original/78bf6788488bdf97bc8b5683d42a6f70.pdf 28499b5aee932356ff3db57649d54f41 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_03_005.pdf Text Any textual data included in the document <h2>Editorial: The Driving Force in Rehabilitation</h2> <h5>William M. Susman, M.A., R.P.T.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>By design, and in daily clinical practice, rehabilitation is a multi-disciplinary effort. The patient is best served by professionals addressing the psychosocial and vocational aspects of disability as well as the various aspects of physical impairment in a specialized manner. The driving force behind the effective functioning of this approach is communication among the professionals comprising the rehabilitation team. This communication may occur within the structured format of professional publications, the formal yet often spontaneous settings of team clinics and rounds, or the many informal daily contacts between colleagues involved in the treatment of any one patient.</p> <p>Such communication enhances patient management in numerous ways. Consistent definitions and coordination of treatment approaches and goals can be achieved. Different perspectives regarding the same clinical situation can be shared, perspectives tempered by the different relationship each team member has with the patient, the expertise each member brings to the clinical problem, and the priority of concerns each establishes according to his or her functional role. Perhaps most importantly, the team is able to bring its collective clinical experience to bear upon the problem at hand. No one clinician, regardless of depth or breadth of experience, should fail to search out and use this collective experience for it can only serve to broaden the range of possible solutions.</p> <p>An excellent example of such an opportunity is provided in the lead article by Dr. Alexander in this issue of the Newsletter. This is not to say that executive decisions should not be made in the rehabilitation setting, but that if they are based upon the communicated experience and viewpoints of all team members, such decisions will not be autocratic.</p> <p>It should not be forgotten that the clinician also benefits from such communication. The most stimulating workplace is one in which a free exchange of ideas can take place without the fear that image or role is being threatened. In an imperfect world with personality differences and professional pressures, this can be hard to achieve, but must be actively sought. The stimulation of thought through this collective process also leads to clinical innovation and new research ideas and, ultimately, improvement in the professional's level of expertise and advancement of the state of the art of rehabilitation as a whole.</p> <p>Clinical professions involved in rehabilitation are currently undergoing rapid growth in knowledge base, upgrading of standards for entry into practice, and increasing professional responsibility. The fields of orthotics and prosthetics and physical therapy may be the best examples of these trends. It is imperative that no one clinical field, regardless of increased training, authority, or specialization becomes more isolated in clinical practice. Obviously, a given level of clinical skill cannot be replaced by input from another discipline, but the effective use of that skill can be channeled by communication within the clinic team towards better patient treatment, our foremost concern.</p> <b>*<em>William M. Susman, M.A., R.P.T. </em></b><em> Assistant Professor, Ithaca College, Division of Physical Therapy, Albert Einstein College of Medicine, Jacobi Hospital, Bronx, New York.</em><br /> <div style="width: 400px;"></div> Page Number(s) 5 - 6 Year 1980 Volume 4 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: The Driving Force in Rehabilitation Creator An entity primarily responsible for making the resource William M. Susman, M.A., R.P.T. * https://staging.drfop.org/files/original/fdb824053cd07dc56b8a0f9bb5710f77.pdf 040eee9523be02600597ae2e21998310 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_005.pdf Text Any textual data included in the document <h2>Editorial: Tightening The Loops On Sensory Feedback</h2> <h5>John Lyman, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Ma Bell's radio and TV ad theme, "reach out and touch someone", appeals to everyone. It represents contact with those sensitive, often sentimental, emotional connections we have with our environment and the people and things that we value. In real life, it is only one's voice and the feedback of the voices of our familiar compadres that makes situations comparable to the telephone company ad warm and real. We all know the experience. What makes it work?</p> <p>Many years of experience in the serious pursuit of possible answers to this question, and its broader implications concerning the role of sensory feedback in shaping human performance, have brought us only a few answers on which we can count. Mostly, we only know that the importance of sensory feedback varies greatly with specific situations, and that the role of the senses is very complex because of two-way filter interactions with the central nervous system. We do know quite a lot about the specifics of the sensory receptors themselves. It is, however, the manner in which the patterns of sensory stimuli provide information for processing by the spinal cord and higher levels that is clinically provocative.</p> <p>With specific reference to limb amputees, everyone agrees that to achieve functional unity with a prosthesis, there must be some form of awareness established by the wearer about the capabilities of the prosthesis. How reliably does it respond to the amputee's command? Does it react predictably to each familiar environmental situation so that the wearer has an accurate mental model of what to expect? Getting a wrong number does not reach out and touch the expected connection. After too many wrong numbers or too much noise in the connection, one tends to lose that warm feeling of predictable expectation. This appears to be the case in the matter of the state-of-the-art with sensory feedback in limb prosthetics.</p> <p>We have long known that the primary source of sensory feedback for limb prosthesis wearers was an "open loop" mental model of the space occupied by the prosthesis, its dynamic control features and pressure patterns on the stump-all modulated by visual, and sometimes auditory, information from both the prosthesis and its situational environment.</p> <p>To date, except for blind amputees where any feedback from the environment is helpful, we have not been able to definitively establish whether or not specialized sensors located on the prosthesis itself could effectively communicate signals to the wearer that would significantly enhance task performance. Experimental results have, for the most part, been marginal and frustrating, both scientifically and clinically.</p> <p>Despite many disappointments, especially in terms of immediately useable clinical benefits, our knowledge base has been substantially broadened, mostly concerning the scope and complexity of factors that realistically must be brought under control. For example, in the biological model of a limb, it is known that receptor density for cutaneous and kinesthetic senses (pressure, pain, thermal, etc.) may reach several hundred per square millimeter. These high receptor densities provide precise patterns of environmental information. They generate functionally important physiological and psychological adjustments of information flow rates. Refined movement may require highly defined sensory patterns to optimize the available muscle capability of the normal limb. The stability and continuity of these patterns is identified with the integrative function of the central nervous system. The distortion of the patterns by modification from disease, or by total physical destruction, requires laying down new cognitive adaptations. These adaptations can only reach a degree of approximation to the original system. The extent of the sensory side of the approximation is dependent on the capability for sensory input that remains or is replaced. Substitution of one pattern of signals for another depends on achieving a common coding scheme. Whatever scheme is achieved, it must be compatible at both the input and output sides of the person-prosthesis loop. Missing or distorted patterns are functionally reconstructed into new channels, both by means of the "software" of the brain, and substitution of sensors. When the sensations are natural, e.g., from the surface of a stump, the sensors available probably were not previously used for primary information about the location of and forces on the limb in space. New cognitive patterns must be brought into association. These new patterns may only provide part of the information previously presented, or the information provided may not be relevant. Thus, there may be a permanent substantial loss of skill.</p> <p>The original, natural, learning process in the intact person seems to make use of whatever sensory function is available to provide a pliable, plastic motor output capability. This is subject to refinement of precision according to criteria set genetically (e.g., walking), or learned according to environmental and personal, i.e., cognitive set standards for performance. "Normal" gait for a leg prosthesis wearer, "smooth," "coordinated" delivery of a fork full of food by an arm amputee, may have to come to mean something different, cognitively, than these actions for the non-amputee.</p> <p>For the amputee, complex situational vectors are set up by a combination of motor deficits and sensory deficits. This makes it especially difficult to independently assess the role of sensory feedback in task performance. For example, direct observations of the role of the senses is confounded by factors such as the transmission precision of the power train, by dynamic stability properties of the structural interface between the stump and the socket, and by task complexity, e.g., climbing stairs, rotating a door knob, etc. A simple analog would be to try to observe the role of sensory feedback in the performance of a non-amputee who was trying to write with a pencil that had the tip attached to a soft, compliant, rubber-like shaft. The capricious relationship between the tip of the pencil and the writer would make interpretation of the performance associate more closely with the hardware interface between the writer and his task than with the properties of the writer's sensory-motor system.</p> <p>To function with maximum effectiveness, the communications channels, as well as the energy (power) transfer channels, must be locked intimately and reliably together in both the relationship of time, e.g., minimum transmission time-lag, and geometric positions. It seems probable that sensory information, to be effective, must have a tight, reliable, one-to-one superposition with a tight, reliable motor output system.</p> <p>It is, thus, our view that perhaps a major reason for not being able to obtain clear-cut experimental results with artificial sensory feedback techniques for limb prostheses is that the linkages between the subsystem interfaces have usually been excessively "loose." The messages in both directions are garbled. As the requirement for task precision increases, the effects of loose communication links become increasingly evident. Softness of fit between the prosthesis and the flesh of the stump, for example, generates uncertain messages in both directions. The "reach out and touch" is a spongy approximation, a sensory haze at the cognitive level.</p> <p>The bad news is that in the prevailing situation, where direct bone attachments have not reached a level of development suitable for standard clinical practice, the tightening of sensory feedback loops and feed-forward loops seems to be inherently limited in promise. The good news is that with each year, the background research and technology is progressing to significantly more sophisticated levels, achieving denser, more accurate and less power-consuming transducer arrays for picking up the tactile features of the environment. As has often been the case before in the history of important prosthesis development, much of the technology for sensory augmentation is to be found in other applications, in this case, industrial automation and robotics. When, as will happen sooner or later, art and technology reach out and come together, the parts of the limb-prosthesis system will indeed, touch-with feeling.</p> <em><b>*John Lyman, Ph.D. </b> Professor and Chair, Engineering Systems Department Head, Biotechnology Laboratory, UCLA, Los Angeles, CA 90024</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 5 - 6 Year 1981 Volume 5 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Tightening The Loops On Sensory Feedback Creator An entity primarily responsible for making the resource John Lyman, Ph.D. * https://staging.drfop.org/files/original/09fe10baa626726ecfda342c957103aa.pdf d19f909aad10c8d77d23f58e47708607 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_02_007.pdf Text Any textual data included in the document <h2>Editorial: To Fill a Void</h2> <h5>A. Bennett Wilson, Jr.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>I believe that everyone familiar with the recent history of prosthetics and orthotics will agree that the results of the research program in artificial limbs initiated in 1945 by the National Academy of Sciences at the insistence of the Surgeon General of the Army has been very beneficial to amputees and to the prosthetists that serve them. Patients requiring orthopaedic bracing and orthotists have also benefited from this program, which has been supported from the beginning by the Veterans Administration and since about 1956 by the Department of Health, Education &amp; Welfare. Yet for the first five years, or so, of the program, prosthetists and orthotists, not knowing how it would affect their "business," were quite wary of the government-supported research and development teams, and it was not an easy matter to induce practicing private prosthetists to attend the first series of formal education programs offered by the government at UCLA in 1953, even when their attendance was heavily subsidized.</p> <p>Today, the prosthetics and orthotics education programs are considered by all to be essential to the maintenance of a healthy prosthetics and orthotics service, and students pay substantial tuitions to obtain an education in this field. In recent years the AAOP has come forth with continuing education programs that are being improved steadily, and I am sure the younger practitioners probably find it difficult to imagine a world without formal education programs in prosthetics and orthotics.</p> <p>Although the original purpose of the educational programs was to introduce the results of research to practitioners as soon as possible, the government agencies, for reasons known only to the bureaucrats involved, have in recent years essentially abandoned support of research in prosthetics and orthotics. A review of the latest issue of the Bulletin of Prosthetics Research (BPR #10-32) which contains progress reports on all of the research and development efforts in prosthetics and orthotics supported by the VA and DHEW, indicates that less than a quarter of the projects devoted to "Rehabilitation Engineering" relate to prosthetics and orthotics. The percentage in terms of fiscal support is probably even less. This circumstance is reflected also in the source of manuscripts submitted to "Orthotics and Prosthetics." In the past, most of the articles were submitted by workers involved in government-supported research programs. Today, the majority of articles are being received from private practitioners.</p> <p>Perhaps this is as it should be, even though medical research is heavily subsidized, and maybe the prosthetics and orthotics profession has grown to the point where it can assume the leadership in the research, development, evaluation, and education needed if it is to continue to provide the increasingly better services expected of professional groups.</p> <p>In addition to the role of the AAOP in providing opportunities for continuing education, an encouraging signal seems to be coming recently through many of the manuscripts submitted to "O &amp; P" in which practicing prosthetists and orthotists describe their own innovations. However, almost without exception, the authors include only their own experiences with patients, and it never fails to occur to me, as editor, what a pity it is that there exists no group to which these excellent ideas can be submitted for a non-biased evaluation conducted under typical clinical conditions, and thus, be channelled with confidence into the formal educational programs.</p> <p>Even if the federal bureaucrats feel that research and development in prosthetics and orthotics is not important or glamorous enough for support, perhaps AAOP could persuade them that it would be in the public interest to support, at least partially, a clinical evaluation program to be conducted by the Academy. I am confident that Academy members will gladly cooperate by fitting patients on a controlled, experimental basis, and, thus, the government will need to support only staff, travel expenses, and in some instances the cost of materials and devices in connection with this much needed function.</p> <p>If such a project is proposed, I recommend strongly that the universities and colleges offering educational programs in prosthetics and orthotics be given the opportunity to participate, for, in that way, any recommendation that a device or technique be added to their respective programs will come as no surprise, and therefore be accepted more readily.<br /><br /><b>*<em>A. Bennett Wilson, Jr. </em></b><em> Director, Rehab. Engineering Program, University of Texas Health Science Center at Dallas; Editor, O &amp;P Journal</em></p> Page Number(s) 7 - 7 Year 1980 Volume 4 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: To Fill a Void Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/05797d097e7ea7bad20de2770f06ed76.pdf d699846094a3209fce59adbb13245529 https://staging.drfop.org/files/original/f98ef36fe95f94695881ac19925c87a9.jpg 30eb9bb0dc166fc3e4b3e982d869a061 https://staging.drfop.org/files/original/3f4b5b9d7c4f70854173c781c4481798.jpg 5ca81b27f54f0f31107e402d7d5b9cb2 https://staging.drfop.org/files/original/e349ce4b1ee6b4c02285e4909c234840.jpg 8de21023d178bf28467ea698c6b1c205 https://staging.drfop.org/files/original/4d87c9d67d81a8f92e52306ee2883f12.jpg b931c8ba3d44b6753e00a7f4493ef3af https://staging.drfop.org/files/original/d8ae7a1cea1830e2967b85b3afa776ab.jpg 1c823de12ebbf9e31f89866f0b07d59f https://staging.drfop.org/files/original/dbea119e932addf689fac9106cd0855e.jpg dc1f371a8c41a1e8da75e9ff08e496b6 https://staging.drfop.org/files/original/a6b7887debc002729c288b71ad391f6d.jpg de80f95e85cf71e745f38c6290765c9c https://staging.drfop.org/files/original/cefb99637af02427a4920d527a6cde80.jpg 4d5b9c08311b42d45b26abb4f1dfbeb9 https://staging.drfop.org/files/original/8570f07fd1f37cb83a54e7a55184cb89.jpg 107e71ad31ce064c650020317eb40e6e https://staging.drfop.org/files/original/ddde5450ec9bcccfc098853075b0d207.jpg 0e79c7eda7e3e3a0e5fa51bde27aa4f5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_022.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 22 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Elastic-Liner Type of Syme Prosthesis: Basic Procedure and Variations</h2> <h5>Maurice A. LeBlanc <a style="text-decoration:none;">*</a><br /></h5> <p>In the past few years, a number of pros-thetists have been fabricating elastic-liner types of Syme prostheses, and their procedures have been described in the literature. <a></a> This article presents the most commonly used procedure and some of the variations to it.</p> <p>The elastic-liner type of Syme prosthesis has the advantage of eliminating the door on the conventional prosthesis (<b>Fig. 1</b>), thereby allowing greater strength (with no openings) and a smoother cosmetic finish (with no straps) while maintaining total contact and suspension (<b>Fig. 2</b>). However, it cannot be used if the bulbous end of the stump is too large for satisfactory cosmesis of the cylindrical portion or for making the liner (not possible when the distal end is larger than the proximal brim).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Conventional Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Elastic-liner Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Basic Procedure</h3> <ol> <li>Felt patches are placed on the stump for relief of bony prominences and/or sensitive areas.</li><li>A plaster cast is taken of the stump with partial weight-bearing and with blocks making up the length discrepancy.</li><li>The largest diameter of the bulbous end of the stump is measured, and the proximal level of the stump model is marked where its largest diameter equals that of the bulbous end.</li><li>Using nylon stockinette, the inner socket is vacuum-laminated with Silastic (TM) elastomer #384 from the level marked in step 3 to the end of the stump (<b>Fig. 3</b>).</li><li>The remainder of the inner socket (the proximal brim down to the level of the elastomer) is laminated with Laminac (TM) #4110 polyester resin.</li><li>A wax build-up is made over the center portion of the inner socket between the bulbous end and the level marked in step 3 (<b>Fig. 4</b>). The build-up is cylindrical in shape to allow entry of the stump into the socket.</li><li>The outer shell of the socket is laminated with Laminac #4110. <b>Fig. 5</b> shows a cutaway view of the inner socket and outer shell of the prosthesis. Note that the end of the liner must be attached to the outer shell so it will not pull out with the stump.</li><li>Using reference lines established on the plaster cast, the socket is statically aligned following the attachment of a SACH foot which has been cut and shaped to receive the bulbous end of the socket. (There is normally about a three-inch height discrepancy with the Syme's amputation.)</li><li>The socket is then dynamically aligned to the amputee's gait. Depending on the method of attachment of the SACH foot to the socket, adjustment is usually provided by means of an alignment disc or by repositioning the socket with quick-setting epoxy resin.</li><li>The prosthesis is completed by laminating the socket and keel of the SACH foot and reattaching the sole (<b>Fig. 6</b>). Fiberglass reinforcement is usually used in the lamination.</li></ol> <h3>Variations</h3> <ol> <li>Alginate can also be used to make the negative impression of the stump. It gives better detail, and its elasticity allows easy stump removal. However, it is expensive, and one cannot see to position the heel pad while it is setting.</li><li>Modification can be accomplished on the plaster model instead of using the felt patches. Either way is satisfactory, but using the patches saves time and is equally effective if they are properly placed.</li><li> A combination of 80% of Silastic elastomer #384 and 20% of #386 (foam) for the liner can be used to increase its expandability. More than 20% of #386 foams too much and reduces durability. <a></a></li><li> One variation on the size of the liner is to laminate the liner down to the largest diameter of the bulbous end rather than including the entire end. It is then not necessary to attach the end of the liner to the outer shell (<b>Fig. 7</b>).</li><li> Another method of sizing the liner is to make an elastic window in the inner socket instead of making a whole inner bladder (<b>Fig. 8</b>). This allows entry by rotating the stump as it goes into the socket, and makes possible a very cosmetic prosthesis.</li><li> Instead of making a wax build-up, it is possible to use Silastic elastomer #386 foam for the space between the liner and outer shell and to leave it in the prosthesis. It is lightweight and can be compressed to allow entry of the stump. (This procedure is being used by William Sinclair, C.P.O., at Jackson Memorial Hospital in Miami, Florida.)</li><li>Another way to modify the SACH foot and attach it to the socket is shown in <b>Fig. 9</b> and <b>Fig. 10</b>.</li></ol> <p>A wooden block is fitted and fastened to the distal end of the socket, and the bottom is sanded so it establishes the flexion and adduction angles of the socket. The wooden block forms a socket base for attachment of the SACH foot with the hardwood base and plug which reinforce the keel.</p> <h3>Acknowledgments</h3> <p>The author wishes to thank Herbert W. Marx, C.P.O., and Robert Mazet, Jr., M.D., for lending several of the illustrations used in this article.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Eckhardt, Arthur L., and Harold Enneberg, The use of a Silastic liner in the Syme's prosthesis, Inter-Clinic Inform. Bull., 9:6:1-4, March 1970.</li> <li>Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</li> <li>Mazet, Robert, Jr., Syme's amputation, a follow-up study of fifty-one adults and thirty-two children, J. Bone Joint Surg., 50-A:8:1549-1563, December 1968.</li> <li>Meyer, Leslie C, Harry L. Bailey, and Dewey Friddle, Jr., An improved prosthesis for fitting the ankle-disarticulation amputee, Inter-Clinic Inform. Bull., 9:6:11-15, March 1970.</li> <li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, Spring 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Eckhardt, Arthur L., and Harold Enneberg, The use of a Silastic liner in the Syme's prosthesis, Inter-Clinic Inform. Bull., 9:6:1-4, March 1970.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Mazet, Robert, Jr., Syme's amputation, a follow-up study of fifty-one adults and thirty-two children, J. Bone Joint Surg., 50-A:8:1549-1563, December 1968.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Meyer, Leslie C, Harry L. Bailey, and Dewey Friddle, Jr., An improved prosthesis for fitting the ankle-disarticulation amputee, Inter-Clinic Inform. Bull., 9:6:11-15, March 1970.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Maurice A. LeBlanc </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Research Council-National Academy of Sciences.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-10.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 Elastic-Liner Type of Syme Prosthesis: Basic Procedure and Variations Creator An entity primarily responsible for making the resource Maurice A. LeBlanc * https://staging.drfop.org/files/original/0dd9f601769f60d4d41eff49c4f7e903.pdf 6083dd5dd381a8def8f92abd19065155 https://staging.drfop.org/files/original/67b2bb7011e7d4265c42e6b2743f583c.jpg 973338862e76956d2630ed5644e0145b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_01_001.pdf Text Any textual data included in the document <h2>Endoskeletal Prostheses: Cause for Reflection</h2> <h5>Charles H. Pritham, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>American prosthetists have now accumulated a decade of experience with endoskeletal modular prostheses. In light of this experience, it seems logical to reassess the criteria and priorities that guided the development of this method of providing prosthetic care. If one were to choose two events more than others that marked the beginning of the "new era," they would have to be the introduction in the Fall of 1970<a></a> of the Otto Bock endoskeletal system and the convening in March 1971 by CPRD of a workshop entitled, "Cosmesis and Modular Limb Prostheses"<a></a>. Few are unfamiliar with the features of the Otto Bock system and they hardly need to be commented on here. Suffice it to say that the system undoubtedly represents the highest possible physical expression of the modular endoskeletal concept. The second development referred to, the CPRD workshop, is probably less familiar and merits closer attention, especially so since the report from the workshop states the philosophy of the endoskeletal modular approach to limb prosthetics.</p> <p>That philosophy finds its fullest and most concise exposition in the remarks of D.S. McKenzie, M.D.<a></a>, <b>Table I</b>. <br /><br /><img src="https://staging.drfop.org/files/original/67b2bb7011e7d4265c42e6b2743f583c.jpg" p="" width="503" height="296" />In other sections of the report, the CPRD workshop recommended improvements in cosmetic covers and prosthetic skins and development of endoskeletal upper limb prostheses employing center-pull cables and external power. Indeed, so sanguine were the attendees at the workshop about the future of endoskeletal modular limb prostheses that they essentially recommended that all future development be done in this context.</p> <p>Comparison of expectation with reality is very difficult in this situation as there is very little in the literature that describes field experience with endoskeletal modular prostheses. What information there is<a></a>, is largely anecdotal but it suggests that the problems encountered focus on weight and poorer durability than conventional exoskeletal prostheses. The upshot is that endoskeletal prostheses are fundamentally considered luxury items to be prescribed for light-activity, appearance-conscious wearers. Wider-spread acceptance has primarily occurred with hip disarticulation prostheses due to ease of fabrication and favorable weight competitiveness compared to conventional means of construction.</p> <p>It seems fair to conclude, therefore, that anyone who subscribed to the criteria developed in the CPRD workshop of 1971 would be disappointed with the rate of acceptance and continued improvements in endoskeletal prosthetic systems during the past decade. It is convenient to ascribe this failure to intransigent conservatism on the part of the third-party payers and of individual prosthetists. Perhaps a more proper explanation can be found in the precepts that shaped the development of the prostheses themselves.</p> <p>Endoskeletal modular prosthetic systems are intended by their very nature to encompass the needs of the vast majority of amputees. In effect, they represent a series of compromises: strong enough for all but the most punishing of patients and yet light enough for all but the most feeble of patients, etc. Anything or anyone who attempts to be all things to all men generally ends up satisfying no one. In this regard a fundamental fact about the nature of the amputee population needs to be acknowledged. The primary cause of amputation in western society is disease and this primarily affects the older age group. Comparison of amputee censuses<a></a> bears this out. Moreover, with declining birth rates and increased longevity, the age of the population in general is shifting to the higher decades. The one trend reinforces the other and we may confidently expect in the years ahead that even more of our patients will be 65 or over with circulatory disorders and multiple involvement. It is widely admitted that the needs of the geriatric amputee are different from the needs of the younger amputee. Sophisticated knee and ankle function become less important, and light weight, comfort, and ease of donning become more important. In effect, the nature of the amputee population and the precepts guiding development of prostheses have changed, but prosthetists and developers of prostheses have been slow to recognize the change. In part this is due to the fact that the needs of geriatrics are mundane and prosaic as compared to the challenge offered in designing a high performance, sophisticated prosthesis for a young vigorous user who uses a prosthesis maximally and thus offers maximum positive reinforcement to the designer.</p> <p>Another matter that deserves consideration is the concept that it should be readily possible by changing components or alignment to adapt the prosthesis to the changing needs of the amputee and that the same prosthesis that serves him 24 hours after surgery will still be suitable 24 months after surgery. Reference here is made to <b>Table I</b>&nbsp;where the different stages in the experience of an amputee are listed vertically and the various possible features of a prosthesis are listed horizontally. Advocates of the first viewpoint, such as D.S. McKenzie, would have it that at any given moment in the experience of an amputee, all possible features are present. Advocates of the second view would have it that for the sake of expediency, low weight, cost, durability, and other considerations, only those features absolutely necessary at any one stage of development would be present-in effect that form follows function. For example, while quick-disconnect of the pylon and foot from the socket is suitable and even necessary in an immediate post-operative prosthesis (I.P.O.P.), it is unnecessary and a possible source of trouble in a definitive prosthesis. An advocate of this second point of view might fill out the table much as it has been done.</p> <p>Central to this discussion is the question of what is an acceptable range of alignment adjustability at any one stage. Few would dispute that full range of alignment adjustability is necessary in I.P.O.P.s and temporary prostheses. Less unanimity greets the statement that it should be present in definitive prostheses. Some would maintain that it is not necessary in definitive prostheses and that, in any event, some range of adjustability (height, transverse rotation of foot, and in some cases, of the knee) is present and that this is all that is necessary in the vast majority of cases. They would further maintain that any increase in alignment adjustability represents an unacceptable increase in weight and decreases in reliability. Moreover, they would have it that should you have to change any of the other factors of alignment, something is so seriously wrong as to warrant starting over again completely from scratch. This second point of view is exemplified most strikingly in the Adaptive Fixation Prosthesis (A.F.P.) system of Medical Center Prosthetics of Houston, Texas.</p> <p>There is one final topic that merits discussion and that is the matter of cosmesis. Current techniques of providing cosmetic covers entail the carving of internal and external contours and are expensive and time consuming. Moreover, it is questionable as to whether or not the results merit the effort, as the covers for all levels of amputation are flimsy. For above-knee and higher, the one-piece covers inhibit function. Support hose currently used as prosthetic skins are even less durable, yet attempts to provide stronger skins have been defeated by the need to accommodate the extreme motion of the knee. (It remains to be seen whether it will be possible to devise successful one-piece cosmetic covers for above-knee prostheses with current technology or if we will eventually sacrifice some of the cosmesis of one-piece covers and adopt two-piece covers and improved durability.) Again, the work of Medical Center Prosthetics and their technique for foaming cosmetic covers in place are noted.</p> <p>In conclusion, it is possible to pose a number of questions:</p> <p>1.&nbsp;Do available endoskeletal prosthetic systems meet the needs of the majority of amputees as well as do exoskeletal prostheses?</p> <p>2.&nbsp;If they do, why are they not used with greater frequency than casual impression seems to imply that they are?</p> <p>3.&nbsp;Is it desirable to use a common family of endoskeletal components at all stages of an amputee's progress post-amputation or can an increase in desirable qualities be achieved by more specifically matching the available components and the individual's progress?</p> <p>4.&nbsp;Is it desirable and necessary to have full capability for alignment adjustability present in a definitive prosthesis or can some adjustability be sacrificed to decrease weight and heighten reliability?</p> <p>5.&nbsp;If cosmetic covers were better than they are, would more endoskeletal prostheses be prescribed? Or is it that if more endoskeletal prostheses were prescribed, better cosmetic covers would be developed?</p> <p>The present group of endoskeletal systems (with one exception) can be considered as first generation systems. Extensive experience has been gained with them and it seems reasonable to assess this experience with an eye towards developing criteria for second generation systems. Further, it seems only just that those personnel who have day-to-day experience be canvassed in developing these criteria.</p> <p><b>References:</b></p> <ol> <li><i>Below-Knee and Above-Knee Prostheses</i>, Committee on Prosthetic Research and Development, National Academy of Sciences, Washington, D.C. 1973, page 21.</li> <li><i>Cosmesis and Modular Limb Prostheses</i>, Committee on Prosthetic Research and Development, National Academy of Sciences, Washington, D.C. 1971.</li> <li>Wilson, A. Bennett, Jr., "Lower Limb Modular Prostheses, A Status Report," <i>Orthotics and Prosthetics</i>, Vol. 29, No. 1, pp. 23-32, March 1975.</li> <li>Kay, Hector W. and Newman, June D., "Amputee Survey 1973-74, Preliminary Findings and Comparisons,"<i> Orthotics and Prosthetics</i>, Vol. 28, No. 2, pp. 27-32, June 1974.</li> </ol> <div style="width: 400px;"><em><b>*Charles H. Pritham, C.P.O. </b> Formerly Director, Prosthetic and Orthotic Laboratory, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, PA. Presently Manager, Snell's of Louisville, Louisville, KY</em></div> Page Number(s) 1 - 3 Year 1982 Volume 6 Issue 1 Figure 1 TABLE I http://www.oandplibrary.org/cpo/images/1982_01_001/1982_01_001-1.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 Endoskeletal Prostheses: Cause for Reflection Creator An entity primarily responsible for making the resource Charles H. Pritham, C.P.O. * https://staging.drfop.org/files/original/6766332bd317d916ca9a238f35743f60.pdf 2b25dd44f3fa9c14c3be1eeea1a6e844 https://staging.drfop.org/files/original/d5809008a88d66f392efb83a15c98e08.jpg cea990994c7ba243100b8aa3d793d549 https://staging.drfop.org/files/original/d15c4c4e078acbf08e329fb7d2ff3af6.jpg e21aeea4c8203c21cdeedf3e3ec18a7d https://staging.drfop.org/files/original/e80eda1cd3d59fed9f1e0f8852d89735.jpg 56bc08198994bcfc62ee59886d6cf543 https://staging.drfop.org/files/original/5c659ce3f575c3d39ed5ff983405f233.jpg 4196cf554d53ae48ff899b8a51c5f98d https://staging.drfop.org/files/original/4471076f5da8b14d5f383cfef89e77da.jpg 876943b0c3cb1adfe8d456633ea0deb5 https://staging.drfop.org/files/original/7c3a2e144e4bf74065eb614cc24fbc5a.jpg 6efc62a9627b6315da3ef4380c5b8897 https://staging.drfop.org/files/original/7021a0f992d9834c3826a5c1214833c8.jpg ac3f65dc469a2e5b4a83a58c293a1a31 https://staging.drfop.org/files/original/e00bf130dfa52ef46f528d2fdcc21d5a.jpg c5b7c3acf44d1a4edfde62205f5d406e https://staging.drfop.org/files/original/d8cb5c3a16381e1b972ccb339401ad23.jpg a3120f6ef46cc75bdc38ef387740cf62 https://staging.drfop.org/files/original/a746e158f57a6b359bd86178f753b692.jpg 51ffece8c90f2b03a122eb8e92ae3406 https://staging.drfop.org/files/original/69d23ce53227fa4c6a63c9be1e86399a.jpg c51ef4d9e33a90542ed1ab043e4cf346 https://staging.drfop.org/files/original/cf39f04ba9b82003e7d927e8bb478bd8.jpg 4525cdf1a7773f0d3cc0e843b33286f9 https://staging.drfop.org/files/original/05b9623006627347d7649027077c6775.jpg c4d0ddcbb9a3c19966e715953a0b6324 https://staging.drfop.org/files/original/5797c5b8c05087206ffbbd354701687c.jpg ba564008cd8af45856b50ffd5983cfa0 https://staging.drfop.org/files/original/0649b32d8d71675a737acb669446e101.jpg ad21f50147be20e5771cb0b30ecbda1d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_154.pdf Text Any textual data included in the document <h2>Energy Storing Feet: A Clinical Comparison</h2> <h5>John Michael, M.Ed., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The human foot is an exceedingly complex structure. The pair contain 52 separate bones, dozens of intrinsic muscles, and scores of extrinsic ones. The feet are composed of multiple layers of ligaments, fascia, and muscle, and contain numerous interrelated articulations.</p> <p>In combination with the ankle complex, the foot provides the dual functions of support and propulsion. Paradoxically, this is accomplished by combining the diametrically opposite characteristics of flexibility and rigidity as the foot adapts to the gait cycle.<a></a></p> <p>Despite hundreds of historical attempts to imitate this remarkable structure, very few designs have ever achieved widespread acceptance. Within the last three years, however, four new foot components have become commercially available—all in the previously unheard of class called "energy storing" designs. These intriguing new developments will be discussed in chronological order, summarizing our experience at Duke.</p> <h3>Seattle Foot™</h3> <p>In 1978, Bernice Kegal of the Prosthetics Research Study in Seattle published a paper entitled "Functional Capabilities of Lower Extremity Amputees,"<a></a> and noted that a major prosthetic limitation in sports activities was the inability to run. The vigorous amputee athlete was competing despite the components rather than because of them.</p> <p>The Prosthetics Research Study, in cooperation with engineers from Boeing aircraft, began developing a prosthetic foot specifically designed to store energy and release it at push off: the Seattle Foot™. First introduced in 1981 at a course in modern prosthetic rehabilitation presented by the American Academy of Orthopedic Surgeons, the Seattle Foot™ was later field tested by hundreds of Veterans Administration clients. Today, it should be widely acknowledged as the stimulus for the current explosion of new concepts in this area.</p> <p>The design specifics have varied over the past few years as the concept was refined. Originally, the keel was a fiberglas multi-leaf design, somewhat similar to an automobile suspension spring. The key concept was that as the patient increased his cadence, stiffer portions of the spring came into play. Various exotic materials were considered, including titanium, but were clinically impractical.<a></a></p> <p>The commercial version first became available in October, 1985 and consisted of a Delrin bolt block and integral keel, with Kevlar® toe pad (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg"><b>Fig. 1</b></a>). The entire structure is contained in a lifelike injection-molded polyurethane shape. To date, over 8,000 Seattle™ feet have been used in the United States.<a></a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg"><strong>Figure 1. Seattle Foot™ note cantilevered plastic spring keel to store energy (Courtesy MIND).</strong></a><br /> <p>Although patient acceptance has generally been good, several technical difficulties have been noted with this design. During the VA field-testing, catastrophic failure of the plastic keel occurred in some cases. This has been greatly reduced in the commercial version, provided the proper keel configuration is selected using the manufacturer's guidelines.</p> <p>Because of ongoing problems with failure of the flexible rubber toes at the keel tip, the polyurethane composition has recently been reformulated for more tear resistance.<a></a> About one third of our feet at Duke have failed in the forefoot, although all were replaced under manufacturer's warranty. We have experienced no catastrophic failures whatsoever in our series.</p> <p>The "Life-Molds," although very natural in appearance, have presented some difficulties. The first is that the forefoot is fairly wide and often difficult to fit into dress shoes, particularly narrow widths. In addition, there is no uniformity in dimensions from size to size, or even between left and right in the same size. For example, if a patient returns requesting a foot one size smaller since purchasing tighter shoes, and a 26cm foot is substituted for a 27cm foot, the prosthesis has been inadvertently shortened by 5mm (1/4"). Also, the stark contours of the original "Life-Molds" can be difficult to blend into the prosthetic ankle at the retromalleolar area, and are too muscular for some patients.</p> <p>The recently available "Ladies Molds" have effectively addressed the problems noted above. Redesign of the male version is underway, and is expected to achieve similar results.</p> <p>The Delrin keel has also been a source of problems. Because it is very slippery, inadvertent rotation and loss of toe out has occurred. Since drilling and pinning the bolt block would significantly increase the risk of breakage, the manufacturer recommends bonding the foot to the ankle block or endoskeletal adapter with hot-melt glue. This has eliminated problems with loss of toe out in our series at Duke, although we still experienced occasional problems with the keel "slipping" completely out of the polyurethane shell for active walkers.</p> <p>Problems have also been reported with occasional bolt breakage, and speculation regarding cold creep of the plastic has been voiced. The manufacturer supplies special bolts, locktite, and torque specifications to address this issue. We have experienced no bolt problems at Duke.</p> <p>Finally, this is the heaviest solid ankle design commercially available. Although most patients have no apparent difficulties, some find the weight objectionable. One volleyball player, in particular, rejected the foot for jumping activities, even though she found it excellent for jogging and similar sports.</p> <p>Despite the technical difficulties noted, our experience at Duke has generally been favorable. Patients often comment on the "lively" step permitted by the cantilevered spring design. We particularly favor this component in the smaller sizes (26cm and below), as the incidence of breakage seems reduced. One unilateral hip disarticulation amputee commented that the more active push off "lets me pass someone in a crowd for the first time since I became an amputee."<a></a></p> <h3>Flex-Foot™</h3> <p>At the same time the Seattle Foot™ was being developed, an independent collaboration between a plastics engineer and a young research prosthetist-amputee resulted in creation of the Flex-Foot™. This lightweight graphite composite structure offers a radically different approach. All are hand made from a computer-generated design specific to each individual patient. Data such as weight, activity level, and residual limb characteristics determine the specific orientation and thickness of reinforcement fibers.</p> <p>Ultra high pressure, high temperature molding insures the greatest possible strength to weight ratio, but requires several weeks for fabrication. Although this is a very costly approach, it does permit fitting the widest range of individuals. The chief restriction is that a minimum of five inches is required from the end of the residual limb to the floor, and seven inches or greater is preferred. Thus, the Flex-Foot™ is not suitable for small children, Symes and similar amputations, and very long below-knee residual limbs.<a></a></p> <p>Unlike any other component currently available, Flex-Foot™ utilizes the entire distance distal to the socket for function. Since it stores energy throughout its entire length rather than just within a four inch keel, this results in a very responsive and resilient component. It also significantly improves the mass distribution of the prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg"><strong>Figure 2. Flex-Foot™, showing full-length composite strut for energy return (Photo courtesy Flex-Foot, Inc.).</strong></a><br /> <p>Most multi-functional feet bolt onto the prosthesis at the ankle block, and are heavier than a conventional SACH foot. With the weight concentrated at the distal end, the limb swings as if it were a sledgehammer. Overcoming the inertia of this mass in order to propel it through space consumes energy, and the patient perceives it as "heavy."</p> <p>The Flex-Foot™, however, is more akin to an inverted sledgehammer. The bulk of the weight is in the socket and attachment cone, with the rest uniformly distributed in the pylon. This is analogous to holding the head of the sledge and swinging the handle through space. Even if the Flex-Foot™ prosthesis weighs nearly as much as the conventional limb, the patient finds it much easier to propel, and perceives it as "light." Actual weight savings of 10-15 percent are common, but patients typically perceive that the Flex-Foot™ weighs "half as much."</p> <p>Another advantage unique to the Flex-Foot™ is the ability to independently adjust the anterior and posterior lever arms. Overall stiffness is fabricated in at the factory, but tilting the pylon increases the anterior flexibility. Varying the length of the heel pylon independently controls its resistance. Conventional AP linear slide adjustments affect the resistances in the conventional manner: sliding the foot forward decreases posterior leverage while increasing the anterior resistance.</p> <p>Due to the complexity and magnitude of the inter-related alignment changes possible with the Flex-Foot™, we advocate use of a prototype prosthesis, at least initially. By dynamically aligning the new socket on a conventional foot using a conventional alignment fixture, mediolateral alignment and the quality of socket fitting can be easily evaluated and refined.</p> <p>Once these are satisfactory, the vertical transfer fixture can be used to permit substitution of the Flex-Foot™ pylon. A secondary dynamic alignment is then performed, permitting concentration on sagittal plane characteristics without being distracted by a multitude of adjustments in other planes.</p> <p>Although use of slow-motion video analysis has been of some value in refining the sagittal alignment, we strongly encourage an extended field trial prior to finishing the limb. Application of a PVC bag over the alignment fixture followed by several layers of fiberglass casting tape reinforcement will permit the patient to use the limb clinically for a week or two.</p> <p>Upon return to the laboratory, the fiberglass tape can be removed and the alignment further enhanced. As the patient becomes accustomed to the function of the Flex-Foot™, he will often prefer stronger anterior resistance. A knowledgeable physical therapist can be an asset at this stage, as the person must learn to shift his weight onto the Flex-Foot™ throughout stance phase and "ride it into toe off" in order to achieve maximum benefit from its push off characteristics.</p> <p>Casting tape should be reapplied and the field trial continued. Only when the patient returns, needing no additional alignment changes, can it be assumed the alignment is optimized, permitting transfer and finishing to proceed.</p> <p>A comprehensive fabrication manual is provided by the manufacturer,<a></a> and the instructions should be followed explicitly, particularly regarding reinforcement of the attachment cone. Tremendous stresses are concentrated where the resilient pylon meets the rigid socket, and structural failures of the lamination can occur if improperly fabricated.</p> <p>Cosmetic finishing is difficult and time-consuming, but results in a finished structure that is highly water resistant since the foam provided is used in life preserver construction. If immersion is anticipated, a final sealing coat of Lynadure or other flexible "skin" is recommended.</p> <p>Although our series is small, we have experienced no failures with the Flex-Foot™ system, even on very large and very active individuals. One high school athlete, who destroyed SACH and SAFE feet two or three times per year, has been playing varsity football with the Flex-Foot™ for two seasons without incident.</p> <p>The manufacturer reports an overall failure rate of less than four percent with over 2,500 units in the field. Most failures occurred where the heel pylon bolts attached to the anterior pylon. One common denominator has been a sudden increase in the patient's activity level after being fitted with the Flex-Foot™. A highly active individual (or one who has recently gained weight) using a pylon originally designed for standard duty applications is at risk, so the prosthetist must anticipate the ultimate stresses that will be applied.<a></a></p> <p>The recent announcement of a "Modular Flex-Foot™" (MFF) represents an effort to expand the usefulness of the Flex-Foot™. Available in standard configurations, these pre-made pylons can be supplied within two weeks. The heel lever arm bolts through the forefoot rather than the highly stressed ankle area, to enhance durability. A refined attachment system permits easier socket replacements, which should encourage application to more recent amputees. And, limited alignment refinements are possible even after permanent attachment to the socket, via Otto Bock "Modular" components or the "pylon connector" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg"><strong>Figure 3. Modular Flex-Foot™ (MFF), showing improved socket and heel attachment designs.</strong></a><br /> <p>We believe the cost and complexity of the Flex-Foot™ can be justified due to the degree of function offered. A competitive volleyball player reported her vertical leap nearly doubled when using the Flex-Foot™, and its low inertial drag made activities less tiring.<a></a> A severely debilitated geriatric amputee, who ambulated with a cane due to impaired balance, claimed he could walk "twice as far before my wind gives out" after fitting with the Flex-Foot™.<a></a> And a 47 year old nurse completed the New York Marathon's 26 mile race on the Flex-Foot™ one hour thirty-two minutes more quickly than with a conventional design.<a></a></p> <p>Hard data to buttress these anecdotal reports are very limited at this time. A motion analysis conducted at the University of Illinois suggests that the Flex-Foot™ allows a more normal range of motion than the SACH foot, even at normal cadences.<a></a> Several centers are reportedly conducting oxygen consumption studies in an effort to verify claims of lowered energy consumption, but none are yet published.</p> <p>Although most Flex-Foot™ prostheses have been used for unilateral and bilateral below-knee amputees, a significant percentage have been applied to above-knee amputees as well, and some hip disarticulation fittings have been completed.<a></a> Our experience at Duke has been chiefly at the below-knee level. Although higher level amputees would benefit greatly from reduced energy consumption, the addition of a passive knee mechanism may dissipate some of the potential return and bears further study.</p> <h3>Carbon Copy II</h3> <p>The Ohio Willow Wood Company introduced the original all-plastic SACH foot a decade ago called the "Marvel" foot. After its demise due to the availability of lighter and more durable feet from other suppliers, they embarked on a research and development project for what they termed the "next generation" of solid ankle feet.</p> <p>A few years ago, Mauch Laboratories approached Ohio Willow Wood to design a foot shell for Mauch's hydraulic ankle. This lead to the development of life-molds, a special micro-cellular polyurethane elastomer blend, and engineering of a carbon composite keel. The result was Carbon Copy I, a relatively rigid shell whose function comes primarily from the ankle mechanism.</p> <p>Development continued, and in May, 1986, Carbon Copy II was introduced as the latest entry into the energy storage arena. In many ways, it represents the synthesis of some of the best attributes of previous designs. This is a conventional solid ankle design, available with three durometers of heel cushion for simulated planter flexion.</p> <p>The keel, however, is a unique dual structure: a rigid posterior bolt block plus flexible anterior deflection plates. The bolt block is a special ultralight reinforced Kevlar/nylon design which recently won the plastic composite industry's "National Award of Excellence" for innovative engineering. A fiberglass/epoxy attachment plate resists deformation by both ex-oskeletal and endoskeletal ankle blocks, while very low density Styrofoam fills the cavities and prevents infiltration of the heavier polyurethane elastomer which forms the outer shell.</p> <p>The anterior deflection plates provide two-stage resistance at heel off. In normal walking, the thin primary deflection plates (which run to the PIP joints of the toes) provide a gentle energy return. At higher cadence or during more vigorous activities, the auxiliary deflection plate provides additional push off. A Kevlar™ glide sock prevents the plate from knifing through the elastomer shell (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg"><strong>Figure 4. Carbon Copy II; note rigid bolt block plus dual flexible carbon fiber deflection plates (Photo courtesy Ohio Willow Wood Co.).</strong></a><br /> <p>The exterior design shows a similar attention to practical detail. The contours are lifelike, but not as starkly detailed as the Seattle Foot™. Rather, the veins and retromalleolar undercuts are softened into a more practical "humanoid" configuration. The forefoot width is a bit wider than conventional SACH feet, but less than the Seattle Foot™ version (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg"><b>Fig. 5</b></a>). Fitting narrow width shoes can sometimes be a problem.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg"><strong>Figure 5. (Dorsal view, L to R) STEN foot, Carbon Copy II, Seattle Foot™ note retromal-leolar contours and forefoot width.</strong></a><br /> <p>The plantar surface is where the Carbon Copy II contour is most unique. Broad and flat (with a full-width carbon composite plate similar to Flex-Foot™), it is shaped to fit the shoe last. Analogous to a well-posted UCBL foot orthosis, this congruence between device and shoe offers maximum mediolateral stability (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg"><strong>Figure 6. (Plantar view, L to R) Seattle Foot™, STEN foot, Carbon Copy II; the flatter configuration enhances me-diolateral stability within the shoe.</strong></a><br /> <p>Finally, all these practical details are contained in a package that is extremely lightweight. Significantly lighter than the conventional SACH foot, Carbon Copy II is actually slightly lighter than a geriatric "litefoot."</p> <p>Currently available only in adult male sizes, Carbon Copy II should be available in female sizes in the near future. Some practitioners report that the small keel sizes are noticeably suffer than their full-sized counterparts. In response to that observation, Ohio Willow Wood is retooling for a shorter keel block as well as narrower deflection plates for the women's style, which will initially be offered only in a 10mm (3/8") heel height.</p> <p>We have experienced no failures whatsoever with Carbon Copy II thus far, even for very vigorous applications. The manufacturer reports sales of over 2,000 feet, with known failures in nine cases. Seven were rubber tears at the tips of the toes (reportedly from one particular manufacturing run), plus one split deflection plate and one broken rivet.<a></a> If this early reliability continues, this may be one of the most durable prosthetic feet available.</p> <p>The only other problem noted is insufficient threads on the Otto Bock titanium endoskeletal foot bolt, which can be identified by its bright blue color. Placing one or two spacer washers under the head of the bolt allows it to be tightened firmly without running out of threads.</p> <p>One of the key design criteria for this foot was versatility, and we have found it suitable for many levels of amputation—including unilateral and bilateral below-knee, unilateral above-knee, hip disarticulation and hemipel-vectomy, as well as above-knee/below-knee bilaterals.</p> <p>Overall, the Carbon Copy II and Seattle Foot™ seem to offer similar function to the patient, and the wholesale cost is comparable. At least in the larger keel sizes, most patients have preferred the Carbon Copy over the Seattle Foot™, due to lighter weight and the two-stage resistance. In the smaller keel sizes, the difference is less pronounced, and many prefer the responsiveness of the Seattle design. In general, we consider both Carbon Copy and the Seattle Foot™ design to be good, moderately responsive energy storing designs.</p> <h3>STEN Foot</h3> <p>STEN Foot is one of the simplest designs in prosthetic feet. Externally, it uses the familiar Kingsley foot molds and rubber. This means it is the easiest design to fit in a variety of shoe styles, and comes in the greatest selection of sizes and heel heights: from a child's 18cm keel to an adult's 30cm, including women's widths as well. Soft, medium, or firm heel durometers are available as well.<a></a></p> <p>Slightly heavier than a conventional SACH foot, the STEN Foot differs in its dual articulated keel. In addition to a metatarsal-phalangeal articulation, it also features a tarsal-metatarsal articulation, thus permitting a smoother, more gradual roll-over than a solid SACH keel (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg"><b>Fig. 7</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg"><strong>Figure 7. STEN foot; note dual keel articulations and double reinforced belting (Illustration courtesy Kingsley Manufacturing).</strong></a><br /> <p>Although the name stands for "STored EN-ergy" foot, it is our clinical impression that it does not accomplish this goal as effectively as the previous designs. The "keel bumpers" are directly analogous to the toe bumper in an old-fashioned wooden foot; both seem more to dissipate than to return energy.</p> <p>We view the STEN Foot as an additional flexible keel design, similar to the SAFE foot, permitting a smoother roll-over and somewhat greater forefoot supination and pronation than the more rigid SACH design. Since it is lighter than the SAFE foot, fits the shoe more readily, and is available in a broad range of heel heights and sizes, it may offer some advantages.</p> <p>Compared to a SACH foot, patient response has been predominantly favorable. Most preferred the smoother, "softer" roll-over it offers. Some higher level amputees complained of a slight increase in the tendency for the prosthetic knee to "buckle," although this could usually be minimized by plantarflexing or moving the foot more anteriorly.</p> <p>Reliability was a significant problem with early versions of this design, which sometimes failed catastrophically due to rupture of the plantar belting beneath the midfoot articulation. This resulted in a sudden loss of forefoot resistance, causing the amputee to stumble. When three of our initial seven STEN Feet failed in this fashion, we stopped using this component.</p> <p>It has since been redesigned with double belting reinforcements. The manufacturer reports that 3,000 feet have been sold, with no belting failures whatsoever since the reinforcement was added. With the new design, the overall failure rate from all causes is currently under one percent.<a></a></p> <p>At a recent Academy conference, Richard Carey, CP. reported on over 80 successful applications of the reinforced version of the STEN Foot, and suggested it is particularly appropriate for the new amputee as the softer rollover may facilitate gait training.<a></a> This also might allow an easier transition to a more sophisticated design later, since the flexible keel is a common characteristic of all current "energy storing" feet.</p> <h3>Other Designs</h3> <p>Although not a brand new design, the SAFE foot (Stationary Ankle Flexible Endoskeleton) has recently been advertised as "the original energy storing foot." In our view, this may be stretching the point, since we believe the flexible keel serves primarily to dissipate energy as it accommodates to irregular surfaces.</p> <p>The SAFE foot can be viewed as a solid ankle version of the multi-axis concept, and we consider it an alternate to the well-known Greissinger foot. Both provide significant transverse rotation as well as inversion and eversion, in addition to some degree of plantar flexion and dorsiflexion.<a></a> The SAFE foot has the advantage of requiring no maintenance and being moisture and grit-resistant, while the Greissinger permits independent selection of the plantar flexion and other resistances.</p> <p>We summarize the SAFE foot as an "accommodative" design. It is probably unparalleled for use on uneven surfaces, and many amputees report an increase in residual limb comfort because it absorbs much of the shock of everyday walking. But aggressive racquet sportsmen have complained that it takes a fraction of a second to "wind up" before permitting push off, thus lowering their score. Perhaps the SAFE foot and other soft keel designs should be viewed as offering increased shock absorption and comfort at the expense of responsiveness in a competitive situation.</p> <h3>Clinical Ranking</h3> <p>There are currently no accepted definitions of what constitutes an "energy storing" prosthetic foot. In fact, there is currently no hard data to demonstrate any energy savings at all, despite numerous anecdotal reports. Yet, there is a need to have some means of evaluating and ranking the various designs, to add some measure of rational justification for clinical use of a given component.</p> <p>In reviewing slides of a unilateral below-knee amputee playing competitive volleyball, it was noted that her vertical leap appeared to be noticeably higher with the Flex-Foot™ than with the Seattle Foot™. This difference is likely due to the amount of "spring return" inherent in the components, and may represent one plausible criterion to rank their effectiveness.</p> <p>To test this hypothesis, a simple "pogo stick" apparatus was constructed which permitted interchange of various prosthetic feet (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg"><b>Fig. 8</b></a>). A non-amputee subject was instructed to jump on the pogo stick for ten hops, trying to attain as much altitude as possible. It is believed that this measures the spring potential of the component as if it were loaded by body weight at midstance. Since the subject's feet both remained firmly on the foot pegs and did not contact the ground, this was felt to be more accurate than measuring unilateral amputees jumping, where the sound limb could partially compensate for the component's deficits.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg"><strong>Figure 8. Pogo stick device used to test vertical spring capabilities of various feet.</strong></a><br /> <p>Using frame-by-frame slow motion video analysis, the amount of ground clearance was measured to the nearest centimeter (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg"><b>Fig. 9</b></a>). This was not intended to be a controlled study, but rather a simple preliminary investigation; no quantitative judgments should be drawn from this data. Nevertheless, the trends were consistant over multiple trials, and are summarized in <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg"><b>Fig. 10</b></a>.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg"><strong>Figure 9. Frame-by-frame video analysis of ground clearance in centimeter increments.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg"><strong>Figure 10. Ground clearance after vertical leap using pogo stick apparatus; 175 pound male subject, men's size 10 feet.</strong></a><br /> <p>It is interesting to note that <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg"><b>Fig. 10</b></a> coincides with our subjective clinical ranking of the effectiveness of these designs. Patients given the choice between the SACH and STEN foot, for example, generally chose the more flexible STEN, but patients perferred the Carbon Copy II or Seattle Foot™ to the STEN, because the spring keels "felt more natural." Given the choice between Flex-Foot™ and other designs, the choice was generally for the more responsive composite system.</p> <p>Furthermore, the ranking also reflects the degree of sophistication of the design, and the relative wholesale cost from the manufacturer (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg"><b>Fig. 11</b></a>). The weight of the components was less straightforward. The inexpensive designs increased in weight as they increased in complexity, weighing progressively more than a conventional SACH foot. However, the two most expensive energy storing designs—Flex-Foot™ and Carbon Copy II—resulted in a lighter prosthesis than a SACH configuration (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg"><b>Fig. 12</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg"><strong>Figure 11. Relative wholesale costs for prosthetic foot mechanisms.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg"><strong>Figure 12. Weight of men's size 10 foot components, not including ankle block.</strong></a><br /> <h3>Summary</h3> <p>Thanks to the efforts of the Prosthetics Research Study in Seattle, the concept of energy storing prosthetic feet has been widely disseminated.<a></a> Although it is fashionable to claim such benefits, no clear definition of the characteristics required has been established. The author suggests that the ability to leap vertically is one simple measurement of the "springiness" of a component, while reduced oxygen consumption during a measured task would be a more precise definition of an energy-conserving component.</p> <p>All current designs seem to have merit, and have been successfully utilized clinically (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg"><b>Fig. 13</b></a>). Although limited, the Duke experience has been summarized as a first step toward more clearly delineating the indications and contraindications for each design (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg"><b>Fig. 14</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg"><strong>Figure 13. "Energy storing" feet through April 1987, Duke University experience.</strong></a><br /><strong><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg">Figure 14. Clinical comparison of prosthetic feet</a>.</strong> <p>The conventional SACH foot remains the most widely used design in North America, due to its low cost and reliability. In sports applications, it is particularly well suited for sprinting, since the rigid keel digs into the track, permitting rapid acceleration.<a></a></p> <p>Multi-axis feet (Greissinger and SAFE) accommodate uneven terrain and dissipate some of the shocks of ambulation, thereby increasing skin comfort. They have been widely used by amputee athletes, although the softer keel resistance may increase the lag between sudden movements. Except for limiting transverse rotation, the STEN foot offers similar function, and may be worth considering for the novice amputee in particular.</p> <p>The Seattle Foot™ and Carbon Copy II are solid ankle devices that attempt to store energy via a spring keel design. They have been well received for a variety of amputation levels, and seem particularly well suited for joggers and weekend athletes.</p> <p>Flex-Foot™ represents the maximum in energy storage potential, and can be individualized for a wide range of applications. It is by far the best design for vertical jumping, thereby lending itself to such sports as volleyball. It has also performed well for long distance running, as well as vigorous sports in general.</p> <p>Finally, all these components have more widespread application than originally assumed. A more flexible forefoot permits an easier roll-over. For the geriatric individual, even a modest decrease in the effort required for walking can offer a substantial improvement in ambulatory potential. The more debilitated the person, the more important the weight and responsiveness of the foot component become. Virtually any lower limb amputee could benefit from the enhanced functioning that a sophisticated prosthetic foot can offer.</p> <p>Although none of these designs will turn the amputee into Superman, each can add a significant dimension to the degree of restoration that can be offered. Jan Stokosa, CP., has noted that although conventional prosthetic limbs restore mobility rather effectively, many patients feel their <i>function</i> has not been restored, so long as vigorous activities remain difficult or impossible to achieve.<a></a></p> <p>By increasing our collective experience with the components under discussion and pooling our impressions in forums such as this, it is hoped that we can more closely approach that elusive goal: complete functional prosthetic restoration for every amputee.</p> <h3>Appendix</h3> <p><b>SAFE Foot</b>, Campbell-Childs, Inc., 105 East First Street, P.O. Box 120, Phoenix, Oregon 97535.<br /><b>Flex-Foot™</b>, Flex-Foot, Inc., 14 Hughes, B-201, Irvine, California 92714.<br /><b>STEN Foot, Litefoot, SACH, and Single Axis Feet</b>, Kingsley Manufacturing Company, P.O. Box CSN 5010, Costa Mesa, California 92628.<br /><b>Carbon Copy II</b>, Ohio Willow Wood Company, 15441 Scioto Darby Road, P.O. Box 192, Mount Sterling, Ohio 43134.<br /><b>Greissinger, Single Axis, &amp; SACH Feet</b>, Otto Bock Industries, Inc., 4130 Highway 55, Minneapolis, Minnesota 55422.<br /><b>Seattle Foot™</b>, Model &amp; Instrument Development, 861 Poplar Place South, Seattle, Washington 98144.</p> <p><b>References:</b></p> <ol> <li>Beckman, Clarence, personal communication, May, 1983.</li> <li>Brooke, Steve, Marketing Manager, Model Instrument and Development, Inc., personal communication, April, 1987.</li> <li>Burgess, et al., "The Seattle Prosthetic Foot-A Design For Active Sports: Preliminary Studies," <i>Orthotics and Prosthetics</i>, Volume 37, Number 1, pp. 25-32.</li> <li>Burgess, et al., "The VA Seattle Foot," <i>Rehabilitation Research and Development-Progress Reports 1984</i>, Veterans Administration Publications, 1984, p. 5.</li> <li>Campbell, J. and C. Childs, "The S.A.F.E. Foot," <i>Orthotics and Prosthetics</i>, Volume 34, Number 3, 1980, pp. 3-17.</li> <li>Carey, Richard, "The STENFOOT," Continuing Education Course 1-87, American Academy of Orthotists and Prosthetists, Portland, Oregon, March, 1987.</li> <li>Enoka, et al., "Below-Knee Amputee Running Gait," <i>American Journal of Physical Medicine</i>, Volume 61, Number 2, 1982, pp. 66-84.</li> <li>"Flex-Foot™ Fitting and Alignment Procedure," Flex-Foot Inc., 19600 Fairchild, Suite 150, Irvine, CA 92715.</li> <li>Fosberg, Robert, President of Flex-Foot, Inc., personal communication, April, 1987.</li> <li>Graves, J. and E. Burgess, "The Extra-Ambulatory Concept As It Applies To the Below-Knee Amputee Skier," <i>Bulletin of Prosthetics Research</i>, Fall, 1973, pp. 126-131.</li> <li><a href="cpo/1982_04_001.asp">Hittenberger, Drew, "Extra-Ambulatory Activities and the Amputee," <i>Clinical Prosthetics and Orthotics</i>, Volume 6, Number 4, 1982, pp. 1-4.</a></li> <li>Hittenberger, Drew, "The Seattle Foot," <i>Orthotics and Prosthetics</i>, Volume 40, Number 3, 1986, pp. 17-23.</li> <li>Kegal, Bernice, et al., "Functional Capabilities of Lower Extremity Amputees," <i>Archives of Physical Medicine and Rehabilitation</i>, Volume 59, 1978, pp. 109-120.</li> <li>Kegal, et al., "Recreational Activities of Lower Extremity Amputees: A Survey," <i>Archives of Physical Medicine and Rehabilitation</i>, Volume 61, 1980, pp. 258-264.</li> <li>Klenerman, Leslie, <i>The Foot and Its Disorders</i>, Blackwell Scientific Publications, London, 1976, p. 19.</li> <li>"A Material Change for Prosthesis," <i>The Orange County Register</i>, October 31, 1985, Sec.E, p. 12.</li> <li>Martin, Jeffrey, Marketing Director, Ohio Willow Wood Company, personal communication, April, 1987.</li> <li>Michael, J.W., "Prosthetic Feet for the Amputee Athlete," <i>Palaestra</i>, Volume 2, Number 3, 1986, pp. 37-41.</li> <li>Miller, Enoka, et al., "Biomechanical Analysis of Lower Extremity Amputee Running." Final Report to Veterans Administration. Contract Number V5244P-1540/VA Hospital, New York, 1979.</li> <li>Nobbe, Carol, personal communication, September, 1984.</li> <li>Rauch, Colleen, personal communication, November, 1986.</li> <li>Sethi, M.P., "Vulcanized Rubber Foot for Lower Limb Amputees," <i>Prosthetics and Orthotics International</i>, Volume 2, Number 3, 1982, pp. 125-136.</li> <li>Stokosa, Jan, "Total Surface Bearing in Lower Extremity Prosthetics," Region II-III Assembly, American Orthotic &amp; Prosthetic Association, Atlantic City, New Jersey, April, 1986.</li> <li>Truesdell, James, president, Kingsley Manufacturing Company, personal communication, April, 1987.</li> <li><a href="cpo/1987_01_055.asp">Wagner, J., et al., "Motion Analysis of SACH vs. Flex-Foot™ in Moderately Active Below-Knee Amputees," <i>Clinical Prosthetics &amp; Orthotics</i>, Volume 11, Number 1, 1987, pp. 55-62.</a></li> </ol> <em><b>*John Michael, M.Ed., C.P.O. </b> John W. Michael, M.Ed., C.P.O., is Assistant Clinical Professor and Director of Prosthetics &amp;Orthotics at Duke University Medical Center.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 154 - 168 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg Fig 14 cont. http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-15.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Energy Storing Feet: A Clinical Comparison Creator An entity primarily responsible for making the resource John Michael, M.Ed., C.P.O. * https://staging.drfop.org/files/original/0713435cdc66e5d09afab0bd217b4263.pdf 11665dec8ad20d2b3e67e255dcf4c5e6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_001.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Engineering Hope of the Handless</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The human hand, with its elaborate control system centered in the brain, is doubtless the most widely versatile machine that has ever existed anywhere. Its notorious deficiency lies in its persistent inability to create a similar machine as versatile as itself. This circumstance accounts for the fact that, while there has been from earliest times a great need for hand replacements, all attempts to produce successful hand substitutes have thus far ended in only a rather crude imitation of a very few of the many attributes of the living counterpart. For want of complete knowledge of the natural hand-brain complex, and of the ingenuity requisite even to the most modest simulation of the normal hand, artificial hands have always resembled the natural model in a superficial way only. Voltaire is said to have remarked that Newton, with all his science, did not know how his own hand functioned.</p> <p>But the science of Newton, basic as it was, is itself remote from the advanced technology of our own day. Failure in hand prosthetics, though owing in part to the difficulty of replacing any living organ with an inanimate contrivance, stems also in part from failure to apply intensively the principles of modern science generally, and of engineering in particular, to the problems of artificial-hand design. Because in general the engineering profession had not theretofore been much concerned with the development of improved artificial limbs, the hand prostheses available a decade ago represented no appreciable improvement over those to be had at the end of World War I.</p> <p>In all fields of human endeavor, the problems for which men have found tentative solutions in the past often merit the attention of the engineer of today. A new look by competent technologists usually yields gratifying results, for the solutions found by our forebears, while seemingly adequate at the time, do not reflect the progress made in the development of methods of experimental analysis, in the measurement of behavioral characteristics, in the establishment of criteria, in the development of materials, and in the evolution of forming techniques for application of the materials to the needs of man. Just so in the field of prosthetics, where the problem of matching a device to the human system is particularly acute and where, consequently, the application of new methods holds special promise.</p> <p>Perhaps the most compelling reason today for the importance of engineering in prosthetics research lies in the approach and methodology now implicit in the profession. Introduction of the requirements of man in a quantitative manner without neglect of the qualitative, subjective aspects places design on a rational basis for the first time in history. During World War II there arose the problem of designing numerous complicated systems to be operable within the limits of human capabilities. In that urgent work, a substantial number of engineers had occasion to become acquainted with certain important physiological and psychological characteristics of man, so that by the end of the war the stage was set for the impact of the engineering profession on the development of prosthetic devices, which is, after all, a unique and particularly challenging field of biomechanics.</p> <p>When, therefore, in 1945, the then Committee on Prosthetic Devices undertook to conduct basic studies toward the provision of better hand substitutes, it enlisted the services of engineers to cooperate with the medical profession and others in developing the necessary data and in applying the results to improved hand design. In the Artificial Limb Program, principal responsibility for the development of improved hand substitutes has almost from the beginning resided with the Department of Engineering at the University of California, Los Angeles Campus, and with the Army Prosthetics Research Laboratory, Walter Reed Army Medical Center. Out of this cooperative effort have now come not only new and improved devices but also, and perhaps more important, a set of criteria which lay down the basic principles of hand design toward further improvements in the future.</p> <p>Because of the importance of the hand in all human activities, because of the critical nature of adequate hand replacement in the rehabilitation of upper-extremity amputees, and also because of the rather striking advances that have been made in the design of artificial hands in recent years, this issue of Artificial Limbs is devoted entirely to a little symposium on the hand and its substitutes. The mutual cooperation of the several contributors toward a unified approach to the whole subject is typical of the cooperation that has characterized the Artificial Limb Program since its inception.</p> <p>The work in prosthetics will, it is to be hoped, serve as a pattern for further investigations jointly by the medical and engineering professions wherever developments in materials, controls, and systems in general can be brought to bear to augment human functions which an individual can himself no longer provide. One continuing problem is that of convincing able young people now studying engineering that a satisfying future exists for them in such cooperative ventures with the medical profession designed to rehabilitate the less fortunate throughout the world. Those now engaged in prosthetics development can be of great help in presenting to these young men and women the perspective of the future in such a manner that fresh engineering graduates might elect to carry forward the work now already so well under way.</p> <p>Finally, it ought to be noted that, despite the distinct accomplishments evident at this, the tenth anniversary of the establishment of the Artificial Limb Program, only the first faltering steps have been taken toward the "ideal" prosthetic hand. Structural elements and prehensile function are not enough. It remains to provide some reasonable substitute for the sensory-motor apparatus which, in the living hand, is of such consummate perfection as to beggar description. A problem like this should charge the imagination of any young engineer in search of a field of application for service. To him belongs the future in prosthetics research.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service (Central Office) Veterans Administration, 252 Seventh Avenue, New York City; member, Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Engineering Hope of the Handless Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/7cf119166ad87eb06c27bf19aa14601f.pdf 1c96a3b3328679e9ce5c00a407f461c9 https://staging.drfop.org/files/original/7a03de2fa3abd6434dbf35ea90f8a24f.jpg 9a3b91d6d25d0ea128bd129f72052d5c https://staging.drfop.org/files/original/41d2e99ef2712e6bf37fd90b99884729.jpg e365f90de9bf9d37b3e930728b987afe https://staging.drfop.org/files/original/45f9ecdd3583fca4a9b40e43d40b8fcb.jpg a3a4b242703db91a587f408c2738acdf https://staging.drfop.org/files/original/f25d2a79d7de53b2ee49b4c388895c22.jpg 792d3c81e1d5d48a515061f80fe3204a https://staging.drfop.org/files/original/c8ecb78314e07610c4b41af0358a23f4.jpg 68b404353e59f1a8fcdfd73e57d06d44 https://staging.drfop.org/files/original/e0db5f9e5fb35400f61e401dd85599b9.jpg e0b92835fd4de23f0c8bb8fb5d1635fa https://staging.drfop.org/files/original/7aa1f8cbe0e245431055b7fe9d6d2d6f.jpg 4bdf0fe2fee9272b3e8bb7c7a4fd1960 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_023.pdf Text Any textual data included in the document <h2>Evaluation of a Prosthetic Shank with Variable Inertial Properties</h2> <h5>Scott Tashman, M. Eng.&nbsp;<a style="text-decoration: none;">*</a><br />Ramona Hicks, R.P.T., M.A.&nbsp;<a style="text-decoration: none;">*</a><br />David J. Jendrzejczyk, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Above-knee amputees walk slower than the normal population. This has been documented in adults<a></a> and children.<a></a> It has been suggested that the prolonged swing phase of the prosthesis forces a slower cadence and, therefore, a slower walking speed.<a></a> Since children rely on a fast cadence to obtain an adequate walking speed,<a></a> a prolonged swing phase can be a major obstacle to comfortable, efficient normal-speed walking.</p> <p>To date, most efforts to reduce prosthetic swing phase time have been directed towards the prosthetic knee joint.<a></a> Various mechanisms have been designed to accelerate the extension of the prosthetic knee. Mechanical, hydraulic, and pneumatic systems have been developed in an effort to provide a more favorable gait.<a></a> Hydraulic knee units have been shown to provide a more normal cadence and walking speed for adults than simple constant friction knee units.<a></a></p> <p>Most of the prosthetic knee unit research has been directed towards the adult amputee population. Pediatric hydraulic knee units have been considered impractical because of size and weight limitations. Pediatric above-knee amputees are generally fitted with constant friction knee units because they are simple, light in weight, low in cost, easy to install and adjust, and require little maintenance.<a></a></p> <p>It has often been presumed that adjustments in the knee joint friction could be used to provide an optimum cadence for the amputee with a constant friction knee joint. A study was performed at the Newington Children's Hospital Kinesiology Laboratory to test this assumption.<a></a> When subjects were asked to walk at a comfortable speed, no significant changes were observed in cadence or actual prosthetic shank swing time as the knee joint friction was varied over a wide range. In all cases, the swing period of the prosthetic shank was close to the natural swing period of the shank measured off the patient. This indicates that the physical properties of the prosthetic shank play a significant role in determining the natural cadence of the above-knee amputee with a constant-friction knee joint. To force the shank to move at a frequency different from its natural frequency requires significant input of energy in the form of applied torque at the knee joint (from hip or pelvic muscle force). The test subjects, when asked to walk at a comfortable speed, did not supply the extra energy needed for a faster cadence; they instead aligned their cadence with the natural frequency of the shank.</p> <h3>Purpose</h3> <p>The above results led to the current project: the design and testing of a prosthetic shank with variable physical properties. The purpose of this study was to test the following hypotheses:</p> <ol> <li> <p>If the physical properties of the shank section of an above-knee prosthesis with a constant friction knee unit are changed in such a way as to alter the natural swing period, the swing period of the shank during gait will also be altered.</p> </li> <li> <p>Reducing the swing period of the shank will increase natural cadence and walking speed.</p> </li> </ol> <h3>Methods</h3> <p><i>Design</i></p> <p>The principal design goal for the shank was to reduce the natural swing period as much as possible. If the shank/foot is considered as a physical pendulum, it has a period T equal to:<br /><b>T = 2<i>pi</i>(I/Mgd)^(1/2)</b>, I is proportional to Md².</p> <p>Where:</p> <blockquote> <p>T = natural swing period of shank as a pendulum<br />I = rotational inertia of shank/foot above knee pivot<br />g = acceleration due to gravity<br />d = distance from knee pivot to center of mass<br />M = mass of shank/foot</p> </blockquote> <p>These equations indicate that changes in mass alone will not reduce the swing period of the shank; the center of mass must be shifted proximally (towards the knee joint) to significantly reduce the period.</p> <p>With reducing distal weight as the primary goal, an experimental shank was constructed for the test subject, a 13 year old male knee disarticulation patient with a "good" amputee gait pattern. Since the limb was to be used for laboratory testing purposes only, some strength was sacrificed in order to obtain the maximum possible reduction in distal weight while still using readily available materials. The shank was thin and hollow, with layers of polyester resin and one layer of carbon filter cloth laminated over a plaster mold. Excess material was ground away wherever possible. In addition, the prosthesis was set in correct alignment using a heel build-up on an ultra-light SACH foot to eliminate shoes and further reduce distal weight. To enable changes in the natural swing period, a lead mass which attached to a metal rod could be placed proximally or distally inside the shank. The additional mass was chosen so that the experimental shank/foot would weigh the same as the patient's standard prosthesis.</p> <p>The completed prosthesis is shown in <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg"><b>Fig. 1</b>.</a> With the moveable mass placed distally, the shank had a center of mass positioned similarly to the patient's original shank. Shifting the mass proximally caused the center of mass to move proximally by 13 centimeters. To determine the effect of changing the mass position, the pendulum swing period of the shank was measured by timing the swing of the shank, which was suspended by a metal rod through the knee joint axis. The light weight shank, with the mass placed distally, exhibited inertial properties very close to those of the patient's original shank. Shifting the mass to the proximal position reduced the pendulum swing period by 0.20 seconds or 15 percent (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-2.jpg"><b>Table 1</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg"><strong>Figure 1. Completed experimental prosthesis; shown during testing in the Kinesiology laboratory.</strong></a><br /> <p><i>Evaluation</i></p> <p>The Newington Children's Hospital Kinesiology Laboratory measured the effect on the gait of the changes made in the position of the center of mass of the experimental prosthesis. An automated video system was used to acquire three-dimensional kinematic data from 26 retro-reflective markers placed at designated positions on the body.<a></a> The kinematic data were used to determine the motions of all major body segments and calculate dynamic lower extremity joint angles in three planes. Linear movement and temporal measurements, such as stride length, single stance time, swing phase time, cadence, and walking speed were also determined. Swing time was determined by measuring the time from toe-off to heel strike. The shank pendulum time was determined by measuring the time required for the prosthesis to go from full extension into flexion and back to full extension; this is equivalent to one half of the period of the shank measured as a free-swinging pendulum.</p> <p>Kinematic data were acquired for two walks with the subject walking at:</p> <ol> <li> <p>normal speed, weight proximal</p> </li> <li> <p>fast speed, weight proximal</p> </li> <li> <p>normal speed, weight distal</p> </li> <li> <p>fast speed, weight distal</p> </li> </ol> <p>For the normal speed walks, the subject was asked to walk at a speed that was comfortable; no further prompting was given. For the faster speed walks, the subject was instructed to walk as fast as was comfortable; again, no further instructions were given. For each mass position, the knee joint friction was set to "clinically optimal" by matching the prosthetic side heel rise to the normal side heel rise at normal speed, and the patient was allowed to walk around for a while until he seemed reasonably comfortable with the altered characteristics of the limb.</p> <h3>Results</h3> <p><i>Stride Parameters</i></p> <p>Stride parameters measured during the four different conditions are shown in <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-3.jpg"><b>Table 2</b></a>. This data represents the first walk acquired for each condition; the variation between the first and second trials for all conditions was less than five percent. Cadence, stride length, and walking speed were all essentially the same at the "normal" walking speed with the mass placed proximally or distally. At the "fast" walking speed, the subject walked seven percent faster with the mass placed distally than with the mass placed proximally, due to both a faster cadence and a longer stride length.</p> <p><i>Shank Swing Dynamics</i></p> <p>At the normal walking speed, the shank pendulum time was reduced by eight percent with the weight placed proximally, resulting in an eight percent reduction in the swing phase time for the prosthetic limb (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-4.jpg"><b>Table 3</b></a>). Since the swing phase time for the normal side stayed the same, the swing asymmetry (prosthetic side vs. normal side) was reduced from 19.5 percent to 9.1 percent. A similar reduction in swing asymmetry was seen during the fast walk (from 32.4 percent to 19.6 percent). During fast walking with the proximal weight placement, the swing phase time was increased by five percent for the normal limb and reduced by eight percent for the prosthetic limb. The reduction in pendulum swing time was much greater (16 percent).</p> <p><a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-5.jpg"><b>Table 4</b></a></p> <p>The dynamic knee joint motion is shown for both weight positions (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg"><b>Figure 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg"><b>Fig. 3</b></a>). The peak knee flexion was reduced from 64 degrees to 54 degrees at the normal walking speed and from 84 degrees to 62 degrees at the fast walking speed with the weight placed proximally. The plots also indicate delayed initiation of knee flexion and faster motion of the limb with the proximal weight placement.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg"><strong>Figure 2. Knee flexion-extension angle vs. percent of gait cycle: normal walking speed, proximal and distal weight placement.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg">Figure 3. Knee flexion-extension angle vs. percent of gait cycle: fast walking speed, proximal and distal weight placement.</a><br /></strong><br /> <h3>Discussion</h3> <p>As expected, proximal weight placement in the shank produced a shorter shank swing time during gait. This subsequently resulted in a shorter swing phase (toe-off to heel-strike) for the prosthetic limb. At normal speed, the decrease in swing phase was equal in time to the decrease in shank swing time (eight percent). At a faster walking speed, the same eight percent decrease in swing phase was observed, but the shank swing period was reduced by a much greater amount.<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg"> <b>Fig. 3</b></a> illustrates the effect of this discrepancy: the limb reaches full extension well before heel strike. One explanation for this is that the subject did not have sufficient time to fully adjust to the new limb; further use should enable the subject to reduce swing phase as much as the shank swing period was reduced.</p> <p>A less expected outcome was the similarity in walking speed and cadence between the two different weight placements. The reduced swing phase did not result in a reduced gait cycle time; the subject instead lengthened his stance phase to balance the decrease in swing phase. This resulted in a smoother, more symmetric gait.</p> <h3>Conclusions</h3> <p>Limited conclusions can be made based on this single-subject study. However, it appears that decreasing the natural swing period of the shank by shifting the center of mass proximally results in a faster swing phase during gait. In one subject this led to an increase in stance phase for the prosthetic side towards normal values, and considerably reduced left-right asymmetry for this subject. Improved symmetry should lead to a more energy efficient, natural appearing gait. No increase in cadence or walking speed was observed. It is possible that longer wear of the limb might have permitted the subject to naturally increase his cadence; this could not be evaluated with the present limb design.</p> <p>The outcome of this study indicates that weight distribution in the prosthetic shank/foot has a significant impact on gait. This suggests that future prostheses should be designed to minimize distal shank/foot weight.<br /><br /><em><b>*David J. Jendrzejczyk, CP. </b> Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111.<br /><br /></em><em><b>*Ramona Hicks, R.P.T., M.A. </b> Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111.</em><br /><br /><em><b>*Scott Tashman, M. Eng. </b> Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111.</em></p> <p><b>References:</b></p> <ol> <li>James, U., and Oberg, K., "Prosthetic gait pattern in unilateral above-knee amputees," <i>Scand J Rehab Med</i>, 5:35-50, 1973.</li> <li>Godfry, C. M.; Jousee, A. T.; Brett, R.; and Butler, J. F., "A comparison of some gait characteristics with six knee joints," <i>Orthotics and Prosthetics</i>, 29(3):33-38, 1975.</li> <li>Murry, M. P., "Gait patterns of above-knee amputees using constant-friction knee components," <i>Bull Prosthet Res</i>, 17(2):35-45, 1980.</li> <li>Hoy, M. G.; Wiring, W. C; and Zernicke, R.F., "Stride kinematics and knee joint kinetics of child amputee gait," <i>Arch Phys Med Rehabil</i>, 63:74-81, Feb 1982.</li> <li>Drillis, R., "Objective recording and biomechanics of pathological gait," <i>Ann NY Acad Sci</i>, 74:86-109, Sept 1958.</li> <li>Sutherland, D. H.; Olshen, R.; Cooper, L.; and Woo, S., "The development of mature gait," <i>J Bone Joint Surgery</i>, 62A:336-353, April, 1980.</li> <li>Zarrugh, M. Y., and Radcliffe, C. W., "Simulation of swing phase dynamics in above-knee prosthesis," <i>J Bio-mech</i>, 9:283-292, 1976.</li> <li>Wallach, J., and Saibel, E., "Control mechanism performance criteria for an above-knee leg prosthesis," <i>J Bio-mech</i>, 3:87-97, 1970.</li> <li>NYU Medical Center, <i>Lower-Limb Prosthetics</i>, pp. 145-163. Prosthetics and Orthotics, New York University Post-Graduate Medical School, 1980 revision.</li> <li>Murray, M. P.; Mollinger, L. A.; Sepic, S. B.; Gardner, G. M., and Linder, M. T., "Gait patterns in above-knee amputee patients: Hydraulic swing control vs. constant-friction knee components," <i>Arch Phys Med Re-habil</i>, 64:339-345, 1983.</li> <li>New York University Medical Center, "The ISNY PTB Socket," <i>Lower-Limb Prosthetics</i>, 1980 revision, pp. 107-108.</li> <li>Hicks, R.; Tashman, S.; Cary, J. M.; Altman, R. F.; and Gage, J. R., "Swing Phase Control with knee friction in juvenile amputees," In press, <i>J Orthop Res</i>.</li> <li>Gage, J. R., "Gait Analysis for decision-making in cerebral palsy," <i>Bull Hosp Joint Des</i>, 43:147-163, 1983.</li> <li>Gage, J. R.; Fabian, D.; Hicks, R.; and Tashman, S., "Pre- and postoperative gait analysis in patients with spastic diplegia-a preliminary report," <i>J Ped Orthop</i>, 4:715-724, 1984.</li> </ol> Page Number(s) 23 - 28 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 7 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of a Prosthetic Shank with Variable Inertial Properties Creator An entity primarily responsible for making the resource Scott Tashman, M. Eng. * Ramona Hicks, R.P.T., M.A. * David J. Jendrzejczyk, CP. * https://staging.drfop.org/files/original/80bd7e168ac76f3973055be7e00862b9.pdf e97318035d3d30c66366bd3b043f7eed DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_073.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 73 - 74 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_073.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_073.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Evaluation of Polysar Below-Elbow Fitting </h2> <h5>Clyde M. E. Dolan <br /></h5> <p>The technique of forming sockets directly on below-elbow stumps using Polysar<a style="text-decoration:none;">*</a>, presented in a January 1968 manual by Gennaro Labate and Thomas Pirrello of the Veterans Administration Prosthetics Center, was used to prepare complete prostheses for three amputees, following a demonstration of the technique by VA personnel. The subjects were male, unilateral below-elbow amputees, with stump lengths in the range of 40-60% of the sound-side measurement. Each amputee had previously worn a conventional prosthesis; one had been using a Munster-type fitting immediately prior to wearing the experimental prosthesis.</p> <p>The instructions in the manual were considered by our staff prosthetists to be clear and comprehensive; however, the demonstration of the procedure was particularly helpful. No difficulties were encountered in interpretation or application of the fabrication technique. Each prosthesis was fabricated, from measurement to delivery, in approximately one-half day.</p> <p>At the time of delivery, each synthetic-rubber prosthesis was weighed for comparison with the previously worn conventional product. A staff therapist checked out each prosthesis, and the subject was instructed to wear the arm exclusively during the evaluation period. No special precautionary measures were advised. Initial reactions of the subjects were recorded, with specific reference to weight, cosmesis, the soft foam covering, and comfort.</p> <p>The experimental arms were considerably heavier than the respective conventional arms worn by the subjects. The weights of the complete prostheses (including harness, cable, and APRL hand and glove) were:</p> <table> <tbody> <tr> <td> <p><strong>Subject    </strong></p> </td> <td> <p><strong>Conventional    </strong></p> </td> <td> <p><strong>Experimental    </strong></p> </td> <td> <p><strong>Difference    </strong></p> </td> <td> <p><strong>% Increase    </strong></p> </td></tr> <tr> <td> <p>A</p> </td> <td> <p>788.5 g</p> </td> <td> <p>967.5 g</p> </td> <td> <p>179.0 g</p> </td> <td> <p>22.7</p> </td></tr> <tr> <td> <p>B</p> </td> <td> <p>842.0 g</p> </td> <td> <p>1133.5 g</p> </td> <td> <p>291.5 g</p> </td> <td> <p>34.5</p> </td></tr> <tr> <td> <p>C</p> </td> <td> <p>777.0 g</p> </td> <td> <p>921.5g</p> </td> <td> <p>144.5 g</p> </td> <td> <p>18.7</p> </td></tr></tbody></table> <p>Despite these substantial differences, none of the subjects commented adversely about the weight of the synthetic-rubber prosthesis.</p> <p>Two of the subjects experienced problems related to cosmesis during the initial fitting. The cosmetic cover of Subject B's prosthesis was not sufficiently opaque, and irregularities in the foam underlayer presented an unsatisfactory appearance. This defect was remedied by covering the foam with a layer of Helenca stockinet to improve the color uniformity. Subsequent shifting of this layer caused a wrinkle to develop in the vinyl cover, but this did not disturb the patient.</p> <p>On initial fitting of Subject C's prosthesis, it was apparent that the foam (a 50-50 combination of Silastic 385 and 386) had collapsed in the area proximal to the wrist unit, producing an unsightly configuration. This difficulty was remedied by the use of a somewhat denser foam mixture, one which retained sufficient flexibility to simulate normal flesh turgor but which was nonetheless strong enough to maintain cosmetic shape when the cover was applied.</p> <p>Once those initial problems were solved, all reactions to the soft foam, with a vinyl cover, were highly positive. Initial reactions to the comfort of the experimental sockets were also positive.</p> <p>The three subjects wore the experimental prostheses for periods ranging from two to four months. Only one (Subject A) subsequently experienced problems, and these required that the prosthesis be replaced. It is worth noting that this patient was the one who had previously worn a Miinster-type prosthesis. After wearing the experimental socket for five weeks, he expressed a preference for his previously worn prosthesis in terms of comfort. His socket produced from Polysar had developed embossed ridges caused by the stockinet, which resulted in considerable discomfort and skin irritation. In addition, the socket had deformed, becoming elliptical in the direction of cable pull, which may have contributed to a dermatitis which occurred after that fitting.</p> <p>The other two subjects reported at the close of the period of wear that they preferred the synthetic-rubber fitting to their conventional prosthesis. Subject B reported increased comfort and cosmesis, and also reported greater range of motion, which may be due to slightly lower proximal trim lines and some socket flexibility. Subject C felt that he could wear the prosthesis continuously without discomfort; he found no problem with the weight of the prosthesis and felt "more secure" with the experimental prosthesis than with the previously worn arm.</p> <p>To summarize, the fabrication procedure using Polysar, as demonstrated and as presented in the draft manual, seems to offer advantages in terms of: <i>(a)</i> saving of shop time (the technique requires approximately one-half day, while standard techniques require nearly a full day, not considering curing time), <i>(b)</i>elimination of some opportunities for error through the reduction of the number of steps in the fabrication process, and <i>(c)</i> fabrication of a prosthesis with a soft external surface which simulates normal flesh turgor. Difficulties encountered were: (<i>a</i>) collapse of the foam cover (tending to dent when the sleeve was applied), which may be ameliorated by the use of a denser foam; <i>(b)</i>low opacity of the sleeves, which may be improved by using a dilaminar or a thicker material; (<i>c</i>) weight, which seemed excessive although not noted by the subjects; and (<i>d</i>) possible deformation or embossing of the socket, as noted in the case of Subject A.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of the Polymer Corporation Limited.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of Polysar Below-Elbow Fitting Creator An entity primarily responsible for making the resource Clyde M. E. Dolan  https://staging.drfop.org/files/original/dac6e2c4c77d922124f665142308ab03.pdf 07ba4022d5e4a00af7689393d53a592c https://staging.drfop.org/files/original/b6bc3b3683b2300e9b27ae2ed97f13dc.jpg ed1395ee4b4bcc598159c9a0fbf84376 https://staging.drfop.org/files/original/371604048f3ca3974f54163916203dbc.jpg 783624f0922a0b6f959baf9245307c2c https://staging.drfop.org/files/original/4ef0a8b46b25cfcaf6599240c376a532.jpg fcd99d6ba6cfc086b4508d4150bdf886 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_058.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 58 - 67 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_058.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_058.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Evaluation of Synthetic Balata for Fabricating Sockets for Below-Knee Amputation Stumps</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>At the present time, most sockets for artificial limbs are made of a plastic laminate (usually polyester resin and Dacron) which has been molded over a modified replica of the stump. A replica of the stump is required because human tissues cannot withstand the temperatures generated by the exothermic reaction of the plastic as it cures. The replica is modified, using general rules established by research groups, in order to achieve a relationship between the stump and socket that is physiologically satisfactory, yet permits weight-bearing and provides stability. In addition, reliefs must be provided to accommodate bony prominences and any tender spots. A simple plaster-of-paris wrap will usually be too loose for normal use. Therefore, fabrication of plastic-laminate sockets with presently available materials involves at least the following steps <b>Fig. 1</b>: (a) development of a female mold of the stump by wrapping the stump with plaster-of-paris bandages, (b) casting a male model of the stump by filling the female mold with plaster of paris, (c) modification of the male model by trimming away plaster in selected areas and building it up in other areas when necessary, and (d) lay-up and cure of the plastic laminate. The average time required to make a hard socket below-knee plastic prosthesis is eight man-hours.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. <i>A, </i>taking the plaster cast of the stump; <i>B, </i>pouring plaster in the cast to obtain model of the stump; <i>C, </i>introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; <i>D, </i>the plastic-laminate socket mounted on an adjustable shank for walking trials; <i>E, </i>a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; <i>F, </i>the prosthesis after the shank has been shaped. To reduce weight to a minimum, the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It has been the goal of a number of research workers to find a simpler and less time-consuming method for fabricating satisfactory sockets for all levels of amputation. After many experiments involving a number of casting methods and a variety of materials, the Veterans Administration Prosthetics Center<a style="text-decoration:none;">*</a> by 1961 had developed a technique for molding a socket of synthetic balata directly over a below-knee stump. The first successful results were achieved by using an air-pressure sleeve over a tube of synthetic balata,<a style="text-decoration:none;">*</a> which had been softened by immersion in hot water (160 deg F) and then pulled over the stump<a></a> <b>Fig. 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The air-pressure method of forming synthetic balata sockets for PTB prostheses: application of the tube to the lubricated sleeve of the stump; application of pressure to the sock-covered pressure sleeve; and the socket and bonded tubing attached with screws to the pylon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Upon the recommendations of the CPRD Subcommittee on Design and Development, the Subcommittee on Evaluation undertook responsibility for the evaluation of the new technique.</p> <p>The claims of the development laboratory were: (a) a substantial decrease in elapsed time between measurement of the stump and production of a wearable limb, thereby speeding the rehabilitation process, (b) a substantial reduction in man-hours involved, (c) a capability for easy adjustment of the prosthesis at any time, and <i>(d) </i>a decrease in the amount of skill and training required to produce an adequate socket.</p> <h4>Procedure</h4> <p>A protocol (given at the end of this article) was developed and five clinics<a style="text-decoration:none;">*</a> were asked to participate in the evaluation. The prosthetists from the clinics were trained as a group at the Veterans Administration Prosthetics Center on November 6-8, 1968. Each clinic was requested to fit five new amputees and five amputees who had worn PTB prostheses before, and provided with sufficient material and equipment to carry out the fittings.</p> <h4>Results</h4> <p>Follow-up in the spring of 1969 revealed that all the prosthetists were encountering difficulty in obtaining adequate fits in nearly all cases except those with long tapered stumps, most of the sockets being too loose proximally. To overcome this problem, the VAPC devised a method whereby the air bag was eliminated, and molding pressure was brought about by wrapping the softened balata tube with one-inch-wide elastic webbing and controlling the shape of the socket with the hands and fingers as it cooled.</p> <p>All of the participating prosthetists were instructed in the revised method, and other prosthetists were instructed in the new procedure at the same time. Shortly afterwards, plastic pressure-sensitive tape was substituted for the elastic webbing <b>Fig. 3</b>.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The tape-wrap method of forming synthetic balata sockets: application of pressure with elastic, pressure-sensitive tape; molding by hand to define the medial tibial flare and tibial crest; and the heated socket bottom joined to the pylon by an elastic tape wrap. (Courtesy Veterans Administration Prosthetics Center. New York, NY) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The results with the revised procedure were considerably better. The average synthetic balata prosthesis, with pylon but without cosmetic treatment, weighed 3 1/2<i> </i>lb, and could be made in 2 1/2 hr. All of the claims of the developer were substantiated with the exception of the relative amount of skill required, a factor that would be very difficult to measure at this stage of development. At any rate, it is safe to say that no more skill is required for the new technique than for older methods.</p> <p>All prosthetists who used the technique, with one exception, felt that synthetic balata is quite useful for temporary prostheses. Some have adopted the method as standard procedures where procurement practices permit use of temporary prostheses of this type.</p> <h4>Conclusions</h4> <p>When this technique is used, a considerable saving in time can be effected, and the patient can be provided with a prosthesis within a few hours. Furthermore, the use of synthetic balata permits easier adjustment of the socket later, and the adjustable pylon permits adjustment in alignment at any time.</p> <p>It is therefore recommended that use by federal and state agencies of the VAPC technique for fabricating below-knee temporary prostheses be encouraged, and that the technique be included in the curricula of all below-knee prosthetics courses.</p> <p><b>References:</b></p> <ol> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, <i>Artif. Limbs, </i>6:2:25-73, June 1962.</li> <li>The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, <i>Orth. and Pros., </i>23:1:36-61, March 1969.</li> <li>Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, <i>Bull. Pros. Res., </i>10-12:34-47, Fall 1969.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Bull. Pros. Res., 10-12:34-47, Fall 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Rancho Los Amigos Hospital, Duke University, the University of Miami, the Veterans Administration Hospital/Los Angeles, and the Veterans Administration Hospital/Buffalo</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artif. Limbs, 6:2:25-73, June 1962.</td></tr><tr><td class="clsTextSmall"><b>2 .</b> </td><td class="clsTextSmall">The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, Orth. and Pros., 23:1:36-61, March 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">From Polysar X-414 resin produced by thePolymer Corporation Limited, Sarnia, Ontario,Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_058/tmp64A-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_058/tmp64A-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_058/tmp64A-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 Evaluation of Synthetic Balata for Fabricating Sockets for Below-Knee Amputation Stumps Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/a6f72a14629b7806dcca3b174e3141dc.pdf 59d6595db93d81ef8929c3f4dac05b45 https://staging.drfop.org/files/original/90a87026994734a6ca6470b2110bb6cb.jpg 4b459bfe7868166c8ebfce729b080b79 https://staging.drfop.org/files/original/ef5dbe6f889849aa0064644747edf282.jpg 5b9bbfcfb4d77f3ff2fcd6ed5c8a1773 https://staging.drfop.org/files/original/d52c95869fe6d55ff552dd83c67c000c.jpg e09a2be085c93cad6c6099eee0d57d8f https://staging.drfop.org/files/original/3a77241eaf3995510f53411b3c346397.jpg b8f4051742685bfa4f3ea535cb826cac https://staging.drfop.org/files/original/51816043e9faf56d792b7228710319bb.jpg 3a6888379382529c2f6cdfab9d8a8bcb https://staging.drfop.org/files/original/22957bf7e72d6292125d2fb56abe1b8a.jpg 5fa81fef76fccc4f2a1bbc19d49c4e1b https://staging.drfop.org/files/original/14aae14f9431ce4eb09dfe905d0c906b.jpg 98caf1dd5d9ab89ad4631f844719cc23 https://staging.drfop.org/files/original/b9d22a554d95e70fadd9e859a74c569d.jpg 869fcfb814ec950a3cc1f7428854b5b9 https://staging.drfop.org/files/original/e84537af8c9d23e37d303e3e0ebb5e04.jpg 7d06dc402deaaa85101fcb82ce962d8f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_016.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 16 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_02_016.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_016.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Evaluation of the CAPP Cart</h2> <h5>Barbara A. Gehant <br /></h5> <p>Recent studies of juvenile amputees in the United States and Canada have revealed a sizable number of severely handicapped limb-deficient children. Fortunately, many of these amputees have been fitted with prostheses that enable them to perform skills necessary for daily activities. The quadrimembral amputee, however, presents particularly serious problems. While he may achieve considerable arm function with one or two upper-limb devices, the leg loss may not be adequately compensated for, especially in high-level amputees, and locomotion remains at best an exercise. In an effort to solve the problem of mobility for the most severely handicapped children, the Child Amputee Prosthetics Project at UCLA developed an electric cart. This article presents a study that was designed to determine the extent to which the CAPP cart assists children with quadrimembral deficiencies to achieve independent mobility.</p> <p>The CAPP cart (<b>Fig. 1</b>) is 17 in. wide and 23 in. long, and consists of a seat mounted on a chassis. In the driving position, the seat is 18 in. from the floor. The seat can be raised to 27 in. to enable the child to sit at a table or to transfer to a standard chair or bed. The cart, powered by a 12-volt battery, travels at a constant speed of 1 1/2 mph. It is guided by a lever that is controlled by the chin, and which operates on a "joy-stick" principle. The control arm can be swung to the side to facilitate transfer or activities at a table or desk.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The CAPP cart. Power is provided by a 12-v battery; direction is controlled by the chin-operated lever. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Sample</h3> <p>Since the cart was designed for the child with quadrimembral deficiencies, priority consideration was given to such candidates. The children were selected on the basis of the number of limb deficiencies and the degree of limitation. Eleven children from ten clinics participated in the study (<b>Table 1</b>). A twelfth child was provided with a cart (see Appendix) but not included in the sample, because this clinic already had two subjects represented in the study; additional data from the same reporters might have biased the study.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The sample included four boys and seven girls, six to fourteen years of age. Their weights ranged from 20 to 74 lb; the average weight was 30 lb. Trunk measurements were taken of each child from the bottom of the buttocks to the crown of the head. Sitting height averaged 25 in. and ranged from 20 to 32 in.</p> <p><b>Table 2</b> shows the skeletal deficiencies and prosthetic fittings for the eleven children. Of the five children with bilateral proximal femoral focal deficiencies (PFFD), two had not been fitted with lower-limb prostheses. One child ambulated with a lateral-sway walker, one wore below-knee orthoses bilaterally, and one wore a "brace-prosthesis" on the left and a socket, pylon, and SACH-foot prosthesis on the right.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Four children had bilateral amelias. One wore hip-disarticulation prostheses with the knees locked, two used lateral-sway walkers, and the fourth child had not been fitted with any prostheses.</p> <p>One child had a very short below-knee stump on the right, and a knee disarticulation on the left; the last child had a fusion of the right knee and a left knee contracture. Neither had been fitted with prostheses.</p> <p>Again referring to <b>Table 2</b>, two children had bilateral upper-limb phocomelia, and neither had ever been fitted with arm prostheses.</p> <p>Of the two children with bilateral amelia, one wore two conventional shoulder-disarticulation prostheses, and the other had been fitted unilaterally, alternating between an experimental Michigan feeder arm and a conventional shoulder-disarticulation prosthesis.</p> <p>Of the four children with bilateral hemi-melia, three wore conventional above-elbow prostheses, and the fourth was fitted bilaterally with elbow-disarticulation prostheses.</p> <p>Three children had a combination of right amelia and left hemimelia. One wore a Michigan feeder arm on the left only, another wore a conventional shoulder- disarticulation prosthesis on the amelic side and an above-elbow prosthesis contralaterally, and the third had not been fitted with any prostheses.</p> <p>Three of the children were scoliotic, and three had skeletal problems involving the mouth. One child had bilateral hip dislocations; another had sacral agenesis, with associated loss of muscular mass in the lower extremities and bowel and bladder incontinence. Other abnormalities included hearing and visual deficiencies, and one child had an unspecified neuromuscular disorder manifested by generalized weakness.</p> <p>Five children alternated between the use of wheelchairs pushed by others or walked with their prostheses. Two children either were pushed in a wheelchair or carried by adults. Two were able to push themselves in regular wheelchairs, and one child used an electric wheelchair. One child used an adapted cart that had been constructed by his father.</p> <p>Six children lived in homes with steps at the outside entrance. The families of five of the children had ramps built to accommodate the CAPP cart. The sixth child lived in a two-story house, but used the cart only at school. Five children lived in homes with no stairs either outside or inside the building.</p> <p>All the children were of school age. Six attended special schools for the handicapped, and four attended regular classes in public schools. One child received private tutoring at home.</p> <h3>Procedure</h3> <p>The study was conducted over a six-month period, with evaluations performed at the clinics on three occasions. The results were submitted to New York University. Each clinic was responsible for the routine maintenance of the cart, with major repairs or adjustment that required disassembly of the cart being referred to NYU.</p> <p>The characteristics of each child, his physical and environmental conditions, and his prosthetic experience were recorded on the Selection Forms, which were returned to NYU.</p> <p>A representative of the New York University research staff was present when each cart was delivered and described the study to the child, parents, and clinic team. The training instructions and evaluation forms were discussed with the clinic therapist, and the maintenance instructions with the parents and the prosthetist.</p> <p>The child operated the cart under supervision until the clinic members felt that the child could drive it independently with safety. At the end of the training period, the therapist completed the Training Evaluation Form.</p> <p>The child returned to the clinic after he had used the cart for three months. The therapist, in consultation with the child's parents, evaluated the cart in terms of design, safety factors, and function, and recorded the information on the appropriate form. A maintenance check was made, and any necessary repairs and adjustments were also recorded.</p> <p>The child returned again to the clinic with the cart after six months. The clinic personnel recorded suggestions for improvements in the cart, the child was questioned as to his overall reactions to the cart, and all maintenance problems were recorded. The child's parents and teachers completed forms in which they described their reactions to the cart in terms of suggestions for cart modifications.</p> <h3>Results</h3> <p>Ten of the eleven children who participated in the study preferred the CAPP cart to other modes of transportation. Their parents were equally enthusiastic about the cart. The child who ultimately rejected the cart had a personality problem from the beginning; a strong mutual dependence between the child and her father was threatened by the increased independence offered her by the CAPP cart.</p> <p>The features of the cart that were most appreciated by both the parents and the children were the increased independence and mobility it provided. The main objection voiced by the parents was the weight of the cart. <b>Table 3</b> lists the features the children and parents liked best and least about the cart.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Operational Skills</h4> <p>As seen in <b>Table 4</b>, most of the children learned to control the cart with relative ease. The average training time was 5 1/2 hours. The oldest child (14 years) learned to operate the cart in 1/2 hour, while the youngest (6 years) required 14 hours of instruction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training items were divided into ' 'starting and stopping," "driving," and "turning". The children were asked to start and stop smoothly while driving forward and backward. Most of the children learned this with little difficulty; four learned with no formal training.</p> <p>The driving test consisted of moving forward and backward in a straight line and on a diagonal, crossing doorsills, and changing direction on command. The children learned to ascend and descend inclines of 10 degrees, to avoid obstacles, and to drive through a "slalom" course.</p> <p>Finally, the children were taught to turn the cart on its base, using a rear wheel as a pivot, 90 degrees forward and backward. Three children required no training to perform these tasks, and all of the children learned to perform all activities independently.</p> <p>Two of the younger children began training programs using cars with six-volt batteries because the speed of the cart with the larger battery frightened them at first. After training, they found the cart too slow, and the original twelve-volt batteries were reinstalled.</p> <p>Seven children considered driving backward the most difficult operation to learn. Other areas of difficulty mentioned by the subjects were the delicate control required in confined areas, and turning.</p> <p>Three children lost their balance while learning to operate the cart. One child lost his balance while turning and driving backwards and two, when they changed directions rapidly on a level surface. However, none of them lost sufficient balance to fall from the cart during the training period.</p> <p>Six children damaged property while learning to drive the cart: scraping walls, door frames, or furniture. One child scratched the family car; another, through continued reckless driving, endangered other persons who were in his way.</p> <h4>Safety</h4> <p>Five children wore safety belts while driving the cart.</p> <p>One child fell from the cart while at school. She was not wearing a safety belt, because it restricted her movements while in, and transferring in and out of, the cart. She had swung the control arm away while leaving the battery connected to the motor, and a classmate accidently touched the drive control, which sent the cart forward and caused the child to fall from the cart. Although the child was not injured, the episode dramatized the need for additional safety features.</p> <h4>Extent of Use</h4> <p><b>Table 5</b> shows the extent of cart usage. On the average school day, four children were in the cart at least 75% of their waking hours, three children utilized it between 40 and 70% of the day, and four children less than 10% of the time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>On weekends, two children used the cart more than 75% of the time; two children, 25 to 30%; and seven children, less than 25% of the day.</p> <p>In considering where the cart was used primarily, we found that four children used it both at home and at school; five, only in the home; and two, only at school. The principle reason for using the cart in only one location was its excessive weight, which made transportation difficult. Nine people commented on this problem. Those who used the cart only at home considered the danger of driving a cart with such sensitive controls too great to permit unsupervised use. Two clinics stated they were unable to rely on school personnel to pro- vide daily care for the cart, such as charging and filling the battery and reporting breakdowns.</p> <p>As shown in <b>Table 6</b>, most children were independent in such activities as driving through a 24-inch doorway, entering and leaving an elevator, approaching objects, and adjusting the seat height. The children with upper-extremity amelia and phoco-melia continued to require assistance for activities involving reaching, such as pushing elevator buttons and opening and closing cupboards and drawers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The majority of the children were independent in transfer activities (<b>Table 7</b>), e.g., cart to bed, toilet, or chair. The most troublesome transfer activities involved the toilet; presumably, these difficulties arose because of the narrowness of many bathroom doors and the lack of removable armrests on the cart.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After three months of use, most reporters noted a general improvement in driving and maneuvering skills.</p> <h4>Advantages And Disadvantages</h4> <p>Seven clinics reported that the greatest functional advantage of the cart was the adjustable seat (<b>Table 8</b>). Other assets reported were the increased maneuverability, easy control, the movable control arm that facilitated transfers, and the stability of the cart. The greatest disadvantages were the lack of an "on-off" switch, and insufficient ground clearance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Six children depended less on adult help while in the CAPP cart; four reported no change in the amount of adult help required; no information was available for the eleventh child. Nine parents reported that their children required less lifting; however, one child required more lifting. Before the arrival of the cart, this girl spent most of her time on the floor, where things had been built to accommodate her. Since she was unable to transfer in and out of the cart from the floor, she had to be lifted each time.</p> <p>One child was unable to use his prosthesis while in the cart, because the control arm was on the same side and interfered with its use. Most of the children felt that the chin control was not the optimal control site, and they preferred to use their arm stumps. Two therapists suggested that, if the control arm were placed to the side, a child could control the cart more efficiently with his stump. One therapist objected to the chin control because she feared damage to the child's lower jaw while driving the cart over rough terrain, although there was no report that this occurred. It was suggested that, if the control arm were relocated, a child could maintain a more normal sitting posture and turn his head for driving, and the control arm would not hinder activities at a desk.</p> <h4>Cart Maintenance</h4> <p>The twelve-volt battery required recharging every 24 hours. The batteries normally were charged overnight, and none needed replacement during the test period. Filling the battery with water was a considerable problem for parents because of the small storage space in the cart, which made battery-removal difficult.</p> <p>Most maintenance problems concerned the rear wheels and switches; five carts required wheel replacements. The rear wheels attach to the gear box and receive the power to drive the cart. Since they do not swivel as the front wheels do when the cart turns, a torque is applied. These wheels, which were commercially available as wheelchair casters, were not designed for this amount of force and broke as a consequence of the torque overload.</p> <p>All the carts required replacement of the switches in the control mechanism. The original switches were not the model ordered, but, for reasons of expediency (low cost and commercial availability), they were installed in the carts. When it became apparent that these were unsatisfactory, they were replaced with the model originally ordered, and the problems were eliminated.</p> <h3>Conclusions</h3> <p>With one exception, all the children and their parents were very enthusiastic about the CAPP cart and preferred it to other modes of transportation. It provided increased independence to ten of eleven children with quadrimembral deficiencies.</p> <p>Training did not present a problem, even for the youngest child; however, consideration should be given to introducing the very young or apprehensive child to the cart with a six-volt battery. Since the cart is very stable, most driving hazards arose because of recklessness or poor driving skills. Perhaps greater care should be directed toward predriving instructions, and the children should be given more opportunity to practice driving skills under supervision. It must be remembered, however, that children tend to be less responsible and less coordinated than adults, and more accidents are to be expected from them.</p> <p>The CAPP cart afforded the children more independence in terms of mobility and endurance. Hemimelic children were able to perform many activities, such as opening and closing cupboards and drawers, as a result of the adjustable seat, which allowed them to approach objects more closely and normally.</p> <h4>Design Considerations</h4> <p>Although a number of clinics suggested the inclusion of a seat belt, this would tend to restrict a child's independence if he were able to transfer in and out of the cart without assistance, since most arm amputees would be unable to manipulate the belt independently. Seat belts are readily available or easily devised, and the application of a belt might best be left to the discretion of the clinic or the child's parents. Another suggestion was the incorporation of an "on-off" switch that could be controlled by the child, or a switch that would automatically cut the power when the control arm is swung to the side.</p> <p>Although the present velocity of the cart is satisfactory for forward maneuvers, it is clearly too fast for driving backwards or for delicate control. Consequently, consideration should be given to including a variable speed-control mechanism.</p> <p>Although wheelchair casters are commercially available and relatively inexpensive, they are not designed to absorb the high torque forces that are applied to the rear wheels of the CAPP cart. Stronger drive wheels would probably have prevented many of the mechanical breakdowns that occurred. Consideration should also be given to including pneumatic tires, which provide greater traction and more comfort.</p> <p>Since most of the children preferred to control the cart with their arm stumps, consideration should be given to placing the control arm to one side, close to the shoulder or stump. This would also avoid interference with use of an upper-limb prosthesis. A second possibility, particularly for the upper-limb amelic child, is to lower the control arm to the level of the chair seat, which would allow the child to control the cart with his foot or leg stump while enabling him to sit straight and to turn his head freely.</p> <p><i>Note: </i>As a result of the findings of the evaluation study, a new control box was developed that incorporates a variable-speed mechanism, and an "on-off" switch that can be controlled by the child. All carts have been recalled to UCLA, where a detailed analysis is also being conducted of the effect of use on the mechanical segments of the cart. The new control mechanism and a set of stronger wheels have been installed, and the carts were returned to the children for continued use. Each clinic will provide any further training required to operate the cart with the new control system. After six to eight weeks of additional use by the child, the clinic and the children will be asked to record their reactions to the modified cart.</p> <h3>Recommendation</h3> <p>On the basis of the results of the clinical evaluation of this item, and the design modifications implemented by the developer, it is recommended that the CAPP cart be made available to all limb-deficient children for whom conventional methods of transportation are unsatisfactory.</p> <h3>Appendix</h3> <p>J. T. was an eight-year-old girl with bilateral upper-limb amelia and lower-limb terminal-transverse hemimelia (A/K type). Initially, the control arm on the cart was lowered to the seat level to allow her to operate it with her leg stump. She did not wear lower-extremity prostheses while she was in the cart.</p> <p>This child learned to operate the cart in approximately 2 1/2 hours; driving backwards and turning were the most difficult tasks for her to learn. As with the other amelic children, she was able to move about independently, but she continued to be totally dependent in activities involving the arms.</p> <p>She used the cart for the entire school day, but she did not use it at home because her parents found that its weight made transporting the cart very difficult.</p> <p>Both the child and her parents found that the cart was too slow for her to keep up with the other children. The child's other reactions were similar to those of the other children; that is, she liked the adjustable seat and the increased independence, but disliked the lack of an "on-off" switch and of sufficient ground clearance. Her teacher reported that the cart often became stuck in the school yard because of insufficient clearance.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-19.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-20.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-21.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-22.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-23.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-24.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-25.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-26.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-27.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of the CAPP Cart Creator An entity primarily responsible for making the resource Barbara A. Gehant